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Audit (A-02-07-01051)

04-23-2010
Review of New Jersey’s Medicaid School-Based Health Claims Submitted by Maximus, Inc.

Executive Summary

New Jersey’s claims for reimbursement of Medicaid school-based health services submitted by its billing agent, Maximus, Inc., for the period July 27, 2003, through October 4, 2006, did not fully comply with Federal and State requirements. Based on our sample results, we estimated that New Jersey was improperly reimbursed $8 million in Federal Medicaid funds during the audit period. Federal and State rules require that school-based health services be (1) referred or prescribed by a physician or another appropriate professional, (2) provided by an individual who meets Federal qualification requirements, (3) fully documented, (4) actually furnished in order to be billed, and (5) documented in the child’s plan.

Of the 100 school-based health claims in our sample, 51 did not comply with Federal and State requirements. The 51 claims pertained to services that were not (1) provided or supported, (2) in compliance with referral or prescription requirements, (3) in compliance with Federal provider qualification requirements, and (4) documented in the child’s plan.

We recommended that New Jersey refund $8 million to the Federal Government, provide proper and timely guidance on Federal Medicaid criteria to its school-based health providers, and improve its monitoring of school-based health providers’ claims to ensure compliance with Federal and State requirements. New Jersey disagreed with our recommended refund and provided additional documentation for claims questioned in our draft report. New Jersey also questioned our sampling methodology. After reviewing the additional documentation, we revised our findings and recommended refund. We maintain that our sampling methodology was valid.

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