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California Improperly Claimed Enhanced Federal Reimbursement for Medicaid Family Planning Services Provided in San Diego County

The California Department of Health Care Services (State agency) did not always comply with certain Federal and State requirements when claiming Federal reimbursement at the 90-percent rate for family planning services provided under the Family Planning, Access, Care, and Treatment (FPACT) program in San Diego County. As a result, the State agency claimed $5.7 million in unallowable Federal reimbursement. Federal law and regulations authorize Federal Medicaid reimbursement to States for family planning services at an enhanced Federal medical assistance percentage (FMAP) of 90 percent.

Of the 110 sampled claim lines, 81 complied and 29 did not comply with requirements. Of the 29 claim lines, 23 were ineligible for reimbursement because the primary purpose of the visit was not family planning, 4 were eligible for reimbursement only at the regular FMAP because they were for followup visits, and 2 were ineligible for reimbursement because of insufficient documentation. Of the $89,000 we reviewed separately, the State agency claimed $66,000 in unallowable Federal reimbursement for claim lines that contained either no procedure code or a procedure code that was not approved by CMS for reimbursement at the 90 percent rate.

We recommended that the State agency (1) refund $5.7 million to the Federal Government, (2) establish billing procedures to ensure that only services whose primary purpose is family planning are claimed for reimbursement at the 90-percent rate, and (3) establish Medicaid Management Information System edits to ensure that family planning claims meet Federal and State requirements for reimbursement at the 90-percent rate and at the regular FMAP for followup visits. The State agency agreed with our recommendations and provided information on actions that it had taken or planned to take to address our recommendations.

Filed under: Center for Medicare and Medicaid Services