Purpose

To determine the extent of implementation of the three recommendations included in our initial audit report, Overpayments for Services Also Covered by Medicare Part B (2010-S-50).

Background

Many of the State's Medicaid recipients are also eligible for Medicare Part B, which provides supplementary medical insurance covering a broad range of outpatient medical services, physicians' fees, and medical supplies. Individuals enrolled in both Medicaid and Medicare are commonly referred to as "dual eligible." Generally, Medicare is the primary payer of claims for services provided to dual-eligible recipients. After Medicare adjudicates a claim, Medicaid pays the balance that is not covered by Medicare and would otherwise be the financial obligation of the recipient. As a result, for dual-eligible recipients, Medicaid generally would pay deductibles and coinsurance not covered by Medicare.

Our initial audit report, which was issued on June 20, 2012, examined whether the Department of Health (Department) overpaid health care providers' Medicaid claims for Medicare Part B deductibles and coinsurance. The audit covered the year 2008. For that period, we identified 259,152 Medicaid claims that were overpaid by almost $8.5 million because providers did not properly report Medicare payment data on those claims.

Key Findings

Department officials made considerable progress in addressing the issues we identified in the initial audit. This included the recovery of improper payments totaling $4.8 million from providers who inaccurately billed Medicare Part B claims. However, further actions are still needed. Of the three prior audit recommendations, one was implemented and two were partially implemented.

Key Recommendation

Officials are given 30 days after the issuance of the follow-up report to provide information on any actions that are planned to address the unresolved issues discussed in this report.

Other Related Audit/Report of Interest

Department of Health: Overpayments for Services Also Covered by Medicare Part B (2010-S-50)