Nebraska Claimed Almost All Medicaid Payments for Targeted Case Management Services in Accordance With Federal Requirements but Claimed Some Unallowable Duplicate Payments

Why OIG Did This Audit

Targeted Case Management (TCM) services assist specific State-designated Medicaid groups in gaining access to medical, social, educational, and other types of services. Previous Office of Inspector General audits found that some States did not always claim Federal Medicaid reimbursement for TCM services in accordance with Federal and State requirements.

Our objective was to determine whether Nebraska claimed Federal Medicaid reimbursement for TCM services during Federal fiscal years (FYs) 2016 through 2018 in accordance with Federal and State requirements.

How OIG Did This Audit

During this period, Nebraska processed claims totaling $87.7 million ($45.4 million Federal share) through the Medicaid Management Information System (MMIS), a computerized payment and information reporting system.

We reviewed documentation for a stratified random sample totaling 150 TCM paid claims to determine whether the services provided were allowable, recipients receiving services were eligible, and case managers providing services were qualified to do so. We also compared the rates paid to the payment rates that Nebraska approved for the months in which services were rendered.

What OIG Found

Nebraska claimed almost all Federal Medicaid reimbursement for TCM services during FYs 2016 through 2018 in accordance with Federal and State requirements. The 150 claims we sampled had no errors with respect to services provided, recipient eligibility, or provider qualifications.

However, 6 of the 150 sampled claims were not allowable because the claims had duplicate monthly payments. In these instances, a provider received two or more monthly payments on behalf of a single recipient in a single month, which resulted in a total payment amount that exceeded the approved monthly rate. Nebraska made 164 duplicate monthly payments during our audit period, which resulted in overpayments of $22,484 (Federal share). Nebraska made these duplicate payments because its system edits did not always prevent it from paying total monthly amounts that exceeded the approved monthly rates to providers on behalf of these recipients.

What OIG Recommends and Nebraska Comments

We recommend that Nebraska refund $22,484 (Federal share) in overpayments to the Federal Government and implement the necessary MMIS edits to prevent and detect duplicate payments.

Nebraska agreed with both of our recommendations and said that it would refund the $22,484 in overpayments to the Federal Government. Additionally, Nebraska described corrective actions that it had taken or planned to take to avoid future overpayments associated with duplicate payments. Specifically, Nebraska described the results of its analysis of the causes of the errors we identified. Nebraska also said that it had begun to implement necessary edits to prevent and detect duplicate payments in the future.