IG audit reveals $129,000 in Medicaid payments to Planned Parenthood did not comply with requirements
The Department of Health and Human Services, Office of the Inspector General, conducted a review which covered 3,251 clients with claims for Medicaid family planning services (Medicaid services) that Planned Parenthood of North Texas ( PPNT ) submitted, totaling $493,112 ($443,800 Federal share), during the period March 1, 2007, through September 30, 2008 (audit period).
The IG conducted their field work at Planned Parenthood locations in Dallas and Ft Worth.
In Texas, the State agency is responsible for administering the Medicaid program. In addition to family planning services for Medicaid recipients, Texas established the waiver under section 1115 of the Social Security Act to provide a limited and defined set of family planning services to uninsured women who are not eligible for Medicaid
The review also covered 5,548 clients with claims for waiver family planning services (waiver services) that PPNT submitted totaling $800,000 ($720,000 Federal share), during their audit period. They selected a stratified random sample of 105 clients from each of these client populations. They then reviewed the services and determined the unallowable Federal share of the payments made.
Here is what they found:
The State agency did not always claim Medicaid reimbursement for family planning services provided by PPNT in accordance with Federal and State Medicaid requirements or the conditions of the waiver, whichever was appropriate.
Of the 210 sampled Medicaid and waiver client records:
(1) 50 Medicaid client records contained 1 or more deficiencies (totaling $3,983) on insufficient supporting documentation, and 39 waiver client records contained 1 or more deficiencies (totaling $1,855) on insufficient supporting documentation;
(2) 23 Medicaid client records contained 1 or more deficiencies (totaling $738) on incorrect billing, and 28 waiver client records contained 1 or more deficiencies (totaling $972) on incorrect billing; and
(3) 5 Medicaid client records contained 1 or more deficiencies (totaling $104) on services unrelated to family planning.
The State agency did not always properly claim Medicaid reimbursement for family planning services because it did not ensure that:
(1) PPNT maintained the appropriate required supporting documentation,
(2) PPNT properly billed for family planning services, and
(3) services claimed had a family planning purpose.
As a result of these errors, the State agency incorrectly claimed a total of $7,651 for Medicaid and waiver services.
On the basis of their sample results, the IG estimated that the State agency improperly claimed a total of $129,028: $67,019 for Medicaid services and $62,009 for waiver services.
The agency is now recommending a refund of $129,028 to the Federal Government: $67,019 for Medicaid services and $62,009 for waiver services that did not comply with Federal and State requirements for family planning service.
According to the audit:
THE STATE AGENCY DID NOT ENSURE THAT PLANNED PARENTHOOD OF NORTH TEXAS HAD SUFFICIENT SUPPORTING DOCUMENTATION
Providers must keep records to fully disclose the extent of services provided to Medicaid beneficiaries. Additionally, all Medicaid records must be kept for 5 years from the date of service or until all pending audit questions are resolved, whichever is longer. Records and supporting documentation must be made available upon request to the Texas Department of Health or its designated agent.
For 50 of the 105 Medicaid clients in the IG’s sample, PPNT did not have the required supporting documentation for at least 1 family planning service.
For 39 of the 105 waiver clients in the sample, PPNT did not have the required supporting documentation for at least 1 family planning service.
For example, all of the medical records for the dates of service were missing, or the records did not have sufficient information to support the services claimed.
These errors occurred because the State agency did not ensure that PPNT maintained the appropriate required supporting documentation for family planning services.
As a result, the State agency improperly claimed $3,983 for Medicaid services and $1,855 for waiver services.
The Medicaid program pays for services provided to a client only when the extent of the services is fully disclosed.
According to the official coding guidelines,billing codes are determined using several components, including client’s history, examinations, medical decision making, counseling, coordination of care, the nature of the presenting problem, and the amount of time spent with the client.
For 23 of the 105 Medicaid clients in our sample, at least 1 family planning service was incorrectly billed.
For 28 of the 105 waiver clients in our sample, at least 1 family planning service was incorrectly billed
Examples of this type of error included billing an incorrect office visit code when the client received only a birth control injection, billing a counseling code in addition to another code that already included the counseling, or billing for a service that was claimed during a previous visit and that was not allowed to be billed again.
These errors occurred because the State agency did not ensure that PPNT correctly billed for family planning services. As a result, the State agency improperly claimed $738 for Medicaid services and $972 for waiver service
The State agency said that it would collect the overpayment from Planned Parenthood North Texas and refund the Federal share.
In 2013, Planned Parenthood’s Houston-based affiliate settled for $4.3 million with the state of Texas after an audit revealed that the agency charged for “fraudulently over billing the taxpayer-funded Medicaid program.”
Details of other Planned Parenthood state and federal audits are linked at this blog post (here).