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DMA ADMINISTRATIVE LETTER NO: # 03-06 MEDICAID QC ERROR FINDINGS OCTOBER 2003 - SEPTEMBER 2004

DATE: MARCH 21, 2005

SUBJECT: Medicaid QC Error Findings

September 2003 – October 2004

DISTRIBUTION: County Directors of Social Services

Medicaid Eligibility Staff

(Note: This letter obsoletes DMA Administrative Letter 07-04.)

The Division of Medical Assistance’s Quality Assurance Section received approval from the Centers for Medicare and Medicaid Services (CMS) to conduct a specialized Medicaid QC Pilot project for the active and negative samples during the October 2003 through September 2004 sampling period. Although the QC process is still federally mandated, CMS has strongly encouraged states to conduct targeted reviews that focus on more error prone and/or high dollar cases instead of traditional sampling of the overall Medicaid universe.

During eight months of the October 2003 – September 2004 sampling period, the pilot permitted us to limit the regular QC monthly sampling methodology to non-SSI adult recipients age 19 or older, who were authorized for Medicaid under the Community Alternatives Program (CAP) waivers for Disabled Adults, Persons with Mental Retardation/Developmental Disabilities and for Persons with AIDS.

i. summary of error findings for the special Cap pilot project

ii. highlights for supervisors and trainers

2. Of the remaining agency responsible errors, 7 out of 22 or 32% were due an understated liability and 3 out of 22 were due to categorical eligibility requirements:

III. Comparison of CAP review to ltc and pcs qc reviews

Sample

Eligibility Error Rate

Payment Error Rate

Agency

Error

Client

Error

Source: Reserve

Source: Income

Source:

Disability

PCS

02/01-06/01

9.83%

8.14%

79.31%

20.69%

20.7%

37.9%

37.9%

PCS

07/01-09/01

1.68%

8.27%

0%

100%

100%

0%

0%

LTC

10/01-09/02

15.05%

4.61%

71.74%

28.26%

37%

23.9%

0%

LTC

10/02-09/03

12.08%

4.56%

69.44%

30.56%

52.8%

13.9%

2.8%

CAP

10/03-09/04

8.49%

4.14%

81.48%

18.52%

59.3%

7.4%

1.1%

Findings to Note:

IV. Description of case errors

3. MAA-Q Region III Real Property Agency $2,899
11. MAA-Q Region III Real Property Agency $2,118

We hope you will find this information helpful in your efforts to reduce Medicaid errors. If you have any questions, please contact the Quality Assurance Section or your Medicaid Program Representative.

(This material was researched and written by Jackie Franklin, Assistant Chief, Medicaid Quality Assurance Section.)

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