West Virginia may have paid managed care organizations up to $32.4 million for ineligible Medicaid participants, according to an October audit report.
The audit examined payments from 2019 to 2020 and was inspired by Louisiana audits involving Aetna. MCOs get a monthly capitation payment based on each member. West Virginia’s Bureau for Medical Services is supposed to alert MCOs when a Medicaid participant loses eligibility. This should shift calculations of capitation payments.
After reviewing multiple data sets with discrepancies, the auditors eventually found roughly $31.7 million in possible overpayments for 117,447 incarcerated individuals and $770,000 for 15,346 deceased people.
The Bureau for Medical Services has started to correct overpayments and make changes to avoid future issues, the report said.
At the Becker's 5th Annual Fall Payer Issues Roundtable, taking place November 2–3 in Chicago, payer executives and healthcare leaders will come together to discuss value-based care, regulatory changes, cost management strategies and innovations shaping the future of payer-provider collaboration. Apply for complimentary registration now.