"Review of Outpatient Medicaid Claims Billed as Family Planning By New Jersey," (A-02-06-01010)
June 17, 2008
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For the period February 1, 2001, through January 31, 2005, we estimate that New Jersey improperly received $597,000 in enhanced 90-percent Federal funding for clinic, laboratory, radiology, practitioner, or outpatient hospital services that did not qualify as family planning services. Section 1903(a)(5) of the Social Security Act and 42 CFR §§ 433.10 and 433.15 provide enhanced 90-percent Federal Medicaid funding for family planning services. According to section 4270 of the CMS “State Medicaid Manual,” family planning services prevent or delay pregnancy or otherwise control family size. Of the 107 family planning claims in our sample, 43 claims did not qualify as family planning services.The overpayment occurred because the State’s electronic Medicaid claims database did not identify all improperly coded claims that did not meet the requirements for 90-percent Federal funding, and some family planning clinics improperly billed all services as family planning eligible for 90-percent Federal funding. We recommended that the State (1) refund $597,000 to the Federal Government, (2) develop edits in its Medicaid claims database to identify all claims that do not meet 90-percent Federal funding requirements, and (3) issue guidance to family planning clinics that all services should not be billed as eligible for 90-percent Federal funding. The State generally agreed with our findings and recommendations.