Purpose

To determine the extent of implementation of the three recommendations included in our initial audit report, Medicaid Overpayments for Certain Medicare Part C Claims (Report 2013-S-35).

Background

Medicaid provides health care services to those who are economically disadvantaged and/or have special health care needs. Many of the State’s Medicaid recipients are also enrolled in Medicare, the federal health insurance program for the elderly and disabled. Under Medicare Part C, also known as Medicare managed care or Medicare Advantage, private managed care companies administer Medicare benefits. Medicare pays a fixed amount for each Medicare Part C beneficiary every month to companies offering Medicare Advantage plans, and plans reimburse health care providers directly for services provided to enrollees. For individuals enrolled in both Medicaid and Medicare Part C, plan providers bill Medicaid directly for the enrollee’s Part C cost-sharing liabilities (deductibles, coinsurance, and copayments).

We issued our initial audit report on January 16, 2015. The audit objective was to identify Medicaid Part C claim overpayments made to medical providers for services rendered to Medicaid recipients enrolled in the Medicare Advantage plan: UnitedHealthcare Dual Complete. The audit covered the period September 1, 2008 through August 31, 2013. Our initial audit identified 5,571 Medicare Part C claims that either had unreasonably high patient cost-sharing amounts or indicated UnitedHealthcare did not cover the service. We reviewed 125 Medicaid claims totaling $151,069 and found Medicaid overpaid 54 claims (43.2 percent) by $61,711. Most overpayments occurred because the providers billed claims with incorrect Medicare Part C coinsurance, copayments, or deductibles. During the initial audit, $23,374 was recovered, leaving $38,337 that still needed to be recovered. We recommended the Department recover the remaining overpayments and instruct providers to bill Medicare Part C claims in accordance with the existing requirements. Additionally, our audit recommended the Department assess the propriety of the remaining 5,446 high risk claims (5,571 - 125) totaling $506,239 that we did not examine in detail, and make recoveries where warranted.

Key Finding

Department officials made progress in implementing the recommendations we made in our initial audit, which included recovering $21,648 in overpayments and instructing providers to bill Medicare Part C claims in accordance with the existing requirements. Of the initial report’s three 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: Medicaid Overpayments for Certain Medicare Part C Claims (2013-S-35)