Medicaid Fee-for-Service Payments for Dually Eligible Medicare Managed Care Enrollees

February 7, 2003

EXECUTIVE SUMMARY:

The objectives of this review were to determine the appropriateness of Medicaid fee-for-service payments made on behalf of dually eligible beneficiaries enrolled in Medicare health maintenance organizations (HMO) and to ensure that services purchased from Medicare HMOs through capitation payments were not also paid by Medicaid through a capitation payment.  We found that the Florida Agency for Health Care Administration (FL-AHCA) made fee-for-service payments that were the responsibility of Medicare HMOs.  In addition, capitation payments were made to both Medicare and Medicaid HMOs on behalf of the same beneficiary.  This occurred because the Florida Medicaid Management Information System was not updated to reflect the enrollment of Medicaid beneficiaries in Medicare HMOs.  As a result, FL-AHCA made over $3.9 million in improper payments during our audit period ($2.2 million federal share).