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."
Hashtags
Try Our AI Features
Explore what Daily8 AI can do for you:
Comments
No comments yet...
Related Articles
Business Journals
8 minutes ago
- Business Journals
Dr. Frist to Dr. Oz: Use Nashville's health care leaders as a resource
Nashville's health care leaders gathered July 22 to hear a discussion between Dr. Bill Frist and Dr. Mehmet Oz, the new Centers for Medicare & Medicaid Services administrator. Here's what Frist said to Oz, and what Oz had to say about Medicaid cuts, improving the health care landscape and getting people back to work.
The Hill
2 hours ago
- The Hill
AARP endorses bill to prevent upcoding in Medicare Advantage
In a statement Thursday, AARP noted that upcoding is expected to increase care costs for Medicare Advantage enrollees by $40 billion this year. The No UPCODE Act was introduced by Sens. Bill Cassidy (R-La.) and Jeff Merkley (D-Ore.) earlier this year. The bill would disincentivize upcoding by developing a risk-adjustment model using two years of diagnostic data as opposed to one, limiting the use of unrelated medical conditions when estimating the cost of care, and bridging the gap between how patients on Medicare Advantage and traditional Medicare are assessed. In a letter to Cassidy and Merkley, AARP senior vice president for government affairs Bill Sweeney wrote, 'While many Medicare beneficiaries appreciate the flexibility and ease of use that MA provides, we are concerned that upcoding leads to both inflated payments to insurance plans and higher premiums for American seniors.' 'These resources would be better spent strengthening Medicare, such as by providing dental, hearing, and vision coverage,' Sweeney added. 'This bill addresses a problem both Republicans and Democrats have labeled as waste, fraud, and abuse. AARP agrees the No UPCODE Act protects seniors by preserving benefits and eliminating waste,' Cassidy said in a statement Thursday. 'When companies upcode, taxpayers foot the bill and patients get nothing. That's wrong.' While the Trump administration has railed against waste, fraud and abuse in Medicare and Medicaid, the vast majority of Medicare payments are made properly. As KFF found in its analysis of fiscal year 2024 payments, 94.4 percent of Medicare Advantage payments were made properly, with improper Medicare payments totaling $54.3 billion.
San Francisco Chronicle
2 hours ago
- San Francisco Chronicle
Planned Parenthood closes 5 Northern California clinics, citing Trump budget bill
President Donald Trump's budget cuts to Medicaid have forced Planned Parenthood Mar Monte to shutter five clinics across Northern California and the Central Coast, including one in South San Francisco, the group said Thursday. The GOP-led federal spending bill that Trump signed into law earlier this month eliminated federal Medicaid funding for any type of medical care to organizations that perform abortions. Mar Monte is the largest Planned Parenthood affiliate in the country, with health care centers from Bakersfield, the Bay Area, Stockton and Sacramento. The now-shuttered facilities also include San Mateo, Santa Cruz, Gilroy and Madera. The closures represent the first wave of how the recent federal budget cuts will have real-life consequences for health clinics across the country — particularly for low-income Americans. They are also a crushing blow to a state that set it up to be an abortion haven after the U.S. Supreme Court overturned Roe v. Wade in 2022. In the year after the decision, political leaders in California — led by Gov. Gavin Newsom and the Democratic-controlled Legislature — passed more than a dozen new laws and invested more than $200 million to increase access across the state. Thursday's announcement drives home the extent of the federal government's tremendous power to impact abortion access. Roughly 80% of Mar Monte's patients received Medi-Cal, California's version of Medicaid. Ten million people are expected to lose their health insurance because of nearly $1 trillion in Medicaid cuts over the next decade in the One Big Beautiful Bill Act, according to the nonpartisan Congressional Budget Office. Meanwhile, the wealthiest Americans will receive a disproportionate share of the tax cuts funded by those cuts, according to the Center for Budget and Policy Priorities. In just one week since Mar Monte stopped billing Medicaid, the Planned Parenthood affiliate with 35 locations said it saw 5,000 patients — amounting to about $1.7 million in care costs it covered without reimbursement — Mar Monte Chief of Staff Andrew Adams told the Chronicle Thursday. 'It's just not sustainable,' said Adams. 'We can't keep our doors open if we continue doing that.' Mar Monte said the funding law also forced it to end services in family medicine, behavioral health and prenatal care. The Planned Parenthood affiliate estimates it will lose $100 million in annual revenue from care that can no longer be reimbursed under the law because they provide abortion care. Americans tend to support abortion rights, according to public polling. A May 2025 Gallup Poll found that 51% of respondents described themselves as 'pro choice' while 43% described themselves as 'pro life.'Of those respondents who said they were 'dissatisfied' with the nation's abortion polices, 42% said they would like to see them made 'less strict' while 14% wanted them to be 'stricter.'
