Pennsylvania taxpayers paid more than $350,000 due to UPMC failures, according to the audit by the Auditor General’s Office.
An audit into a UPMC health insurance program found failures to update data and delays in reporting changes. This led to the state overpaying thousands of dollars.
A performance audit into UPMC’s Community HealthChoices insurance program found a loophole that cost Pennsylvania taxpayers more than $350,000. The Pennsylvania Auditor General’s Office conducted the audit, and said it revealed that UPMC did not adequately perform all its required participant assessments.
Gordon Denlinger, deputy auditor general for audits, said, “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.”
The audit found that UPMC did not notify the state department of human services of eligibility status changes in a timely manner.
Denlinger said, “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.”
There were 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, according to Denlinger.
The audit examined 66 cases. Within those cases, DHS made incorrect payments for eight participants and overpaid UPMC by about $357,000 in 2022. The state was not able to recover about $121,000 because of restrictions that exist in the contract with UPMC.
Denlinger said, “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.”
The auditors suggested that UPMC ensure DHS is informed of status changes on a weekly basis, as required, and Denlinger said UPMC has agreed with most of their recommendations.
In a statement, a UPMC Health Plan spokesperson said, “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.”
The spokesperson for UPMC 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.”
