Corporate Compliance

Gov’t audit insider: Medicaid fee-for-service payments

Healthcare Auditing Weekly, October 28, 2003

The Office of Inspector General (OIG) performed this audit to determine whether Ohio's Medicaid fee-for-service (FFS) payments were allowable for beneficiaries also enrolled in Medicaid managed care.

The OIG used the following steps in its audit:

1. State agency staff compiled a list of Medicaid beneficiaries enrolled in managed care organizations (MCO) during the period July 1999 through June 2001.

2. Using data from the Centers for Medicare and Medicaid Services Medicaid Statistical Information System, the OIG created a file containing all Medicaid FFS claims paid in Ohio during fiscal year 2001.

3. The OIG matched the two files to develop a list of Medicaid FFS payments for beneficiaries enrolled in Medicaid MCOs.

4. The OIG identified more than 9,100 Medicaid FFS payments, totaling more than $1 million, for beneficiaries enrolled in Medicaid managed care. The charges included 19 for inpatient hospital stays, 29 for long-term care stays, almost 2,800 for pharmacy services, and 6,300 for other services.

5. The OIG selected 25 beneficiaries to determine why FFS claims were paid for beneficiaries enrolled in MCOs. The 25 judgmentally selected beneficiaries included 16 inpatient hospital charges and nine with other services. In all, the OIG selected 296 charges, totaling $554,246 for review.

Click here to read the OIG audit report "Review of Medicaid Fee-For-Service Payments For Beneficiaries Enrolled In Medicaid Managed Care."

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