Department of Health

Medicaid Clinic and Emergency Room Claims Paid During a Recipient's Hospital Stay (Follow-Up Review)

Medicaid reimbursement rates for inpatient hospital care are intended to cover all the costs associated with a hospital stay, including the cost of any services provided by a clinic or emergency room either during hospitalization or on the day a patient is hospitalized. However, in our prior audit report 98-S-10, which covered a 57-month period, we determined that as much as $16.9 million in Medicaid payments were made for services provided by clinics or emergency rooms either during a patient's hospital stay or on the day the patient was hospitalized. We also found that, while other overpayments of this kind had been identified by Department of Health auditors, the Department was slow to recover many of the overpayments. We recommended that all identified overpayments be recovered promptly, and controls be improved to prevent such overpayments in the future. In our follow-up review, we found that some of our recommended improvements have been made and some of the previously identified overpayments have been recovered. However, additional actions are needed if our prior recommendations are to be fully implemented.

For a complete copy of Report 2000-F-9 click here.
For a copy of the 90-day response click here.