Department of Health

Controls Over Certain Medicaid Payments to Managed Care Providers (Follow-Up Review)

In Medicaid managed care programs, the medical services needed by program participants are arranged for by a single service provider, who receives a flat monthly fee for each program participant rather than a fee for each service provided. In our prior audit report 96-S-67, we examined the monthly Medicaid fees paid to managed care providers for program participants under the age of one. We identified as much as $19.5 million in overpayments over a six-year period, and noted that the circumstances surrounding some of the inappropriate claims needed to be investigated to determine whether the claims were the result of error or fraud. We also found that the monthly Medicaid fees paid to managed care providers sometimes duplicated health insurance coverage provided elsewhere. In our follow-up review, we found that actions have been taken to prevent the kind of overpayments identified in our prior audit; however, actions have not been taken to recover the overpayments identified in our prior audit.

For a complete copy of Report 99-F-2 click here.