Purpose

To identify Medicaid overpayments made to medical providers for services rendered to recipients enrolled in UnitedHealthcare’s Medicare Advantage plan: UnitedHealthcare Dual Complete. The audit covered the period September 1, 2008 through August 31, 2013.

Background

Many Medicaid recipients are also enrolled in Medicare. Such recipients are commonly referred to as “dual-eligibles.” In 1997, Congress established Medicare Part C, the Medicare managed care program also known as Medicare Advantage. Under Medicare Part C, private managed care companies administer Medicare benefits. These Medicare Advantage Plans typically have networks of participating providers they reimburse directly for services provided to enrollees. For dual-eligibles, plan providers bill Medicaid directly for the enrollee’s Part C cost-sharing liabilities (deductibles, coinsurance, and copayments).

Key Finding

From a review of Medicare Part C claims for services rendered to Medicaid recipients enrolled in UnitedHealthcare Dual Complete, we identified 5,571 claims (totaling $657,308) that contained either unreasonably high patient cost-sharing amounts or indicated UnitedHealthcare did not cover the service. From a review of a sample of 125 claims totaling $151,069, we determined Medicaid overpaid 26 providers $61,711 (40.8 percent) for 54 claims. Most overpayments occurred because the providers billed claims with incorrect Medicare Part C coinsurance, copayments, or deductibles. Ten providers adjusted and re-submitted their claims to eMedNY resulting in Medicaid repayments totaling $23,374.

Key Recommendations

• Recover the remaining overpayments totaling $38,337 ($61,711 - $23,374). Formally assess the 5,446 higher risk claims totaling $506,239 that we did not examine in detail. Determine if overpayments were made that warrant recovery.
• Formally instruct providers, including those identified in this report, to bill Medicare Part C claims in accordance with existing requirements to help ensure Medicaid claims are accurately billed.

Other Related Audits/Reports of Interest

Department of Health: Medicaid Payments Made Pursuant to Medicare Part C (2012-S-133)
Department of Health: Overpayments for Medicare Part C Coinsurance Charges (2011-S-33)
Department of Health: Medicaid Payments to Selected Providers for Services to Recipients with Medicare Part C Coverage (2010-S-22)