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Audit (A-04-12-04021)

Acute Care Hospitals in Georgia Did Not Always Reconcile Invoice Records With Credit Balances and Report the Associated Medicaid Overpayments to the State Agency

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Seven of the eight acute care hospitals that we sampled did not always reconcile invoice records with credit balances and report associated Medicaid overpayments to the State agency. Of the 123 invoice records with both Medicaid payments and credit balances in our sample, 67 contained no Medicaid overpayments; however, 56 contained Medicaid overpayments.

Credit balances may occur when a provider's reimbursement for services that it provides exceeds the allowable amount or when the reimbursement is for unallowable costs, resulting in an overpayment. Credit balances also may occur when a provider receives payments from Medicaid and another third-party payer for the same services.

The hospitals did not identify and report Medicaid overpayments because the State agency did not require providers to exercise reasonable diligence in reconciling invoice records with credit balances to determine whether overpayments existed. Also, the State agency did not provide adequate oversight to ensure that providers identified and reported Medicaid overpayments.

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