Purpose

To determine whether Medicaid inappropriately paid for recipients’ Medicare Part C cost-sharing liabilities. The audit covered the period January 1, 2012 through December 31, 2016.

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 through Medicare Advantage plans, which have networks of participating providers that they reimburse for services provided to enrollees. For dual-eligibles, Medicaid reimburses the plan providers for the enrollee’s Part C cost-sharing liabilities (deductibles, coinsurance, and copayments).

Key Findings

• We reviewed selected Medicare Advantage plan contracts offered by Fidelis and WellCare and, based on judgmental sampling, determined certain providers reported inflated Part C cost-sharing liabilities on 7,072 Medicaid claims resulting in overpayments of $770,935.
• We determined three of the providers were overpaid 58, 74, and 79 percent of the total Medicaid payments they received for claims in our review. We analyzed the remaining Part C cost-sharing claims billed by these providers during the audit period and found – if the rate of overpayment is consistent with our initial review – Medicaid potentially overpaid an additional $562,356 to these providers.

Key Recommendations

• Review the $1,333,291 in actual ($770,935) and potential ($562,356) Medicaid overpayments and recover as appropriate.
• Formally instruct the three providers identified in this report to bill Medicare Part C claims in accordance with existing requirements.
• Develop a risk-based approach to identify and prevent inappropriate Medicaid claims for Medicare Part C cost-sharing liabilities.

Other Related Audits/Reports of Interest

Department of Health: Medicaid Payments Made Pursuant to Medicare Part C (2012-S-133)
Department of Health: Medicaid Overpayments for Certain Medicare Part C Claims (2013-S-35)