Health and Human Services
An Audit Report on Medicaid Long-Term Care Claims Data
at the Department of Human Services
January 2002
Report Number 02-018
Overall Conclusion
The Department of Human Services has not complied with certain federal and
state requirements in its processing of Medicaid long-term care claims.
We tested key processes in the automated Claims Management System by analyzing
all payments made during January 2001. During January 2001, the Department of
Human Services processed $287.5 million in Medicaid long-term care claims together
with its contractor, National Heritage Insurance Corporation.
Key Facts and Findings
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The Department has not complied with Code of Federal Regulations, Title 42, Section 447.75, which requires the Department to require providers to submit all claims no later than 12 months from the date of service. We identified 6,681 payments totaling $5.0 million for which the claim submission date was more than 365 days after the date of service.
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The Department has paid for services provided on the same date to the same client by two different programs, contrary to its policies and procedures. We identified 240 occurrences of overlapping claims totaling $379,114. We estimate the associated questionable payments range from $30,929 to $348,184.
Contact the SAO about this report.
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