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Audit of Medicaid Payments of Deceased Beneficiaries in Florida, A-04 -03-07029

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19 pages
Offlce of Inspector General DEPARTMENT OF HEALTH & HUMAN SERVICES Washington, D.C. 20201 JUL 2 7 2005 TO: Dennis G. Smith Director, Center for Medicaid and State Operations , Mv7 Services FROM: for Audit Services SUBJECT: Audit of Medicaid Payments for Deceased Beneficiaries in Florida (A-04-03-07029) Attached is an advance copy of our final report on Medicaid payments for deceased beneficiaries in Florida. We will issue this report to Florida within 5 business days. Our objective was to identify any Medicaid overpayments resulting from payments to providers for medical services claimed to have been rendered after the month in which a beneficiary died. The State made Medicaid payments for medical services claimed to have been rendered after the month of a beneficiary's death. Specifically, for a sample of 200 Medicaid payments made on behalf of eligible beneficiaries who died during our audit period, the State made 48 payments after the beneficiaries' deaths that amounted to $15,765 ($8,811 Federal share). Based on our sample, we estimated that Medicaid claims paid in Florida for services after death totaled $1 1.6 million ($6.5 million Federal share) during the audit period (October 1, 1998, to September 30,2001). The State paid for services claimed to have been performed after death and did not recover some of these overpayments because it did not have adequate payment controls for the prevention, identification, and recovery of payments after a ...
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 Page 2 Dennis G. Smith   If you have any questions or comments about this report, please do not hesitate to call me, or your staff may contact George M. Reeb, Assistant Inspector General for the Centers for Medicare & Medicaid Audits, at (410) 786-7104 or Lori S. Pilcher, Regional Inspector General for Audit Services, Region IV, at (404) 562-7750. Please refer to report number A-04-03-07029 in all correspondence.  Attachment  
Page 2 – Mr. Alan Levine   Direct Reply to HHS Action Official:  Renard Murray, Associate Regional Administrator Division of Medicaid and Children’s Health Centers for Medicare & Medicaid Services 61 Forsyth Street, SW., Suite 4T20 Atlanta, Georgia 30303-8909
 Department of Health and Human Services OFFICE OF INSPECTOR GENERAL  
 
 
       A UDIT OF M EDICAID P AYMENTS FOR D ECEASED B ENEFICIARIES  IN F LORIDA     
 
 
 Daniel R. Levinson Inspector General  JULY 2005 A-04-03-07029  
 
  
 
 
 
Office of Inspector General http://oig.hhs.gov
 The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended, is to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as the health and welfare of beneficiaries served by those programs. This statutory mission is carried out through a nationwide network of audits, investigations, and inspections conducted by the following operating components:  Office of Audit Services OIG’s Office of Audit Services (OAS) provides all auditing services for HHS, either by conducting audits with its own audit resources or by overseeing audit work done by others. Audits examine the performance of HHS programs and/or its grantees and contractors in carrying out their respective responsibilities and are intended to provide independent assessments of HHS programs and operations in order to reduce waste, abuse, and mismanagement and to promote economy and efficiency throughout HHS.  Office of Evaluation and Inspections  OIG’s Office of Evaluation and Inspections (OEI) conducts short-term management and program evaluations (called inspections) that focus on issues of concern to HHS, the Congress, and the public. The findings and recommendations contained in the inspections reports generate rapid, accurate, and up-to-date information on the efficiency, vulnerability, and effectiveness of departmental programs. OEI also oversees State Medicaid fraud control units, which investigate and prosecute fraud and patient abuse in the Medicaid program.  Office of Investigations  OIG’s Office of Investigations (OI) conducts criminal, civil, and administrative investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of unjust enrichment by providers. The investigative efforts of OI lead to criminal convictions, administrative sanctions, or civil monetary penalties. Office of Counsel to the Inspector General  The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, rendering advice and opinions on HHS programs and operations and providing all legal support in OIG’s internal operations. OCIG imposes program exclusions and civil monetary penalties on health care providers and litigates those actions within HHS. OCIG also represents OIG in the global settlement of cases arising under the Civil False Claims Act, develops and monitors corporate integrity agreements, develops compliance program guidances, renders advisory opinions on OIG sanctions to the health care community, and issues fraud alerts and other industry guidance.    
EXECUTIVE SUMMARY
BACKGROUND  Medicaid is a jointly funded Federal-State health program for eligible low-income and needy individuals. The Centers for Medicare & Medicaid Services provides Federal oversight of the Medicaid program. In Florida, the Agency for Health Care Administration (the State Medicaid agency) administers the program.  To administer its programs, the Social Security Administration (SSA) maintains comprehensive death record information by purchasing death certificate information from State governments and obtaining death notifications from funeral homes and from friends and family of the deceased. All reported deaths of people who have Social Security numbers are routinely added to SSA’s Death Master File. This information is available to State and Federal agencies as a way to prevent payments for services claimed to have been rendered after a beneficiary’s death.  In calendar years 1997, 1998, and 1999, the Florida State Auditor issued a series of reports identifying $7.2 million in Medicaid overpayments for services shown as provided after a beneficiary’s death. The State Medicaid agency recovered $5 million, leaving an outstanding balance of $2.2 million.  In 2002, the State Medicaid agency determined that the most cost-effective and efficient method to recover payments made to providers after a beneficiary’s reported date of death was to use the services of a third-party liability contractor, Health Management Systems (the contractor). The contractor identified and recovered $2.9 million in additional overpayments for calendar years 1998 through 2001.  OBJECTIVE  Our objective was to identify any Medicaid overpayments resulting from payments to providers for medical services claimed to have been rendered after the month in which a beneficiary died.  SUMMARY OF FINDINGS  The State made Medicaid payments for medical services claimed to have been rendered after the month of a beneficiary’s death. Specifically, for a sample of 200 Medicaid payments made on behalf of eligible beneficiaries who died during our audit period, the State made 48 payments after the beneficiaries’ deaths that amounted to $15,765 ($8,811 Federal share). Based on our sample, we estimated that Medicaid claims paid in Florida for services after death totaled $11.6 million ($6.5 million Federal share) during the audit period (October 1, 1998, to September 30, 2001).  The State paid for services claimed to have been performed after death and did not recover some of these overpayments because it did not have adequate payment controls for the prevention, identification, and recovery of payments after a beneficiary’s death.   
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RECOMMENDATIONS  We recommend that the State:   review our sampling universe to identify and recover, where appropriate, overpayments estimated at $11.6 million ($6.5 million Federal share) made on behalf of deceased beneficiaries and  improve its procedures for identifying deceased beneficiaries to prevent overpayments in the future.  STATE MEDICAID AGENCY’S COMMENTS   In response to our draft report, the State Medicaid agency agreed to implement the recommendations.  
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 TABLE OF CONTENTS  
 Page INTRODUCTION ..............................................................................................................1   BACKGROUND.....................................................................................................1   OBJECTIVE, SCOPE, AND METHODOLOGY ...................................................1  Objective ......................................................................................................1  Scope............................................................................................................2  Methodology ................................................................................................2  FINDINGS AND RECOMMENDATIONS .…………………………………………... 3   OVERPAYMENTS TO PROVIDERS....................................................................3  Overpayments Not Identified by the Florida Auditor General or  Recovered by the State Medicaid Agency .............................................4  Overpayments Not Identified or Recovered by the Contractor ...................4  Summary of Overpayments .........................................................................4       CAUSE OF OVERPAYMENTS.............................................................................4   RECOMMENDATIONS.........................................................................................5   STATE MEDICAID AGENCY’S COMMENTS ...................................................5   APPENDIXES A – SAMPLING METHODOLOGY                                                                              B – SAMPLE RESULTS AND PROJECTIONS  C – STATE MEDICAID AGENCY’S COMMENTS
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INTRODUCTION
 BACKGROUND  Medicaid (Title XIX of the Social Security Act) is a jointly funded Federal-State health program for eligible low-income and needy individuals. Medicaid covers approximately 41 million individuals, including children; the aged, blind, and/or disabled; and people who meet the criteria to receive federally assisted income maintenance payments. The Centers for Medicare & Medicaid Services provides Federal oversight of the Medicaid program. In Florida, the Agency for Health Care Administration (the State Medicaid agency) administers the program. During the State’s fiscal years (FYs) 1998 through 2001, Medicaid medical assistance payments totaled $29.3 billion ($16.5 billion Federal share and $12.8 billion State share).  To administer its programs, the Social Security Administration (SSA) maintains comprehensive death record information by purchasing death certificate information from State governments and obtaining death notifications from funeral homes and from friends and family of the deceased. All reported deaths of people who have Social Security numbers are routinely added to SSA’s Death Master File. This information is available to State and Federal agencies as a way to prevent payments for services claimed to have been rendered after a beneficiary’s death. In calendar years 1997, 1998, and 1999, the State Medicaid agency did not have a process in place to identify Medicaid payments for medical services claimed to have been rendered after a beneficiary’s death. Medical services included services provided by hospitals, health maintenance organizations, pharmacies, and nursing homes. During the same 3 years, the State Auditor issued a series of reports identifying $7.2 million in Medicaid overpayments for services shown as provided after a beneficiary’s death for the period February 1997 through December 1999. The State Medicaid agency has recovered $5 million for claims made during this period, leaving an outstanding balance of $2.2 million. In the spring of 2002, the State Medicaid agency determined that the most cost-effective and efficient method to recover payments made to providers after a beneficiary’s reported date of death was to use the services of a third-party liability contractor, Health Management Systems (the contractor). The contractor identified and recovered $2.9 million in additional overpayments from health maintenance organizations, nursing homes, and hospitals for calendar years 1998 through 2001. For its efforts, the State Medicaid agency paid the contractor 4.85 percent of the amount it recovered.  OBJECTIVE, SCOPE, AND METHODOLOGY  Objective  Our objective was to identify any Medicaid overpayments resulting from payments to providers for medical services claimed to have been rendered after the month in which a beneficiary died.  
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