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Colorado Made Capitation Payments to Managed Care Organizations After Enrollees’ Deaths

Issued on  | Posted on  | Report number: A-07-21-05132

Why OIG Did This Audit

  • Colorado pays Medicaid managed care organizations (MCOs) for health care services provided to Medicaid enrollees; in return, MCOs receive a monthly fixed payment for each enrollee (capitation payment).
  • Previous OIG audits found that other States had improperly paid capitation payments on behalf of deceased enrollees.
  • This audit of Colorado is one of a series that examines whether States made capitation payments to MCOs on behalf of deceased enrollees.

What OIG Found

Colorado made unallowable capitation payments to MCOs on behalf of deceased enrollees, whose dates of death preceded the service periods covered by the monthly capitation payments. Specifically:

  • Of the 120 capitation payments in our stratified random sample, 109 payments were made on behalf of deceased enrollees whose dates of death preceded the service period covered by the monthly capitation payment.
  • We also identified almost 39,000 unallowable capitation payments that Colorado made on behalf of deceased enrollees even though their dates of death were accurately recorded in the State’s eligibility system.

Accordingly, we estimated that Colorado made at least $3.8 million (Federal share) in unallowable capitation payments to MCOs on behalf of deceased enrollees. In addition, Colorado incorrectly reported other Medicaid expenditures to CMS totaling over $2.2 million (Federal share).

What OIG Recommends

We make six recommendations to Colorado, including that it refund an estimated $6.0 million to the Federal Government. The full recommendations are in the report.

Colorado agreed with three of our recommendations and partially agreed with one of our monetary recommendations. Colorado disagreed with our remaining two recommendations but described corrective actions that it had taken or planned to take to address all of our recommendations.

25-A-07-044.01 to CMS - Open Unimplemented
Update expected on 08/13/2025
We recommend that the Colorado Department of Health Care Policy and Financing refund $6,012,198 to the Federal Government, consisting of $3,509,358 (Federal share) of capitation payments made on behalf of deceased enrollees who had a date of death recorded in SSA's DMF but not in the State agency's eligibility system; $293,890 (Federal share) of capitation payments made on behalf of deceased enrollees who had a date of death recorded in SSA's DMF and in the State agency's eligibility system; and $2,208,950 (Federal share) in other Medicaid expenditures that the State agency had previously overreported.

25-A-07-044.02 to CMS - Open Unimplemented
Update expected on 08/13/2025
We recommend that the Colorado Department of Health Care Policy and Financing identify and recover unallowable capitation payments made to MCOs during our audit period on behalf of deceased enrollees who did not have a date of death recorded in the State agency's eligibility system but who did have a date of death recorded in the DMF, which we estimate to be at least $6,737,760.

25-A-07-044.03 to CMS - Open Unimplemented
Update expected on 08/13/2025
We recommend that the Colorado Department of Health Care Policy and Financing recover unallowable capitation payments totaling $582,406 that were made to MCOs during our audit period on behalf of deceased enrollees who did have a date of death recorded in the State agency's eligibility system.

25-A-07-044.04 to CMS - Open Unimplemented
Update expected on 08/13/2025
We recommend that the Colorado Department of Health Care Policy and Financing identify and recover unallowable capitation payments made on behalf of deceased enrollees after our audit period and repay the Federal share of any amounts recovered.

25-A-07-044.05 to CMS - Open Unimplemented
Update expected on 08/13/2025
We recommend that the Colorado Department of Health Care Policy and Financing strengthen internal controls, to include strengthening policies and procedures on identifying and verifying date-of-death information, so that the State agency's eligibility system is updated based on information provided by data sources, and that capitation payments that have been made on behalf of verified deceased enrollees are recovered.

25-A-07-044.06 to CMS - Open Unimplemented
Update expected on 08/13/2025
We recommend that the Colorado Department of Health Care Policy and Financing strengthen policies and procedures for the accurate reporting of all Medicaid expenditures to CMS, to include strengthening the State agency's procedures for the routine reconciliation of information provided by the State agency's fiscal data vendor, so that only actually incurred Medicaid expenditures are reported on the Forms CMS-64 to CMS.

View in Recommendation Tracker

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