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Fraud, Abuse, Or Retaliation
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Washington State Did Not Comply With Federal and State Requirements for Claiming Enhanced Federal Reimbursement for Medicaid Managed-Care Health Home Service Expenditures

Submitting OIG: 
Department of Health & Human Services OIG
Date Issued: 
Friday, May 13, 2022
Agency Reviewed / Investigated: 
Department of Health & Human Services
Submitting OIG-Specific Report Number: 
A-09-20-02008
Component, if applicable: 
Centers for Medicare & Medicaid Services
Centers for Medicare and Medicaid Services
External entity, if applicable: 
Washington State Health Care Authority
Location(s): 
WA,
United States
Type of Report: 
Audit
Questioned Costs: 
$403,740
Funds for Better Use: 
$0
Number of Recommendations: 
8
View Document: 
AttachmentSize
PDF icon 92002008.pdf1.77 MB

Related Open Recommendations

Recommendation Number Recommendation Status Significant Recommendation Additional Details
22-A-09-055.03 Open No
We recommend that the Washington State Health Care Authority determine the portion of the remaining $1,367,120 that should have been claimed for managed-care health home service expenditures based on the portion of the MCOs' capitation payment rate that was specifically attributable to health home services, and refund any unallowable amounts.
22-A-09-055.04 Open No
We recommend that the Washington State Health Care Authority review all managed-care health home encounters from July 1, 2013, through March 31, 2017, to determine the enhanced Federal reimbursement that should have been claimed for Medicaid managed-care health home service expenditures based on the portion of the MCOs' capitation payment rate that was specifically attributable to health home services and refund to the Federal Government any unallowable amounts.
22-A-09-055.05 Open No
We recommend that the Washington State Health Care Authority review all managed-care health home encounters from July 1, 2013, through March 31, 2017, to identify whether the encounters used to support claims for enhanced Federal reimbursement have since been removed from the encounter data and refund to the Federal Government any amounts that are no longer supported.
22-A-09-055.06 Open No
We recommend that the Washington State Health Care Authority review all managed-care health home encounters from July 1, 2013, through March 31, 2017, to identify whether the encounters exceeded the number of reportable encounters that were allowed for an enrolled beneficiary and refund to the Federal Government any amounts related to unallowable encounters.
22-A-09-055.07 Open No
We recommend that the Washington State Health Care Authority implement a procedure to identify whether encounters used to support journal vouchers have been removed from the encounter data and refund to the Federal Government any Federal reimbursement that was claimed and is no longer supported.
22-A-09-055.08 Open No
We recommend that the Washington State Health Care Authority strengthen its MMIS edits to limit the reporting of an encounter for a tier-1 health home service to only once in a beneficiary's lifetime and ensure that only one encounter per beneficiary is reported each month.
Displaying 6 of 6 Recommendations