Georgia Medicaid Managed Care Organizations Received Capitation Payments After Beneficiaries' Deaths

WHY OIG DID THIS REVIEW

Effective June 1, 2006, Georgia implemented Georgia Families, a managed care program between Georgia and private health plans to provide benefits and health care services to Medicaid, PeachCare for Kids members, Planning for Healthy Babies enrollees, and Georgia Families 360° members. As of July 2016, managed care covered approximately 69 percent of Georgia Medicaid beneficiaries. In State fiscal year 2018, the Georgia Medicaid expenditures for approximately 2 million beneficiaries were $9.9 billion, including $4 billion to managed care. Previous Office of Inspector General reviews identified internal control weaknesses and lack of documented policies and procedures that contributed to States improperly paying for capitation payments on behalf of deceased beneficiaries. We conducted a similar review in Georgia.

Our objective was to determine whether Georgia made capitation payments on behalf of deceased beneficiaries.

HOW OIG DID THIS REVIEW

We reviewed a random sample of 120 capitation payments that Georgia made to managed care organizations (MCOs) from July 1, 2009, through June 30, 2014, on behalf of deceased beneficiaries. We reviewed documentation to confirm whether the beneficiaries were deceased and limited our review to determining whether MCOs in Georgia received capitation payments on behalf of beneficiaries whose dates of death preceded the payment dates.

WHAT OIG FOUND

Georgia did not always stop making capitation payments after a beneficiary's death, despite its efforts to identify and recover any payments made after a beneficiary's death. Of the 120 capitation payments in our random sample, 2 payments were for beneficiaries who were still alive. For the remaining 118 payments, Georgia made payments totaling $109,252 ($82,362 Federal share) after a beneficiary's death.

On the basis of our sample results, we estimated that Georgia made payments totaling nearly $2.2 million ($1.6 million Federal share) after a beneficiary's death to MCOs during our audit period.

WHAT OIG RECOMMENDS AND GEORGIA COMMENTS

We recommend that Georgia (1) use additional sources of date of death to help reduce the risk of making payments after a beneficiary's death; (2) implement additional controls to more effectively detect payments involving deceased beneficiaries to reduce the risk of payments after a beneficiary's death; and (3) continue to identify payments made after a beneficiary's death to prevent additional payments similar to the $2.2 million identified in this report.

In written comments on our draft report, Georgia generally concurred with our findings and described actions it has taken or plans to take to address our recommendations.