01-04-2025
Audit reveals over $120k of taxpayer money lost on UPMC healthcare contract
HARRISBURG, Pa. (WTAJ) – A state audit revealed that the Department of Human Services (DHS) overpaid for a UPMC healthcare program, resulting in thousands of taxpayer dollars being lost.
The auditor general's office released the findings of a performance review of UPMC's Community HealthChoice contract, finding several failures along the way. According to the auditor general's office, Community HealthChoice is a health insurance program for Pennsylvanians 21 or older who get long-term support from Medicaid and Medicare or who 'receive long-term supports through Medicaid because they need help with everyday personal tasks.'
UPMC and the DHS have a contract for the state to provide funding for the program. However, the audit revealed that UPMC did not accurately update 'participant information,' which skewed the numbers for how much money the DHS was supposed to give.
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'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,' Deputy Auditor General for Audits Gordon Denlinger said.
In 2022, the program served over 140,000 people and received close to $360 million in payments from the commonwealth, according to Denlinger. As a result of the skewed numbers, the DHS overpaid $357,048 in 2022, with $120,977 unable to be recovered due to 'limits in the contract,' according to a press release sent out by the auditor general's office.
'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.
However, he also mentioned this was a failure on both ends of the contract – which includes the DHS.
'DHS can make sure that Pennsylvanians get back all the money owed to them when they overpay for services by changing the contract language to close this loophole,' Denlinger said.
WTAJ reached out to UPMC for comment, and this was their response:
'Even before the start of the two-year audit, we had implemented myriad improvements to our systems and methodologies through our own continuous review processes, and made additional modifications based upon the Auditor General's recommendations. 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.'
Denlinger offered advice in hopes of preventing something like this from happening again and said UPMC has 'agreed with most' of the office's recommendations.
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