Ohio Medicaid Long- Term-Care Payments to Two Providers for the Same Beneficiaries for the Same Dates of Services

The DHHS Office of the Inspector General conducted an audit of the Ohio Medicaid long-term care payments for the period October 1, 1998 through September 30, 2005. During the audit period, the State agency paid $70,644,566 ($41,157,524 Federal share) to 3,100 long-term-care providers (1,550 provider pairs) for services provided to the same beneficiaries for the same dates of service. The State agency should not have paid two different providers for services provided to the same beneficiares for the same dates of service unless one of the providers fuished services that were not reimbursed through the long-term-care daily rate. Of a judgmental sample of 100 providers (50 pairs claiming services for the same beneficiaries for the same dates of service) that were paid $38,783,184 ($22,595,083 Federal share), the Statefor the same dates of State agency appropriately claimed $20,699,649 ($12,059,616 Federal share) and paid 52 providers for long-term-care services. However, the State agency nappropriately claimed $18,083,535 ($10,535,467 Federal share) and paid 48 providers that did not provide medical assistance to Medicaid beneficiaries. Of the unallowable payments totaling $18,083,535 ($10,535,467 Federal share), the State agency, as of the start of our audit in July 2007, reported and refunded $8,446,697 ($4,921,045 Federal share) through adjustments decreasing its Medicaid claims for prior quarters on the CMS-64 for the quarter ended June 30, 2005, and had not reported and refunded $9,636,838 ($5,614,422 Federal share). The State agency made the unallowable payments because it did not implement controls within its automated payment system to identify payments to two providers for services claimed for the same beneficiaries for the same dates of service. In addition, the State agency’s policies and procedures for reporting and refunding previous overpayments on the CMS-64 did not ensure the identification of all the unallowable payments.