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Review of Pennsylvania's Medicaid Payments for Targeted Case Management Services for Calendar Years 2003 Through 2005

Pennsylvania's claims for targeted case management (TCM) services did not always comply with Federal and State requirements. The Social Security Act authorizes State Medicaid agencies to provide case management services to Medicaid beneficiaries. These services are referred to as TCM when they are furnished to specific populations in a State. Based on our review of 375 claims in 100 sampled beneficiary-months, 36 claims included in 15 beneficiary-months were unallowable because the services were unsupported by case records or insufficiently documented. As a result, we estimated that during calendar years 2003 through 2005, the State claimed $11.9 million ($6.5 million Federal share) in unallowable TCM costs.

We recommended that the State (1) refund to the Federal Government the $6.5 million for undocumented and unsupported claims for TCM services, (2) review TCM claims submitted subsequent to our audit period and report any necessary adjustments, and (3) ensure that future TCM services claimed under the Medicaid program are properly documented in accordance with Federal and State requirements.

In written comments on our draft report, the State partly agreed and partly disagreed with our findings. Based on additional documentation provided by the State, we revised our report and recommendations to reflect that we are questioning 15 sampled beneficiary-months with 36'errors.

Filed under: Center for Medicare and Medicaid Services