Texas Wrongly Claimed $3.8M in Medicaid Reimbursements
The state of Texas claimed millions in improper Medicaid managed care reimbursement over a two-year period.
Source: Thinkstock
By - Texas’s Department of Health and Human Services failed to adhere to federal guidelines and inappropriately claimed $3.8 million in Medicaid managed care reimbursement.
The Office of Inspector General (OIG) recently published findings from their audit of the state agency in which it discovered that the state improperly claimed millions of dollars in managed care payments due to some beneficiaries having more than one Medicaid identification number. This resulted in multiple, excessive claims for a single beneficiary.
Federal and state governments jointly fund and carry out Medicaid programs, where the federal government administers Medicaid programs and the state government establishes which plans are covered.
While the state programs have flexibility, they must adhere to a specific set of federal guidelines, and sometimes fail to meet said guidelines.
Recently, Wisconsin failed to adhere to federal guidelines for invoicing providers for Medicaid drug reimbursement, resulting in $3 million inappropriate claims.
Under federal law, states such as Texas are responsible for establishing an individual’s eligibility in the program as well as making sure beneficiaries only have one identification number.
After OIG conducted the audit, the state agency complied with federal requirements for 125 out of the 3,170 Medicaid managed care beneficiaries. The remaining 3,045 had more than one identification number.
The managed care organizations (MCOs) receive fees from the state agency to ensure that they can provide beneficiaries with necessary services. Because of the federal laws in place, a state cannot provide payments to MCOs if a beneficiary is not properly identified for eligibility.
As a result of the duplicate identification numbers, the state’s state health department paid MCOs $3,507,450 and in total paid $6,515,023 for managed care payments that did not comply with federal standards.
OIG found that the state did not allocate proper staffing and research to prevent wrongly associated claims.
“The improper payments occurred because the State agency did not ensure that beneficiaries were assigned only one Medicaid identification number,” it said.
“Specifically, the State agency stated that its eligibility staff failed to appropriately research potential beneficiary matches identified during the application process before assigning a Medicaid identification number,” the report continued. “In other instances, the State agency explained that it did not identify potential beneficiary matches because insufficient applicant information was available during the application process or that the applicant provided incorrect information.”
To maintain accountability, OIG recommends that the state refunds the $3.8 to the federal government.
Other OIG recommendations include identifying additional unallowable monthly Medicaid managed care payments made before and after the audit period for 3,045 beneficiary matches. OIG believes the state agency should also identify any other beneficiaries who are assigned more than one Medicaid identification number, and refund any unallowable payments associated with those beneficiaries.
Also included in those recommendations for the state agency is strengthening its procedures to determine beneficiary eligibility for managed care services.
The state agency accepted several of the suggestions following the final audit.
“In its written comments on our draft report, regarding the first and second recommendations, the State agency stated that it would research our findings and refund any unallowable payments,” OIG concluded. “Regarding our third recommendation, the State agency said that it would identify any additional beneficiaries assigned more than one Medicaid identification number and refund any unallowable payments associated with those beneficiaries.”
