Purpose

To determine (1) whether certain eye care providers who appeared to be affiliated complied with Medicaid provider enrollment rules and (2) if Medicaid paid for improper claims billed by the eye care providers. This audit covered the period January 1, 2010 through December 31, 2015.

Background

Health care providers must apply for enrollment into the Medicaid program and meet certain requirements in order to participate. In addition, providers must revalidate their enrollment every five years. The enrollment and revalidating processes are intended to prevent improper payments and to protect Medicaid recipients from receiving services from providers who do not meet federal and State requirements for participation in the Medicaid program. The Department of Health (Department) requires Medicaid providers to disclose accurate and timely information, including information about their owners and affiliations. The Department uses this information to screen enrollment applications and revalidations, and ensure that only qualified providers participate in the Medicaid program.

Key Findings

• We identified vulnerabilities in the Department’s provider enrollment and revalidating processes and procedures that undermine the Department’s ability to ensure that only qualified providers participate in the Medicaid program and prevent improper payments for services rendered by providers who do not meet federal and State requirements. As a result of these weaknesses, six eye care professionals who did not fully comply with the Department’s Medicaid policies for provider enrollment and revalidation were able to obtain Medicaid eligibility under questionable circumstances. For example, the six eye care professionals obtained Medicaid eligibility under 34 provider identification numbers without disclosing all of their apparent affiliations.
• We identified 1,177 improperly billed eye care services totaling $34,625. The improper payments included $16,542 for excessive Medicare coinsurance and $18,083 for services not supported by proper medical records. (This review was based on judgmental selections of claims that involved the same procedure performed on the same recipient by different providers within a short period [45 days or less] and claims for multiple procedures performed on the same recipient on the same day at different provider locations.)

Key Recommendations

• We made seven recommendations to the Department to review the appropriateness of the providers’ enrollment, enhance controls over the Department’s enrollment process, monitor the appropriateness of the providers’ Medicaid claims, and recover improper payments.

Other Related Audits/Reports of Interest

Department of Health: Eye Care Provider and Family Inappropriately Enroll as Recipients and Overcharge for Vision Services (2013-S-1)
Department of Health: Overpayments of Certain Medicare Crossover Claims (2011-S-28)