Objective

To determine the extent of implementation of the five recommendations included in our initial audit report, Medicaid Overpayments for Medicare Advantage Plan Services (Report 2017-S-46).

About the Program

The Department of Health (Department) administers the State’s Medicaid program. Many Medicaid recipients are also enrolled in Medicare Part C, commonly referred to as Medicare Managed Care or Medicare Advantage. Under Part C, managed care companies administer Medicare benefits and offer different health care plans (referred to as Medicare Advantage plans [Plans]) to meet the specific needs of Medicare enrollees. When a health care service is covered by a Medicaid recipient’s Plan, Medicaid is generally the secondary payer and reimburses providers for financial balances not covered by the Plan (typically deductibles and coinsurance).

Our initial audit report, issued on December 11, 2018, examined whether the Department overpaid health care providers’ Medicaid claims for services also covered by Plans. The audit covered the period from January 1, 2013 through July 31, 2017 and identified almost $12.8 million that was paid for services typically covered by recipients’ Plans. We determined many overpayments occurred because adequate controls were not in place to detect the improper claims. We recommended the Department review the claims we identified and recover overpayments as warranted, develop and implement procedures for identification and analysis of high-risk claims, and remind providers of their obligation to bill all liable third parties before billing Medicaid.

Key Finding

Department officials made some progress in addressing the problems identified in the initial audit report; however, additional action is needed. In particular, the Office of the Medicaid Inspector General had yet to take action on approximately $11 million of the identified claims. Of the initial report’s five audit recommendations, one was implemented, three were partially implemented, and one had not yet been 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.