Medical benefits administration needs better controls to protect against fraud, audit finds

By Megan Poinski

Widespread lack of accountability may have led to millions of dollars wasted by the Medical Care Programs Administration of the Department of Health and Mental Hygiene, an audit released Monday found.

The medical administration spent $6.8 billion to provide low-income residents with health care benefits like Medicaid in the last fiscal year. The General Assembly’s Joint Audit Committee will review the audit this afternoon (Tuesday).

The Office of Legislative Audits found 14 places where the program administration could improve its controls to ensure that money is spent correctly and to keep employees and others from defrauding the agency.  Auditors did not identify any potential fraud, but Legislative Auditor Bruce Myers said that the agency needs to make some changes.

“I think there are some big issues that need to be addressed, especially because the agency handles so much money,” Myers said. “If you change a few things, you can do a lot and save a lot of money.”

One of the biggest issues is fixing problems with the system that determines whether a person is eligible for medical assistance. Responsibility for determining eligibility is split between the medical agency and the Department of Human Resources, with MCPA establishing the regulations, guidelines  and procedures, and Human Resources determining who is eligible. The memorandum of understanding that divvied up the responsibilities, the audit states, has not been updated since 1985 and creates problems for both agencies.

Multiple payments

MCPA, for example, cannot keep an eye out for clients who have multiple recipient numbers, and who may therefore be getting multiple payments. Auditors found that there were 424 people who had multiple numbers. In a field test of 11, nine of them were overpaid a total of $63,000.

Auditors found that there were other data that wasn’t adequately verified, including data on medical visits and risk factors for Medicare patients in the HealthChoice program. This resulted in claims being submitted without documentation of visits, and almost 15 percent of medical records not matching MCPA data. Additionally, MCPA did not thoroughly investigate cost recovery methods of contractors using the HealthChoice program to make sure they were doing what they could to keep their costs down.

The division also failed to double-check that appropriate amounts were being spent in two volatile areas. One was repayment to Medicaid recipients who also had Medicare coverage – resulting in at least 372 claims where providers were overpaid $231,000. There was also no procedure in place to ensure that prescription drug prices were not inflated. In fiscal year 2009, the program spent $271 million on drugs.

Auditors also pointed out that the medical care agency had not implemented several policy recommendations made by the department’s inspector general to improve controls over the Kidney Disease Program after a former employee was convicted of embezzling nearly $1.8 million. These changes, which included requiring that claims are approved by a supervisor and verifying third-party insurance payments, should be made as soon as possible to prevent future fraud, auditors wrote.

Other problems identified in the audit include:

·         Allowing inmates to process sensitive information, including recipients’ Social Security numbers.

·         Not making sure claim adjustments were legitimate.

·         Not adequately reviewing provider applications.

·         Lack of records of cost settlements with long-term care facilities. MCPA contracted these duties to a vendor, which did not provide adequate information.

·         Not providing adequate monitoring of the Transportation Grant Program, which the state spent $32 million on during fiscal year 2009.

·         Inadequate security on a computer system that allows health care providers to electronically submit Medicaid claims.

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