Review of The Maine Claims Management System

EXECUTIVE SUMMARY :

Our objective was to determine whether the State agency had effective controls to ensure that claims processed and adjudicated through the Maine Claims Management System (MECMS) from January 21, 2005, through December 31, 2005, were in compliance with Medicaid requirements.  We found the State agency did not establish effective controls to ensure that Medicaid claims were processed correctly and paid appropriately, and that all claim-related expenditures were reported accurately for Federal reimbursement. 

  We recommended the State agency reprocess all claims processed through MECMS after the CMS certifies the system; continue to reconcile interim payments; maintain supporting documentation; continue to ensure all MECMS claims processing and reporting controls are implemented; ensure that MECMS reporting controls adequately identify overpayments related to third party liability and over-utilization of services; ensure that all overpayments are reported within 60 days of discovery; and submit quarterly data from its Medicaid Statistical Information System to CMS after reprocessing the claims. The State agency generally concurred with our recommendations except for the recommendation to reprocess all claims after CMS certifies the system.