From several state audits revealing Medicaid billing errors to an attorney general accusing UnitedHealth of inflating drug costs, here are eight recent stories involving improper Medicaid reimbursements:
New Jersey recovers $9M in unspent funds from Medicaid provider
New Jersey's Medicaid program recovered $9 million in a settlement with provider Community Access Unlimited in April. The settlement comes after a 2017 audit from the New Jersey comptroller's office found that Community Access Unlimited improperly kept millions in unspent public funds that it was required to return. The provider returned $7.8 million in unspent funds.
California improperly reimbursed $23M for opioid treatments
An audit from the HHS Office of the Inspector General estimated California improperly claimed at least $23.1 million in Medicaid reimbursement for opioid treatment services from January 2018 through December 2019. The state received $259.8 million in federal reimbursements during that span.
Louisiana attorney general accuses UnitedHealth of inflating drug costs
Louisiana's attorney general filed a lawsuit against UnitedHealth, alleging the payer inflates prescription drug charges in the state's Medicaid program. The lawsuit accused UnitedHealth's pharmacy benefits manager, Optum Rx, of using secret prices and the complexity of the supply chain to cause the Medicaid program to needlessly pay billions of dollars more per year for prescription drug benefits.
New York Medicaid audit finds $965M in billing errors
New York's Medicaid program erroneously paid out $965 million in claims over four years. The audit looked at claims made from January 2015 to December 2019. Auditors found the state's Medicaid claims-processing system allowed improper payments for services involving ordering, prescribing, referring and attending providers who were no longer actively enrolled in the Medicaid program at the time of the service.
Anthem ordered to pay $4.5M to Indiana hospitals over ER billing issues
A federal arbitrator ordered Anthem to pay $4.5 million to a group of 11 Indiana hospitals. Anthem said it complied with the order, but the hospitals say they could ask for $12 million more. The case involved contracts between Anthem and the hospitals to cover Medicaid patients. The payer's reimbursement system identified emergency room claims from the hospitals and matched them with approved diagnosis codes. For claims that didn't align with approved codes, Anthem charged a triage fee between $50 and $70 and asked the provider to submit additional patient records to avoid denial. The arbitrator ruled that Anthem must stop using their list of diagnostic codes to downgrade or deny the hospitals' claims.
Kansas paid out $193M in ineligible Medicaid claims
Kansas paid managed care organizations $193 million for idle home and community-based service program beneficiaries, the Medicaid inspector general reported April 13. The audit covered services delivered to Medicaid enrollees in home- and community-based service programs from January 2018 through April 2021.
Centene subsidiary must pay $9.1M fine after missing challenge deadline
Sunshine State Health Plan, a subsidiary of Centene based in Tampa, Fla., paid a $9.1 million fine over software problems that caused nearly three months of delayed payments to providers. The billing software glitch affected 121,227 health claims of patients under 21 who were enrolled in the Sunshine Health Medicaid program and the Children's Medical Services Health Plan it operates on behalf of the Florida Department of Health.
Oregon to pay $22.5M to settle Medicaid provider's lawsuit
Oregon has agreed to pay $22.5 million to settle a years-long legal dispute with a provider of care to Medicaid patients. An amended complaint filed in April 2021 alleged repeated issues with how the state decided the provider's rates. It alleged the rates were lower than that of any other coordinated care organization from 2015-17. The company stated in the lawsuit that the low rates forced it to stop providing services to Medicaid patients in early 2018.