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Audit (A-09-11-02010)

Oregon Improperly Claimed Federal Reimbursement for Medicaid Family Planning Services Provided Under the Family Planning Expansion Project

Executive Summary

Our review found that the Oregon Health Authority (State agency) claimed $1.7 million in unallowable Federal reimbursement for Medicaid family planning services provided under the Family Planning Expansion Project (Expansion Project) during the period October 1, 2006, through September 30, 2009.

The Expansion Project extends Medicaid coverage for family planning services to Oregon women and men who do not qualify for regular Medicaid and have family incomes at or below 185 percent of the Federal poverty level (Federal income limit). Because Expansion Project clients are not eligible for the regular Medicaid program, unallowable expenditures charged to the Expansion Project are unallowable in their entirety.

We reviewed a random sample selected from 401,486 claims totaling $56.4 million, and we separately reviewed 46,550 claims totaling $6.3 million. For 11 sampled claims, the State agency did not comply with Federal income eligibility requirements, or providers made billing errors. Based on our sample results, we estimated that the State agency claimed $1.4 million in unallowable Federal reimbursement. Of the $6.3 million that we reviewed separately, the State agency claimed $285,000 in unallowable Federal reimbursement for (1) clients who were not eligible to receive family planning services because they had family incomes that exceeded the Federal income limit or did not provide valid Social Security numbers or (2) claims that the State agency identified as duplicates. In addition, of the $6.3 million that we reviewed separately, the State agency did not verify clients' family incomes or Social Security numbers for claims totaling approximately $3 million (Federal share). Because the supporting documentation was not readily available for these claims, we have set aside this amount for resolution by the Centers for Medicare & Medicaid Services (CMS) and the State agency.

We recommended that the State agency (1) refund $1.7 million to the Federal Government, (2) work with CMS to resolve the $3 million that we set aside, (3) verify clients' family incomes and limit income eligibility in accordance with Federal requirements, (4) verify that Social Security numbers provided by clients are valid, and (5) strengthen controls to prevent and detect duplicate claims for family planning services. The State agency concurred with our recommendations.

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