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Missouri Claimed Some Unallowable Medicaid Payments for Targeted Case Management Services

The Missouri Department of Social Services (State agency) claimed Federal Medicaid reimbursement of at least $6 million (almost $3.8 million Federal share) for unallowable targeted case management (TCM) payments during Federal fiscal years 2014 and 2015. The State agency paid TCM providers and claimed unallowable Federal Medicaid reimbursement because its policies and procedures did not ensure that those providers complied with Federal and State requirements for documenting case managers' qualifications and for documenting and claiming TCM services. In addition, the State agency did not have policies and procedures to ensure that it correctly reported, in its claims for Federal Medicaid reimbursement, TCM paid claims it had recouped from a TCM provider.

Of the 155 randomly sampled TCM claims we reviewed, 21 claims had at least 1 error related to provider qualifications, unallowable services, unsupported services, or TCM paid claims that the State agency had recouped but which it incorrectly accounted for when claiming Federal reimbursement.

We recommended that the State agency refund almost $3.8 million to the Federal Government for unallowable TCM claims. We also made procedural recommendations to the State agency that it strengthen its policies and procedures (1) to ensure that TCM providers maintain documentation of case manager qualifications and to support the TCM services provided and (2) to ensure that the State agency does not pay TCM providers or claim Federal reimbursement for services that are not TCM services and correctly reports recoupment of TCM claims from providers.

After reviewing the State agency's comments and the additional documentation it provided, we revised, for this final report, the number of sampled claims in error that we identified, from 23 to 21 claims. Accordingly, we revised our statistical estimate and the dollar amount conveyed in our first recommendation. Although the State agency disagreed with all but two of the claims that we had found to be unallowable, we maintain that our findings and recommendations, as revised, are valid.

Filed under: Centers for Medicare and Medicaid Services