The Office of Inspector General has issued lengthy audit reports for Pennsylvania, Connecticut, and Texas documenting the extent to which each state's agencies sent in claims for more reimbursement than they could justify.
In Pennsylvania, Medicaid officials have disallowed one in 10 sampled state claims for reimbursement of case management services targeting people with mental illness or mental retardation, about $11.8 million, because they lacked case record support.
About $6.5 million of the amount was spent from federal funds, which the OIG recommends the state should refund.
In Connecticut, Medicaid officials have questioned $19.8 million in claims for 80 contracted mental health and related social services. Connecticut's documentation did not contain enough information to determine whether the claims qualified for payment.
"The state agency's calculation of the CBMACs (Community Based Medicaid Administrative Claim) was based on the Medicaid-allocable costs incurred by the 80 contracted organizations ($161,480,735), which exceeded by $19 million the total amount that the DMHAS (the Department of Mental Health and Addiction Services) actually paid to these contracted organizations for both Medicaid and non-Medicaid services and activities," the OIG audit said.
And, in Texas, 22% of sampled medical claims for care provided to undocumented immigrants did not satisfy the state's definition of emergency care. In Texas, as in other states, coverage for medical care and prescription drugs for undocumented people is allowed only during medical emergencies. The amount in question involved 193 of 854 claims for care, totaling $262,000, which lacked documentation.
Texas officials requested federal reimbursement for 7,114 claims for prescription drugs totaling $147,805 that did not meet the state's definition of emergency care.
In addition, the program to "prevent payment of family planning services claims for undocumented aliens and legal aliens did not always operate correctly or was manually overridden to allow services to be claimed as family planning services, which are paid at an enhanced federal medial assistance rate of 90%."
Perhaps more important, the OIG said, the Texas "state agency did not have adequate internal controls to ensure that, for undocumented aliens and legal aliens restricted to emergency services, federal reimbursement was claimed only for those conditions that it defined as emergency services."
The claims are quite old. For Pennsylvania, they involve services provided between Jan. 1 2003 and Dec. 31, 2005. For Connecticut, they involved spending in fiscal years 2005 and 2006, and in Texas, they covered Oct. 1, 2004 through Sept. 30, 2005.