October 10, 2006

Complete Text of Report is available in PDF format (1.6 mb). Copies can also be obtained by contacting the Office of Public Affairs at 202-619-1343.

EXECUTIVE SUMMARY:

Our objective was to determine the extent to which the State agency made Medicaid payments on behalf of beneficiaries who did not meet Federal and State eligibility requirements. The State agency (1) made some Medicaid payments on behalf of beneficiaries who did not meet Federal and State eligibility requirements and (2) did not always adequately document eligibility determinations. Of the 200 payments in our statistical sample, 16 payments totaling $874 (Federal share) were unallowable because the beneficiaries were ineligible for Medicaid. In addition, for 58 sampled payments totaling $10,699 (Federal share), the case files did not contain all documentation supporting eligibility determinations as required. As a result, for the 6-month audit period from January 1 through June 30, 2005, we estimated that the State agency made 4,217,888 payments totaling $230,375,748 (Federal share) on behalf of ineligible beneficiaries. We also estimated that case file documentation did not adequately support eligibility determinations for an additional 15,289,843 payments totaling $2,820,569,979 (Federal share). We did not recommend recovery primarily because, under Federal laws and regulations, a disallowance of Federal payments for Medicaid eligibility errors can occur only if the errors are detected through a State’s Medicaid eligibility quality control program. We recommended that the State agency use the results of this review to help ensure compliance with Federal and State Medicaid eligibility requirements. Specifically, the State agency should (1) reemphasize to beneficiaries the need to provide accurate and timely information and (2) require its district office employees to verify eligibility information and maintain appropriate documentation in its case files.

To build a better fraud trap
Minnesota companies Ingenix and Fair Isaac are each working on technology to help identify false claims that contribute to skyrocketing health-insurance costs.

BY JULIE FORSTER
Pioneer Press

Ferreting out intentional crime from a legitimate mistake or simply a difference in opinion between a doctor and insurer is not always black and white. *Robin Mathias*, a health care fraud consultant based in Santa Rosa, Calif., noted that while it is cutting edge, the technology is not as clear-cut when used to find health care fraud as it is in finding fraud in the credit card industry.

States are enacting new laws to help fight Medicaid fraud.

Sebelius Says New Law Will Crack Down on Medicaid Fraud - Kansas City infoZine -