Medicaid Fee-for-Service Payments for Services on Behalf of Beneficiaries Enrolled in Medicare Health Maintenance Organizations

EXECUTIVE SUMMARY:

This final report points out that Florida made Medicaid payments to providers for services to dually eligible beneficiaries that should have been covered by Medicare health maintenance organizations (HMOs). Based on a statistical sample, we estimate improper Medicaid payments of at least $2.6 million (Federal share) in calendar year 1996 for medical services and supplies that should have been paid by the Humana HMO. Based on another statistical sample, we estimate improper Medicaid payments at $6.2 million (Federal share) in 1996 that should have been paid by an additional 50 Medicare HMOs in Florida. The improper payments occurred because the Florida Medicaid agency did not utilize Medicare coverage data from a Health Care Financing Administration (HCFA) database to identify beneficiaries who were enrolled in Medicare HMOs and preclude Medicaid payments for services covered by the HMOs. We recommended financial adjustments and procedural corrections. The State has taken steps to add the Medicare coverage data from the HCFA database to the State's third party resource database.