Purpose

To determine the implementation status of the six recommendations made in our initial audit report, Ambulatory Patient Groups Payments for Duplicate Claims and Services in Excess of Medicaid Service Limits (Report 2013-S-17).

Background

We issued our initial audit report on June 29, 2015. The audit objective was to determine whether the Department of Health (Department) had established adequate controls to prevent duplicate and excessive Medicaid payments to clinics and outpatient facilities reimbursed by the Ambulatory Patient Groups (APG) payment methodology. The audit covered the period December 1, 2008 through May 29, 2013. Our initial audit determined the Department did not implement adequate controls to enforce APG policy and payment rules. As a result, Medicaid made $32.1 million in actual and potential overpayments for services that exceeded Medicaid’s established service limits (such as one clinic that billed 41 dental exams for one recipient over three years when the service limit is two exams per year). Additionally, the audit determined the Department did not have controls in place to prevent duplicate claims (such as when a clinic and individual practitioner both bill Medicaid for the same service), resulting in $7.5 million in overpayments.

In our initial audit, we made six recommendations to the Department to: review and recover the inappropriate APG payments; strengthen controls over APG claims processing to prevent improper payments for excessive services; ensure claims processing controls prevent overpayments for the duplicate (professional) claims identified during the audit; and ensure exemptions from official State Medicaid policies are based on appropriate rationales, are properly documented, and include formal repayment plans for recipients of exemptions.

Key Findings

Department officials made some progress in addressing the problems we identified in the initial audit report. About $800,000 of the identified overpayments were recovered and the Department updated policy manuals to give clearer billing guidance to providers. However, the Department has not recovered a significant amount of the overpayments for services exceeding service limits, or the overpayments for duplicate services. Furthermore, the Department has not implemented system controls to prevent the overpayments we identified in the initial audit. Of the initial report’s six audit recommendations, three were partially implemented, one was not implemented, and two were not applicable during the time of our follow-up.

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 - Ambulatory Patient Groups Payments for Duplicate Claims and Services in Excess of Medicaid Service Limits (2013-S-17)