Department of Health

Fee-for-Service Claims Paid for Recipients Enrolled in Managed Care Plans (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. However, if a program participant needs services not provided by the managed care plan or if the participant chooses to obtain certain services outside of the plan, a fee-for-service claim may be paid on behalf of the participant. In our prior audit report 96-S-83, we examined the payment of such fee-for-service claims over a period of about three years and identified as much as $38.5 million in Medicaid overpayments. The overpayments were made because of delays by counties in updating Medicaid enrollment information for the managed care plans and because duplicate payments were made for certain medical services. In our follow-up review, we found that Department of Health officials have taken actions to prevent the kind of overpayments identified in our prior report, and have made progress in recovering the overpayments that can be recovered.

For a complete copy of Report 99-F-7 click here.