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Georgia Did Not Pay Some Line Items on Medicaid Claims in Accordance With Its Medicaid National Correct Coding Initiative Methodologies Audit (A-04-12-06159) 12-04-2013

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The Georgia Department of Community Health (State agency) did not pay some line items in accordance with its Medicaid National Correct Coding Initiative (NCCI) methodologies on claims hospitals submitted from November 1, 2010, through September 30, 2011. The NCCI promotes correct coding of health care services provided to Medicare beneficiaries and prevents Medicare payment for improperly coded services. Overall, the State agency satisfied Federal and State requirements by implementing the Medicaid NCCI into the Georgia Medicaid Management Information System (GAMMIS), a computerized payment and information reporting system, on schedule. However, the Medicaid NCCI edits did not prevent erroneous payments. The State agency made erroneous payments to providers totaling $1.5 million ($1 million Federal share).

The erroneous payments occurred because the fiscal agent did not ensure that Medicaid NCCI edits incorporated in the GAMMIS approved only comprehensive Healthcare Common Procedure Coding System codes when they were reported with component codes (already included in the comprehensive code) for the same date of service. The State agency acknowledged that the Medicaid NCCI edits did not work as intended and that it paid line items in error. Subsequent to our fieldwork, agency officials stated that all of the erroneous payments identified in our universe have been recovered from providers.

We recommended that the State agency (1) refund erroneous payments totaling $1 million to the Federal Government and (2) ensure that the Medicaid NCCI edits were properly incorporated and are functioning as intended in the GAMMIS. The State agency concurred with our recommendations and described the corrective actions it had taken.

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