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Audit (A-09-09-00039)

12-15-2010
Review of Washington State's Medicaid Claims for Nonqualified Aliens

Executive Summary

We found that Washington State claimed $1.5 million ($760,000 Federal share) for nursing home services provided to nonqualified alien beneficiaries without prior approval from a State medical consultant or to beneficiaries who were misclassified and not eligible for the Alien Emergency Medical program. The State also claimed $6,000 ($3,000 Federal share) for various medical services provided to treat conditions that were not authorized. Finally, the State claimed $1.5 million ($744,000 Federal share) for prescription drugs and $369,000 ($185,000 Federal share) for dental services that the State agency could not determine were related to treating emergency medical conditions.

Federal Medicaid funding is available to States for medical services provided to nonqualified aliens only when those services are necessary to treat an emergency medical condition. A nonqualified alien is an individual who is not a citizen or national of the United States and is not in a satisfactory immigration status.

We recommended that the State (1) refund $763,000 to the Federal Government for nursing home services and medical services that were improperly claimed, (2) work with CMS to determine what portion of the $1.9 million ($929,000 Federal share) claimed for prescription drugs and dental services was related to emergency medical conditions and refund any improperly claimed amounts, (3) ensure that only nursing home claims that receive prior approval from a State medical consultant and that are eligible for the program are claimed for reimbursement, (4) ensure that the Medicaid cards issued to nonqualified aliens limit services to those necessary to treat conditions defined as emergency medical conditions, and (5) ensure that the Medicaid Management Information System edits limit claims for services provided to nonqualified aliens to emergency medical conditions or to services approved by a State medical consultant. The State concurred with our recommendations.

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