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Report File
Date Issued
Submitting OIG
Department of Health & Human Services OIG
Other Participating OIGs
Department of Health & Human Services OIG
Agencies Reviewed/Investigated
Department of Health & Human Services
Report Number
A-03-16-00205
Report Description

Pennsylvania did not ensure that its managed-care organizations complied with Federal and State requirements prohibiting Medicaid payments to providers for inpatient hospital services related to treating certain provider-preventable conditions. For our audit period, we identified that managed-care organizations paid providers approximately $43.5 million for 576 claims that contained provider-preventable conditions.

Report Type
Audit
Agency Wide
Yes
Number of Recommendations
8
Additional Details
https://oig.hhs.gov/oas/reports/region3/31600205.asp

Open Recommendations

This report has 7 open recommendations.
Recommendation Number Significant Recommendation Recommended Questioned Costs Recommended Funds for Better Use Additional Details
267200 No $0 $0

Pennsylvania Department of Human Services work with the MCOs to determine the portion of the $43,524,609 that was unallowable for claims containing PPCs and its impact on current- and future-year capitation payment rates

267201 No $0 $0

Include a clause in its managed-care agreements with the MCOs that would allow the State agency to recoup Pennsylvania Department of Human Services funds from the MCOs when contract provisions and Federal and State requirements are not met—a measure that, if incorporated, could result in cost savings for Medicaid

267204 No $0 $0

Pennsylvania Department of Human Services require the MCOs to review all claims for inpatient hospital services that were paid after our audit period to determine whether any payments for services related to treating PPCs were unallowable and adjust future capitation payment rates for any unallowable payments identified

267205 No $0 $0

Pennsylvania Department of Human Services require its behavioral health MCOs to review all claims paid after our audit period for PPCs using all of the diagnosis codes submitted by the provider and determine whether any payments for services related to treating PPCs were unallowable and adjust future capitation payment rates for any unallowable payments identified

267202 No $0 $0

Pennsylvania Department of Human Services enforce the provisions in its managed-care agreements that allow sanctions or penalties to be imposed for noncompliance with or failure to meet performance and program standards indicated in the contract and subsequent related agreements

267206 No $0 $0

Pennsylvania Department of Human Services take steps to ensure that the MCOs comply with Federal and State requirements and its managed-care contracts relating to the nonpayment of PPCs

267203 No $0 $0

Pennsylvania Department of Human Services require the MCOs to: implement policies and procedures to prohibit payments for inpatient hospital services related to treating PPCs.

Department of Health & Human Services OIG

United States