Application Controls at the New Hampshire Medicaid State Agency - Identification of Suspect Duplicate Claims

EXECUTIVE SUMMARY:

The objective of this review was to determine if the New Hampshire Medicaid Management Information System (MMIS) claims edit routine and subsequent resolution process for reviewing suspect duplicate claims are adequate.  The MMIS claims edit process is effective in identifying suspect duplicate claims; however, the claims resolution procedures are less than effective in determining the disposition of the duplicate claim - to either deny or pay.  Specifically, we determined that $548,740 ($274,370 Federal share) in suspect duplicate claims should not have been forced through the claims processing system for payment.  We recommended that the New Hampshire Medicaid State Agency (1) recover the potential overpayments, (2) revise and update the instructions and criteria used by claims resolution staff to review suspect duplicate payments, and (3) provide training to claims resolution staff for reviewing suspect duplicate claims.