Purpose

To determine the extent of implementation of the three recommendations included in our initial audit report, Improper Fee-for-Service Payments for Pharmacy Services Covered by Managed Care (Report 2014-S-5).

Background

Our initial audit report, which was issued on January 5, 2015, determined that, for the 27-month period October 1, 2011 through December 31, 2013, Medicaid inappropriately paid 29,289 fee-for-services pharmacy claims totaling $978,251 on behalf of 18,010 Medicaid recipients whose pharmacy benefits were covered by managed care. We recommended the Department review the improper payments we identified and recover overpayments as appropriate. We also recommended the Department take corrective action to help ensure managed care enrollment information is entered and update timely and to determine why certain fee-for-service claims were inappropriately paid and take any necessary corrective actions.

Key Finding

Department officials have made some progress in addressing the problems we identified in the initial audit report.  However, further actions are still needed.  Of the initial reports three recommendations, two were implemented and one was not 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: Medicaid Program - Improper Fee-for-Service Payments for Pharmacy Services Covered by Managed Care (2014-S-5)