Gov’t audit insider: MCO and FFS overlap in Ohio
Healthcare Auditing Weekly, July 13, 2004
The Ohio Department of Job and Family Services paid $4.6 million in unallowable fee for service (FFS) claims that were also covered by the Medicare+Choice Organizations (MCOs), according to an OIG audit report released June 23.
During the audit, the OIG did the following:
- Examined Medicaid FFS claims for services also covered by Medicare managed care
- Compiled a list of the Ohioans enrolled in Medicare MCOs during the 1999-2001 audit period
- Identified Ohio FFS claims paid during the audit period
- Cross-referenced the two lists and found 459,947 FFS claims also eligible for MCO coverage
- Selected a stratified 200-claim sample to further investigate the validity of the claims
- Contacted MCOs to understand the coverage requirements more fully
- Projected the findings in the sample to the overall universe of claims to reach the $4.6 million estimate for overpayments
The auditors only reviewed controls related to preventing payments for FFS claims also covered by MCOs.
Click here to read the audit report called "Review of Medicaid Fee-for-Service Payments for Beneficiaries Enrolled in Medicare Managed Care (A-05-02-00085)."
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