Audit of UPMC finds the healthcare provider used a loophole that cost taxpayers thousands
The Pennsylvania Auditor General's Office announced Monday that a performance audit into UPMC's Community HealthChoices insurance program found a loophole that cost taxpayers more than $350,000.
The AG's office said the audit revealed that UPMC didn't adequately perform all its required participant assessments.
"UPMC either didn't perform their required assessments to see if people were still eligible for care, or when they performed the assessments, they were done too late," said Gordon Denlinger, deputy auditor general for audits.
Denlinger said UPMC also didn't notify the state department of human services of eligibility status changes in a timely manner once they became aware.
"This is important because DHS uses data from these assessments as a key component in determining how much UPMC gets paid to cover the care provided," he said.
"We found instances where DHS paid UPMC for people enrolled in the CHC program who were deceased, went to jail, or were no longer eligible for the program," Denlinger said.
He said in the 66 cases they looked at, DHS made incorrect payments for eight participants and overpaid UPMC by about $357,000 in 2022, and the state wasn't able to recover about $121,000 because of restrictions in the contract with UPMC.
The Community HealthChoices program of UPMC Health Plan is designed for people who receive long-term supports through Medicare and Medicaid. It served 156,000 people in 2022.
The auditors made several strong suggestions to UPMC, including to make sure DHS is informed of status changes on a weekly basis as required.
"UPMC needs to make sure there is greater accountability in its management structure to make sure the required assessments are happening timely and on a regular basis," Denlinger said.
"We recommend process improvements that include a monthly check of participants against the Social Security Administration's death master file to remove people who are deceased from its rolls. And we recommend contacting all participants at least once a year to make sure their status hasn't changed," he added.
He said UPMC has agreed with most of their recommendations.
The auditors have some advice for DHS as well.
"DHS can make sure that Pennsylvanians get back all the money owed to them when they overpay for services by changing the contract languages to close this loophole, and it can update its contracts to make sure UPMC contacts all participants at least once a year to make sure their status hasn't changed," Denlinger said.
A UPMC Health Plan spokesperson provided a statement to KDKA-TV that said:
The spokesperson added, "While Medicaid eligibility is determined by the state, UPMC Health Plan recognizes that information obtained by Managed Care Organizations (MCOs) through interaction with participants is a vital part of the state's ability to make such determinations. As such, we continue to support a strong Medicaid program through our partnership with DHS and operate numerous program integrity efforts beyond what is discussed in the audit. This includes the work of our "Special Investigations Unit" that works to detect fraud, waste and or misuse of the Medicaid program, referring more than 2,100 potential cases to DHS or law enforcement."
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