Review of Medicaid Claims Made for Beneficiaries Under the Age of 21/22 Who Reside in Institutions for Mental Diseases in the Commonwealth of Pennsylvania

EXECUTIVE SUMMARY:

The objective of our review was to determine if controls were in place to preclude the Commonwealth from claiming Federal financial participation (FFP) under the Medicaid program for all medical services, except inpatient psychiatric services, provided to residents of institutions for mental diseases (IMDs) under the age of 21/22.  For the review period from July 1, 1998 through June 30, 2001, we determined that the Commonwealth made 69,801 improper Medicaid claims totaling $1,694,148 FFP for patients who were under the age of 21/22 and were residents of IMDs.  We recommended that the Commonwealth (1)  refund $1,694,148 to the Federal Government, (2)  implement controls to prevent FFP from being claimed for medical services, other than inpatient psychiatric services, provided to IMD residents under the age of 21/22, (3) issue written guidance to medical providers and IMDs advising that all medical services provided to IMD residents should be billed directly to the IMDs, (4)  establish procedures to identify all Medicaid recipients under the age of 21/22 who are admitted to an IMD, and (5) identify and refund to the Federal Government any improper FFP claimed for the period subsequent to our June 30, 2001 audit cutoff date. The Commonwealth generally disagreed with our findings and recommendations.