Latest news with #CommunityHealthChoices
CBS News
01-04-2025
- Health
- CBS News
Audit of UPMC finds the healthcare provider used a loophole that cost taxpayers thousands
State leaders said an audit into a UPMC health insurance program found failures to update data and delays in reporting changes led to the state overpaying thousands of dollars. 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."
Yahoo
01-04-2025
- Health
- Yahoo
Audit finds reporting delays for UPMC program cost taxpayers $120K
A state audit found that UPMC's failure to report patient information cost taxpayers more than $120,000 in 2022. Per Deputy Auditor General for Audits Gordon Denlinger, this finding comes after an audit into UPMC's Community HealthChoices contract with the Pennsylvania Department of Human Services. He explains that UPMC is required to report to the DHS when someone dies, goes to jail or is no longer eligible for the program. That information helps DHS set the rate it pays to UMPC to provide care to people on Community HealthChoices. However, the audit found that UPMC failed to notify DHS of changes to participants' program eligibility status and didn't consistently provide Community HealthChoices participant eligibility information. As a result, DHS overplayed UPMC by $357,048 in 2022, with $120,977 of that money being unrecoverable. 'UPMC either didn't perform the required assessments to see if people were still eligible for care, or when they performed the assessments, they were done too late,' Denlinger said. The Auditor General's Office found that UPMC needs to report changes to participants' status weekly, which is what's required. We reached out to UPMC about the audit but have not yet heard back. Download the FREE WPXI News app for breaking news alerts. Follow Channel 11 News on Facebook and Twitter. | Watch WPXI NOW
Yahoo
31-03-2025
- Health
- Yahoo
UPMC contract audit reveals reporting delays cost taxpayers over $120,000; AG
(WHTM) — A performance audit of UPMC's Community HealthChoices contract with the Pennsylvania Department of Human Services revealed that UPMC failed to update participant information, costing taxpayers over $350,000 in 2022. According to the Pennsylvania Department of the Auditor General, UPMC didn't properly perform all its required participant assessments, failed to notify the DHS of changes to participants' program eligibility status, and didn't consistently provide participant eligibility information to DHS. Close Thanks for signing up! Watch for us in your inbox. Subscribe Now The auditor general's office found that the DHS overpaid UPMC by $357,048 in 2022. The auditor general's office said that the DHS was unable to recover $120,977 due to contract limits. 'UPMC is required to report to DHS whether a person has died, went to jail or is no longer eligible to be part of the program,' Denlinger said. 'DHS uses this as part of the data to set the rate it pays UPMC to provide care to people on Community HealthChoices. UPMC needs to make sure there is greater accountability in its management structure to ensure the required assessments are happening on time and regularly.' The DHS recommended changes to UPMC to prevent future issues. According to the Auditor General's office, some of these include requiring UPMC to have additional procedures in place in its payment reconciliation process and in its Medicare eligibility outreach to participants. 'We have some specific recommendations for DHS as well,' Denlinger said. 'DHS can make sure Pennsylvanians get back all the money owed to them when they overpay for services by changing the contract language 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.' Auditor General Tim Defoor did not participate in this audit due to his past work as an auditor and fraud investigator for UPMC. Copyright 2025 Nexstar Media, Inc. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.
