Inactive providers continued to receive payments
By Pacific Island Times News Staff
The Office of Public Accountability questioned $241.1 million in Medicaid payments made by the Guam Department of Public Health and Social Services to Medicaid providers, which were suspected to be either “unqualified” or “fraudulent."
“Our review of documents and information provided by the DPHSS–Bureau of Health Care Financing Administration relative to 28 (or 13 percent) out of
218 total Medicaid providers revealed several issues and deficiencies,” the OPA said in a report released today amid President Donald Trump's endorsement of the House Republicans' plan to gut Medicaid.
The federally-funded Medicaid program listed payments totaling $399.6
million made to 218 participating on-island and off-island Medicaid providers, OPA said.
An audit of sampled Medicaid providers from the department's list found that some inactive Medicaid providers continued to receive payments, and whose National Provider Identification have undetermined expiry dates, and active physicians with expired licenses or certificates.
“We questioned $241.1 million in Medicaid provider payments – primarily due to noncompliance with local and federal regulations in regards to revalidations of providers’ enrollments once every five years, in which the providers’ eligibilities were already outdated and could be potentially no longer valid,” OPA said.
“The lack of revalidations once every five years could lead to a potential inclusion of unqualified or fraudulent providers.”
The audit identified several issues including outdated information (such as expired licenses), missing current eligibility documents, unorganized filing records and the inclusion of irrelevant documents unrelated to provider eligibility, among others.
The audit covered records for fiscal years 2020 through 2022.
“This audit revealed significant deficiencies relative to record storage and
safekeeping; maintenance of updated and accurate data and information on DPHSS’ database; and an appearance of ineffective and inefficient
eligibility screening, approval, documentation and revalidation processes and procedures,” the OPA said.
“These findings need management’s attention and corrective action to inspire the public’s confidence in the administrator’s decisions to achieve program objectives and uphold its integrity, Public Auditor Benjamin J. Cruz said. “We made nine recommendations and DPHSS management has promptly provided us with their action plans to implement these recommendations.”
Noting that the audit represented only a sample of 28 providers, Sen. Sabrina Matanane suspected that what the OPA uncovered could be just the tip of the iceberg.
“I am convinced that a larger sample would have highlighted even more questionable costs,” said Matanane, chair of the health committee.
She further explained that while the audit findings in Part 1 did not point to intentional fraud at the moment, the audit clearly shows systemic issues in how provider records are managed.
"Whether these questionable payments stem from fraudulent activity or are the result of mismanagement and poor record-keeping, my primary concern is that this could jeopardize future Medicaid funding and other federal dollars," Matanane said.
"At a time when our president is committed to cutting costs and reducing waste and abuse, we cannot continue to operate this way. In the coming weeks, an informational briefing with DPHSS will be held to discuss the audit, discuss their corrective plan, and address other critical public health issues," she added.
The report released today was the first of the OPA’s three-part performance
audit series on the DPHSS Medicaid Program.
“The objectives of Part I of this audit are focused on assessing the accuracy of the Medicaid provider database; selection approval and revalidation processes and procedures; and compliance with licenses and other
documentation requirements by local and federal laws and regulations,” OPA said.
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