Review of Medicaid Claims for School-Based Health Services in New Jersey

EXECUTIVE SUMMARY:

Our objective was to determine whether Federal Medicaid payments for school-based health services claimed by school health providers in New Jersey were in compliance with Federal and State requirements.  Of the 150 school-based claims in our statistical sample, 109 did not comply with Federal laws and regulations, State statute, or the Medicaid State plan.  Based on our sample, we estimated that $51,262,909 in Federal Medicaid funding was unallowable.  We also set aside certain claims containing transportation services for consideration by CMS and the State because Federal Medicaid law and regulations require that transportation services be documented but do not specify how the services should be documented.  Based on our sample, set-aside claims totaled an estimated $1,046,786 in Federal Medicaid funding. 

We recommended that the State: (1) refund $51,262,909 to the Federal Government, (2) work with CMS to resolve $1,046,786 in set-aside claims, (3) provide proper and timely guidance on Federal Medicaid criteria to its school health providers, (4) reinforce the need for school health providers to comply with Federal and State requirements, and (5) improve its monitoring of school health providers' claims to ensure compliance with Federal and State requirements.  In its written comments, the State asserted that it was currently unable to concur with our recommended financial adjustment of $51,262,909 but agreed to work with CMS to resolve all issues concerning the $1,046,786 in set-aside claims.  The State also described procedural improvements addressing the three remaining recommendations.