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North Dakota Claimed Some Unallowable Medicaid Payments for Targeted Case Management Services

The North Dakota Department of Human Services' (State agency) claims for Medicaid reimbursement for Targeted Case Management (TCM) services provided and paid for during Federal fiscal years (FYs) 2013 and 2014 were not always in accordance with Federal requirements. Specifically, the State agency claimed at least $349,000 (Federal share) of unallowable Medicaid reimbursement and an estimated $862,000 (Federal share) of potentially unallowable Medicaid reimbursement for TCM services during this period. These errors occurred because the State agency did not have adequate policies and procedures in place to ensure that the TCM services it claimed were allowable for Medicaid reimbursement in accordance with Federal requirements.

We recommended that the State agency (1) refund $349,000 to the Federal Government for claims for unallowable TCM services; (2) work with the Centers for Medicare & Medicaid Services to determine the allowability of the estimated $862,000 (Federal share) in claims for potentially unallowable TCM services; and (3) strengthen its policies and procedures to ensure that it claims Medicaid reimbursement only for TCM services that are allowable in accordance with Federal requirements, are adequately supported, and do not include unallowable TCM services on the same claims with allowable services.

Filed under: Center for Medicare and Medicaid Services