Medicaid Audit Raises Questions About Controlled Substances
The audit involves as many as 36,411 claims totaling $5.45 million.
Florida’s Medicaid program paid $3.7 million for tens of thousands of prescriptions for controlled substances over a nearly two-year period for patients who had not recently been hospitalized or seen physicians and in one instance paid for prescriptions for 900 days of OxyContin, a new audit from the Florida auditor general shows.
The audit included a review of nearly 10 million Medicaid claims paid between April 2017 and February 2019 for controlled substances, HIV prescriptions, home health visits and dental services and found “potential irregularities” with as many 36,411 claims totaling $5.45 million.
Most of the claims flagged for irregularities --- 34,761 --- related to controlled substances. As another example, auditors cited a claim for a Medicaid patient who received 660 days of fentanyl over a period of 21 months and 360 days of oxycodone over a 12-month period without a recorded Medicaid hospital or physician visit.
“For this recipient, Medicaid also paid a claim in January 2018 for a Narcan prescription,” auditors found, referring to a drug used to treat overdoses.
The majority of Florida's Medicaid patients receive health services through managed-care plans, which are paid monthly fees from the state. Some patients, meanwhile, are enrolled in the Medicaid “fee for service” system, where health-care providers are paid by the state for each service provided, such as office visits, medical tests or procedures.
The audit includes a review of managed-care and fee-for-service claims.
In an initial response to the audit findings, the state Agency for Health Care Administration said payments in the fee-for-service and managed-care programs were made in compliance with Medicaid rules and regulations.
And in an Aug. 27 letter to Auditor General Sherrill F. Norman, agency Secretary Mary Mahyew noted that federal law precludes refilling prescriptions of OxyContin and other controlled substances and that consultation with health care providers is required for prescriptions.
Mayhew also said Medicaid has safeguards such as a utilization management system. Mayhew said that if systematic program improvements are “deemed necessary at any time they will be made.”
But the auditors wrote that ”adequate monitoring of patients receiving controlled substances prescriptions, particularly for substances such as opioids, would better ensure that the prescriptions are working as intended and risks for dependency and overdose are appropriately monitored and mitigated. “
Such operational audits are designed to identify deficiencies in internal controls, instances of noncompliance with laws, rules, or contracts and instances of inefficient or ineffective policies, procedures or practices.
The audit was conducted between February 2019 and March 2020.
Meanwhile, auditors flagged nearly $750,000 in dental payments to 289 providers. One of the claims cited for potential irregularities was for six root canals on a single patient, procedures that would take an estimated nine hours to complete. Auditors found that the procedures were not performed at a hospital or ambulatory surgical center and they had not received prior authorization from a Medicaid managed care plan.
Audrey Brown, president and CEO of the Florida Association of Health Plans, said the audit was positive overall, with just a "fraction" of the claims flagged as potentially irregular.
"But there is always more work to be done, and health plans will continue to strive toward eliminating fraud within the system," Brown said in a statement to The News Service Florida. Brown's association represents many Medicaid managed-care plans.
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