Department of Health

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 State Comptroller maintains audit staff on site 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, 2004, these weekly examinations found that health care providers were overpaid as much as $32.5 million. Most of these overpayments were made because third-party insurance coverage was not taken into account, claim forms were incorrectly completed by providers, or the reimbursed treatment may not have been medically necessary. We also identified an error that would have resulted in an overpayment of $8.6 million, if actions were not taken to correct the error before the payment was processed. In addition, through the joint efforts of the State Comptrollerís auditors and Department staff, certain health care providers that had yet to repay past overpayments were identified; $439,744 in overpayments was recovered from these providers and an additional $349,475 in overpayments was referred to the Department for recovery.

For a complete copy of Report 2003-S-60 click here.
For a copy of the 90-day response click here.
For a copy of the associated follow-up report click here.