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.
