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(The Center Square) – About $41 million in Georgia’s Medicaid and PeachCare claims were inadequately screened, leaving the programs susceptible to fraud and potential overpayments by the state, a recent state audit found.
The lack of coordinated oversight of the programs between 2013 and 2019 could also lead to the state paying more to managed care organizations (MCOs).
“Efforts to detect, prevent, and address fraud and abuse within the Georgia Medicaid and PeachCare programs occur in siloed functional areas within DCH [The Georgia Department of Community Health] and its four MCOs, causing those efforts to be fragmented and uncoordinated,” the state auditor’s office said.
DCH oversees the partially federal-funded programs that provide health insurance for low-income Georgians. Participants are either covered directly through the department or through a partnership with four MCOs.
Instead of paying medical providers for each service, the state pays premiums to MCOs for each program participant.
In fiscal year 2019, nearly 75 percent, or 1.5 million, Medicaid and PeachCare enrollees were insured through the MCOs.
State funds were used to pay $4.4 billion in premium payments to the companies, more than 41 percent of its total Medicaid and PeachCare expenses.
The U.S. Centers for Medicare & Medicaid Services (CMS) requires states to have a process that detects and prevents fraud and abuse cases. The MCOs are also required to screen claims for the same issues. However, the state auditor said the process allowed several claims to slip through.
“DCH has not analyzed the MCOs’ activity reports to identify trends or baseline data that could help DCH develop program integrity standards or goals. After reviewing these reports, we found that activity levels and outcomes varied among MCOs; however, without defined performance goals, we cannot determine whether MCOs’ efforts have been sufficient or effective.”
Some of the reports were incomplete and or contained inconsistencies, the audit also found.
“Because DCH does not review the quality of these reports, the deficiencies we observed had not been identified or addressed by DCH management,” the state auditor’s office wrote.
State auditors said the department needs to implement a structured process for both fee-for-service and MCO claims and select a point-person such as a program integrity director to oversee it.
The General Assembly also needs to change state law to give MCOs more time to conduct post-payment audits and recover overpayments, auditors said.
Current law gives MCOs 18 to 24 months to recover the overpayments, while the fee-for-service overpayment can be recovered after three years.
“These improvements should help reduce Medicaid overpayments and reduce the state’s managed care premium costs,” auditors wrote.
DCH agreed with most of the state auditor’s recommendations and has already started to work to improve oversight.