Report No. 2009-26
March 2009
Complete Audit Report
The following findings were included in our audit report on the Missouri Department of Social Services, MO Healthnet Division, Program Integrity Unit.
The State Auditor is required by state law to conduct an audit of the Department of Social Services (DSS), MO HealthNet Division (MHD), Program Integrity Unit (PIU) "…to quantitatively determine the amount of money invested in the unit and the amount of money actually recovered by such office." The PIU needs to ensure all information required by state law is included and accurately reported in its annual report submitted to the General Assembly and Governor. In fiscal year 2007, the PIU reported recoveries in excess of $5.3 million.
The report did not include some participant investigations completed during the reporting period. In addition, the age and type of provider/participant investigations were not reported. Some overpayments, identified as a result of completed investigations, reviews, or audits, are not reported. Although the report includes overpayments identified by the Welfare Investigations Unit (WIU), the overpayments identified by the PIU and Cost Recovery Unit (CRU) are not reported. The PIU records indicated overpayments identified totaled almost $4.7 million for the year ended June 30, 2007.
The amount of fines and restitution ordered to be reimbursed, and other required information on provider investigations closed by the Office of Attorney General, Medicaid Fraud Control Unit (MFCU), are not reported. Some monetary recoveries (collections) resulting from completed investigations, reviews or audits are not reported. Although the report lists the total amount of recoveries for the PIU and CRU, the monetary recoveries for the WIU are not reported.
The annual report amounts were not always complete and accurate. The report identified overpayments, collections, and costs; however, these amounts were incomplete and/or misclassified. In addition, the amounts identified as cost recovery for the MO HealthNet Investigations Unit (MHIU) and the WIU were actually the overpayment amounts and the actual cost recovery amounts were not reported.
The DSS has not established adequate procedures to ensure the accuracy of amounts included in the annual report and some amounts were not accurately reported. Also, some amounts reported were not always calculated in the same manner from year to year. In March 2007, the PIU began including paper denials when calculating cost avoidance; however, this change in calculating the cost avoidance amount was not disclosed in the annual report. Additionally, the DSS does not disclose that some amounts included in the cost avoidance total were estimates. Finally, the DSS has not established procedures to retain supporting documentation for the report in a centralized location.
The PIU does not have adequate procedures in place to ensure referrals submitted to the MFCU are received and addressed timely. We noted delays between the date the PIU indicated a referral was sent to the MFCU and the date the MFCU indicated the referral was received. In addition, adjustments to the overpayment amounts identified and reported are not tracked and reported in the annual report. Adjustments to overpayment amounts may occur due to the conclusion of an appeal process, or due to a mathematical error in the original overpayment calculation.
The DSS does not deposit monies recovered by the MFCU in the proper funds as provided by state law. According to Section 191.905.11, RSMo, restitution should be deposited in the MO HealthNet Fraud Reimbursement Fund and reimbursements of investigation/prosecution costs should be deposited in the MO HealthNet Fraud Prosecution Revolving Fund. These funds have not had receipt or disbursement activity since (at least) fiscal year 2000.
Complete Audit Report
Missouri State Auditor's Office
moaudit@auditor.mo.gov
