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Department of Health and Human Services

Office of Inspector General -- AUDIT

"Review of Managed Care Payments Made Under the State of Texas Access Reform Managed Care Program," (A-06-00-00075)

September 27, 2001

Complete Text of Report is available in PDF format (517 kb). Copies can also be obtained by contacting the Office of Public Affairs at 202-619-1343.


This report provides the results of an audit of Medicaid payments made by the Texas Department of Health (TDH) under the State of Texas Access Reform (STAR) managed care program.  The review disclosed that managed care payments made for 437 STAR members during the period September 1, 1998 through August 31, 2000, were improper because the members were either:  (1) not eligible and the payment amount should have been zero; or (2) misclassified as dual eligible and the payment amount may need to be adjusted.  We recommended that the Commission: (1) review and revise as necessary, the State’s payment system for STAR enrollees in order to ensure that Medicare entitlement dates are identified in a timely manner, and managed care payments are not made for ineligible STAR enrollees; (2) ensure that TDH reviews and makes the appropriate payment adjustments for the 437 members inappropriately enrolled in the STAR program under the Medicare risk group during FYs 1999 and 2000 and report the results of the adjustments to the Office of Inspector General; and (3) ensure that TDH identifies, reviews, and makes the appropriate payment adjustments for STAR members assigned to the Medicare risk group for prior years.