Department of Health and Human Services

Office of Inspector General -- AUDIT

Complete Text of Report is available in PDF format (1.02 mb). Copies can also be obtained by contacting the Office of Public Affairs at 202-619-1343.

EXECUTIVE SUMMARY:

Contrary to Federal and State requirements, the State agency claimed unallowable targeted case management (TCM) services during fiscal years 2003 and 2004.  Of the 200 State agency claims for Medicaid reimbursement in our sample, 127 were allowable, the State agency did not properly claim 60, and 13 may not have been allowable.  As a result, the State agency improperly claimed $2,495,948 ($1,510,153 Federal share) for TCM services that did not comply with Federal and State requirements.

We recommended that the State agency (1) refund $1,510,153 to the Federal Government for unallowable TCM claims; (2) work with the Centers for Medicare & Medicaid Services to determine the allowability of the $196,116 of direct medical services incorrectly claimed as TCM services; and (3) establish policies and procedures strengthening its internal controls to ensure that TCM services claimed for Federal reimbursement are sufficiently documented to support the provision of TCM services, are provided in accordance with Federal regulations, and do not include direct medical services.  The State agency partially concurred with our third recommendation and did not concur with the first two recommendations.