Ga. Med­i­caid pro­grams lack tight over­sight, au­dit says

Rome News-Tribune - - EDITORIALS & OPINION - By Beau Evans Capi­tol Beat News Ser­vice

Lack of co­or­di­na­tion and in­ad­e­quate over­sight could lead to pos­si­ble over­pay­ments of Ge­or­gia’s Med­i­caid and Peach­care for Kids low-in­come as­sis­tance pro­grams, a state au­dit has found.

Re­leased Tues­day, the au­dit es­ti­mated around $41.1 mil­lion in Med­i­caid and Peach­care pay­ments be­tween 2013 and 2019 did not re­ceive enough over­sight by the state De­part­ment of Com­mu­nity Health, which over­sees the pro­grams and co­or­di­nates with out­side providers.

The over­sight is­sues could lead to over­pay­ments to ben­e­fi­cia­ries and higher monthly fees paid to four man­aged-care or­ga­ni­za­tions that work with the DCH to pro­vide ser­vices. Those or­ga­ni­za­tions con­tract with doctors, hos­pi­tals and other health-care providers.

Ac­cord­ing to the au­dit, sev­eral DCH di­vi­sions are tasked with col­lab­o­rat­ing with the man­aged-care or­ga­ni­za­tions to mon­i­tor provider con­tracts, an­a­lyze fi­nan­cial data and in­ves­ti­gate fraud claims.

The au­dit found co­or­di­na­tion among those di­vi­sions has been lax, lead­ing to po­ten­tial lapses in iden­ti­fy­ing ques­tion­able pay­ments or im­proper ac­tiv­i­ties on the part of providers. The au­dit also found in­for­ma­tion-shar­ing be­tween DCH and the man­aged-care or­ga­ni­za­tions should be tight­ened.

The au­dit made sev­eral rec­om­men­da­tions for DCH in­clud­ing to con­sol­i­date cer­tain over­sight func­tions, im­prove com­mu­ni­ca­tions about over­pay­ment claims and re­quire the man­aged-care or­ga­ni­za­tions to con­duct more risk as­sess­ments.

In a re­sponse, DCH largely agreed with the au­dit’s rec­om­men­da­tions and out­lined steps to make changes in how it co­or­di­nates over­sight of the pro­grams.

In 2019, DCH over­saw around $10.6 bil­lion in Med­i­caid and Peach­care pay­ments to more than 2.1 mil­lion Ge­or­gians. The pro­grams serve low-in­come fam­i­lies and chil­dren, preg­nant women, el­derly per­sons and those with dis­abil­i­ties.

The au­dit comes as state of­fi­cials field com­ments on pro­pos­als by Gov. Brian Kemp to tweak Ge­or­gia’s ad­min­is­tra­tion of Med­i­caid via a rein­sur­ance plan for state sub­si­dies that the gov­er­nor has touted as a way to help lower pre­mi­ums. His pro­pos­als still need fed­eral ap­proval.

Gov. Brian Kemp

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