A much-hyped audit of the Arkansas Medicaid program by legislative auditors was delivered on Friday afternoon (Feb. 8) with fewer fireworks than promised.
Republican state lawmakers, who pushed for an early release of the Medicaid audit, had indicated more than a week ago that the report would show “hundreds of millions of dollars” of waste, fraud and abuse in the nearly $5 billion program.
The report, which was hotly contested by the Department of Human Services (DHS), re-hashed three years worth of older Medicaid auditing and included some findings from 2012. The Division of Legislative Audit conducted the 36-page review with the objective of examining eligibility requirements of Medicaid recipients and providers.
Some GOP lawmakers have contended that they have heard anecdotally of recipient abuse of the system and have used the need for reforming current programs as a reason to hold off consideration of an expansion of Medicaid – a policy move advocated by Gov. Mike Beebe (D) and notable Democratic legislators.
The audit is unlikely to move hardening positions in the Medicaid expansion debate. While legislative auditors reported discrepancies and deficiencies in the program, DHS officials refuted and disagreed with many of the audit findings.
Auditors disclosed in the opening of the report that “the methodology used in conducting this review was developed uniquely to address the stated objectives; therefore, this review was more limited in scope than an audit or attestation engagement performed in accordance with Government Auditing Standards issued by the Comptroller General of the United States.”
MEDICAID RECIPIENT ELIGIBILITY
In 2009, auditors reviewed 155 of the state’s more than 700,000 Medicaid recipient files for eligibility and found 24 ineligible recipients, a 15.48% error rate from the sample. In 2010, auditors upped their review to 645 Medicaid filers and found 43 ineligible cases, a 6.67% error rate. In 2011, auditors examined just 153 recipients with only 5 being ineligible, a 3.27% error rate.
In 2012, however, the error rate jumped up to 14.09% after 21 ineligible recipients were found out of a sample universe of 149 Medicaid participants. DHS officials questioned the 2012 results, claiming that legislative auditors shifted the focus of their audit to a different target audience in what is known as “spend-down” cases.
“Spend-down” cases involve those eligible for Medicaid, but who have irregular excess income that they can apply to large medical bills. Those cases are limited to children under 21; adults over 65; disabled or blind persons; and families with one or both parents absent, dead, disabled or out of work.
“There are only about 1,000 active spend-down cases at any point in time,” DHS managers said in the audit report. “All of the error cases identified in the SFY 2012 audit were from this small group of Medicaid eligibles… The audit did not identify any errors in the remaining sample cases from other Medicaid coverage categories.”
Legislative auditors admitted that the variation in error rates “partially resulted” from changes to the sample population selection.
Auditors also questioned the methodology for determining if participants in the ARKids First program were income-eligible. The report said state officials ended income verification requirements for ARKids First in 2012 and made it a “self-declared income program.”
DHS disputed the finding. “ARKids was implemented in 1997 as an income self-declaration program, and continues as such today,” DHS management countered.
MEDICAID PROVIDER ELIGIBILITY
Findings related to Medicaid providers – doctors, hospitals, transportation companies, and home health care agencies – provided the most contention in the report.
Legislative auditors said they reviewed 64 provider files in 2010 to determine if documentation existed for proper payments. In 53 cases, or 82.81%, “discrepancies resulted in insufficient information to determine if the service was rendered in accordance with requirements,” the report stated. Those 53 providers accounted for $1.3 million in payments.
It did not define what the discrepancies were and it did not conclude that payments were not warranted – just that documentation requirements to receive Medicaid payments were not met.
“Without documentation of services, it is impossible to determine what, when, and where services were delivered to Medicaid beneficiaries and whether delivery of services complied with state and federal requirements,” the audit said.
DHS issued its strongest rebuke to this finding.
“Of the 53 cases DLA [Division of Legislative Audit] identified, DHS agreed with only 1 finding, a case that DHS identified and corrected before the audit,” the agency responded.
In 2012, legislative auditors examined 90 provider files in home and community-based services. The review revealed that 55, or 61.11%, had inadequate documentation for the $1.3 million in payments to those providers.
DHS said it would respond to the 2012 findings in its normal response process related to a larger agency audit, due out next month. However, it warned that auditors were taking the findings out of context.
“…[W]hen audits review a statistically valid sample in a focus area, the audit findings rarely form a basis to make conclusions outside that area,” DHS said.
– The audit also criticized DHS for a lack of sufficient staff in its county offices, but correcting that deficiency would require more state employees – an unlikely scenario as legislators are aiming to corral expenses and tighten the Medicaid budget.
– The audit highlighted the program participation of one doctor who had been convicted in 2000 of possession of sexually explicit material involving sexual exploitation of a minor, which auditors said should be disclosed to the Medicaid Provider Enrollment Unit. The provider’s Medicaid recipients were under the age of 18 and he had been paid $489,813 in benefit payments as of January 2013.
DHS countered that the disclosure was known and that the State Medical Board had reinstated the provider’s practice privileges with knowledge of the conviction. “The State Medical Board, not DMS [Division of Medical Services] determines whether a person is qualified and fit to practice medicine,” DHS officials said.
– Legislative auditors also singled out an unnamed individual they claim had unrestricted access to protected health information and violated HIPPA by transferring the information to a non-state entity. DHS said the confusion related to the person’s access to health data involved a state email address, but it added that, after investigation, it found no breach occurred as alleged by auditors.
– Finally, auditors criticized the agency for the reporting flow chart for its Program Integrity (PI) unit. “The Director of the PI Unit does not report directly to the DMS Director or the DHS Director,” auditors stated.
DHS responded, “The office of the manager of the Medicaid PI unit is two doors down from the office of the DMS Director. The PI unit manager is free to contact the Director to discuss investigations, reports or policy concerns, and has done so a number of times over the past year.”
They also noted that the PI unit had completed 410 reports in the last three years recouping $3.8 million in questioned costs.
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