Review of the State of Wisconsin's Reporting Fund Recoveries for Federal State Medicaid Programs on the Form CMS-64 for Fiscal Years 2006 and 2007

摘要

Pursuant to Title XIX of the Social Security Act (the Act), the Medicaid program provides medical assistance to certain low-income individuals and individuals with disabilities. The Federal and State Governments jointly fund and administer the Medicaid program. At the Federal level, the Centers for Medicare & Medicaid Services (CMS) administers the program. Each State administers its Medicaid program in accordance with a CMS-approved State plan. Although the State has considerable flexibility in designing and operating its Medicaid program, it must comply with applicable Federal requirements. In Wisconsin, the Department of Health Services, Division of Health Care Financing (State agency) administers the Medicaid program. The State agency uses a statewide surveillance and utilization control program to safeguard against unnecessary or inappropriate use of Medicaid services and excess payments. The State agency through the Bureau of Health Care Program Integrity (BPI) conducted audits of Medicaid providers. In addition, the State agency contracted with HWT, Inc. (HWT) to conduct State Medicaid audits of Medicaid providers. When they identified overpayments, BPI and HWT sent letters on behalf of the State agency to the providers that (1) identified the overpayment amounts and (2) directed the providers to send payments to Wisconsin Medicaid. Section 1903(d)(2) of the Act, requires the State to refund the Federal share of a Medicaid overpayment. Implementing regulations (42 CFR SC 433.312) require the State agency to refund the Federal share of an overpayment to a provider at the end of the 60-day period following the date of discovery, whether or not the State agency has recovered the overpayment. The date of discovery for situations other than fraud or abuse is the date that a provider is first notified in writing of an overpayment and the specified dollar amount subject to recovery (42 CFR SC 433.316(c)). Federal regulations (42 CFR SC 433.304) define an overpayment as the amount paid by a Medicaid agency to a provider in excess of the amount that is allowable for the services furnished under section 1902 of the Act and which is required to be refunded under section 1903 of the Act. Because the Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program, Form CMS-64 (CMS-64), is due on a quarterly basis, the CMS State Medicaid Manual requires the Federal share of the overpayments be reported no later than the quarter in which the 60-day period ends.