Report Materials
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.
19-A-03-120.01 to CMS - Closed Implemented
Closed on
04/02/2025
We recommend that the 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.
19-A-03-120.02 to CMS - Closed Implemented
Closed on
02/03/2022
We recommend that the Pennsylvania Department of Human Services 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.
19-A-03-120.03 to CMS - Closed Implemented
Closed on
02/03/2022
We recommend that the 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.
19-A-03-120.04 to CMS - Closed Implemented
Closed on
02/03/2022
We recommend that the Pennsylvania Department of Human Services require the MCOs to implement policies and procedures to prohibit payments for inpatient hospital services related to treating PPCs.
19-A-03-120.05 to CMS - Closed Implemented
Closed on
02/03/2022
We recommend that the 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.
19-A-03-120.06 to CMS - Closed Implemented
Closed on
02/03/2022
We recommend that the 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.
19-A-03-120.07 to CMS - Closed Implemented
Closed on
02/03/2022
We recommend that the 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.
19-A-03-120.08 to CMS - Closed Implemented
Closed on
07/20/2022
We recommend that the Pennsylvania Department of Human Services ensure all inpatient hospitals submit POA codes as required in the State plan.
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Notice
This report may be subject to section 5274 of the National Defense Authorization Act Fiscal Year 2023, 117 Pub. L. 263.