Maine Did Not Always Claim Federal Medicaid Reimbursement for Clinical Diagnostic Laboratory Services in Accordance With Requirements

The Maine Department of Health and Human Services, Office of MaineCare Services (State agency), did not always claim Federal Medicaid reimbursement for clinical diagnostic laboratory services in accordance with Federal and State requirements. Of the 1,151,170 services that we reviewed, the Medicaid payments that the State agency made for 795,812 services did not exceed the amounts allowed by Federal and State requirements. However, for 355,358 services, the State agency paid providers more than they would have been paid under the Medicare program or more than the amounts allowed by State regulations. As a result, the Federal reimbursement that the State agency claimed exceeded the rates allowed by Federal and State requirements by $3.5 million ($2.5 million Federal share).

The Medicaid overpayments occurred because the State agency did not always follow its policies and procedures to ensure that the amounts claimed for hospital outpatient and independent clinical laboratory services did not exceed the amounts that would have been paid under the Medicare program or the amounts allowed by State regulations.

We recommended that the State agency (1) refund $2.5 million to the Federal Government and (2) follow its policies and procedures to ensure that the amounts claimed for hospital outpatient and independent clinical laboratory services do not exceed the amounts that would be paid under the Medicare program or the amounts allowed by State regulations.