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Ohio Did Not Always Make Correct Medicaid Claim Adjustments

The Ohio Department of Medicaid (State agency) did not always use the correct Federal medical assistance percentages (FMAP) when processing Medicaid claim adjustments reported on the CMS-64. Of the 1,585,792 claim adjustments we reviewed, we determined that 1,204,718 adjustments (composed of 900,413 private and 304,305 public provider claims) used the correct FMAP or did not result in a payment difference. However, the remaining 381,074 claim adjustments were paid using incorrect FMAPs resulting in an overpayment to the State agency of $151,000 (Federal share). These errors occurred because the State agency did not have adequate internal controls to process all private and public claim adjustments in accordance with Federal requirements. Specifically, the State agency did not always report claim adjustments using the FMAP associated with the original claim when required.

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Office of Inspector General, U.S. Department of Health and Human Services | 330 Independence Avenue, SW, Washington, DC 20201