Report No. 2009-39
April 2009
Complete Audit Report
Medicaid Provider Monitoring Can Be Improved
Medicaid is a jointly funded state and federal partnership providing health coverage for selected categories of people with low incomes who might otherwise go without medical care. The state's Medicaid Program spent between $6.7 and $7.2 billion (approximately split 60 percent federal and 40 percent state) annually over the last several years. The Program Integrity Unit (PIU) of the Department of Social Services, MO HealthNet Division (division) is responsible for monitoring the utilization of Medicaid services in the state. The audit objectives included determining whether the Missouri Medicaid Program has an effective system for (1) preventing improper payments to service providers, and (2) identifying and recouping any improper payments that occur.
Staffing levels and resources limit productivity
PIU analysts told us heavy workloads impacted the timeliness of case reviews and the extent of work performed. An analysis of case assignments showed (1) PIU analysts responsible for provider reviews opened cases, but did not begin working the cases for several months or longer, (2) PIU provider reviews are not always expanded to additional time periods outside the initial review period or to similar providers when concerns are identified, (3) PIU management had inadequate procedures to identify and track open cases, (4) staff primarily conducted desk reviews instead of on-site visits of providers due to a limited or no travel budget, and (5) staff limited record requests from providers due to concern over potential charges for copies. (See page 9)
Problem providers need to be better monitored
The division does not effectively monitor known problem providers or use available sanctions. Concerns identified include (1) there are no established follow-up procedures for providers sent education letters, cited for over billings, or with a previous history of abusive billing practices, (2) re-enrolled providers with past billing problems are not monitored more closely, and (3) few providers are put on prepayment review. (See page 13)
Disqualified Medicaid provider paid $669,000
In 2004, division staff approved a Medicaid provider that was on the federal Department of Health and Human Services (DHHS) - Office of Inspector General (OIG) disqualified list. The provider remained an active Missouri Medicaid provider until a federal DHHS employee contacted the division in March 2006. The provider was paid a total of $669,000.
The provider had pleaded guilty to mail fraud related to a federal health program in 1994 and had been placed on the federal OIG disqualified list for 5 years beginning November 1995. The provider had not applied for removal from the disqualified list at the end of the disqualification period. A division official said the provider's approval in 2004 was a mistake and could provide no explanation why the approval occurred. Division officials are seeking reimbursement for payments made to the provider. As of January 2009, the Administrative Hearing Commission case remained open. (See page 23)
Missouri's False Claims Act does not mirror federal act
The 2007 Missouri General Assembly enacted legislation modifying existing state Medicaid fraud laws to include false claims act provisions. However, state law does not include required provisions to allow Missouri to retain an additional 10 percent of funds recovered under the act. To encourage states to pass false claims act legislation, the Federal Deficit Reduction Act of 2005 included provisions allowing states which pass laws that mirror the Federal False Claims Act to keep 10 percent more than the Medicaid matching rate of monies recovered from cases that are settled or prosecuted under the state act. (See page 27)
Complete Audit Report
Missouri State Auditor's Office
moaudit@auditor.mo.gov
