The federal Office of the Inspector General (OIG) recently released results of two separate audits where they claimed the Washington State Medicaid program made improper payments. In one audit, OIG claimed the state made $9.2 million in improper electronic health record incentive payments. In the other, the OIG claimed the state made improper hospital payments for in the amount of $18.2 million for services involving provider preventable conditions. In its initial responses, the Health Care Authority contested the amounts calculated by OIG. Next steps will be the HCA to work out with CMS a plan in response to the OIG audit. WSHA is in contact with the Health Care Authority regarding the audit results, though HCA has not yet determined how it plans to resolve the issue. We will provide additional information as it becomes available.
In its audit of electronic health record incentive payments, OIG determined HCA made improper payments due to using a methodology based on cost-report data rather than hospital accounting records. In its initial response, HCA stated its cost report-based methodology had been approved by CMS.
In its audit of payment for provider-preventable conditions, OIG claimed overpayments occurred because the HCA did not review certain categories of claims for provider preventable conditions. Among those categories were claims from hospitals exempt from Present on Admission (POA) coding requirements, Medicare crossover claims where Medicaid pays only the deductible or coinsurance, and claims where the APR-DRG assignment was unrelated to the preventable condition. In its response, HCA indicated that OIG overestimated the amount of the overpayments by including the full payment amount for claims rather than just the portion of the payment that may be attributable to the preventable condition.
The OIG has conducted similar audits of a number of states and thus far has found the majority to be out of compliance to varying degrees. (Andrew Busz, firstname.lastname@example.org)