Department of Health
Office of Temporary and Disability Assistance

Accuracy of Managed Care Claims Processing

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. We examined the monthly Medicaid fees paid to managed care providers during the two years ended September 30, 1996. We found that the providers may have been overpaid as much as $7.4 million during this period, because fees were paid for participants who were no longer enrolled in that managed care program. We recommend that program enrollment records, which are maintained by the Office of Temporary and Disability Assistance, be updated promptly and accurately, and procedures be developed to prevent such overpayments in the future. We also recommend that the potential overpayments be investigated and all actual overpayments be recovered.

For a complete copy of Report 96-S-53 click here.
For a copy of the associated follow-up report click here.
For a copy of the 90-day response click here.