Department of Health

Accuracy of Medicaid Managed Care Claims Processing (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-53, 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 be updated promptly and accurately, procedures be developed to prevent such overpayments in the future, and the potential overpayments be investigated and recovered, as appropriate. In our follow-up review, we found that our prior recommendations have, for the most part, been implemented.

For a complete copy of Report 99-F-3 click here.