OIG audits fee-for-service claims for pregnant women with Medicaid
The Audit and Inspections Division reviewed Health and Human Services Commission Information Technology section to determine if delays in communicating enrollee information from the Medicaid for Pregnant Women program resulted in fee-for-service payments made for items covered by managed care organizations during state fiscal year 2019.
OIG discovered that managed care enrollment information was not confirmed or transmitted within 60 days for 1,788 of 19,698 (nine percent) individuals in the Medicaid for Pregnant Women program during the scope of this audit. The nine percent of non-timely enrollees led to Texas Health and Human Services issuing retroactive capitation payments totaling $3,721,939 for periods in which it also paid fee-for-service claims totaling $1,409,762 for pregnancy related care.
OIG has issued recommendations to the Medicaid and CHIP Services and Health and Human Services Information Technology to reduce overpayment in the future which have been agreed to by the audited sections. For more information find the full audit here.