Department of Health
Department of Social Services

Medicaid Claims Processing Accuracy

The Medicaid Management Information System (MMIS) is a centralized, automated medical assistance information and payment system that is operated by a fiscal agent under a contract with the Department of Health (the contract was previously administered by the Department of Social Services). The State Comptroller maintains audit staff on site at the Department of Health to conduct continuous audits of the MMIS, including weekly examinations of the accuracy of the Medicaid claims that are processed. During the year ended March 31, 1997, these weekly examinations found that health care providers were overpaid $16.6 million and may have been overpaid an additional $1.6 million. Most of these overpayments were made because claim forms were incorrectly completed by providers, third-party insurance coverage was not taken into account, or the reimbursed treatment may not have been medically necessary. In addition, through the joint efforts of the State Comptroller's auditors and Department staff, the Department was able to identify certain health care providers who had yet to repay past overpayments and recover about $670,000 in overpayments from these providers.

For a complete copy of Report 96-D-8 click here.
For a copy of the associated follow-up report click here.