North Dakota Claims Unallowable Case Management Payments

The North Dakota Department of Human Services’ claims for Medicaid reimbursement for Targeted Case Management (TCM) Services did not meet all federal requirements and lacked appropriate policies and procedures for claims, according to the Office of Inspector General (OIG).

The OIG found that the state agency improperly claimed at least $682,106 ($349,211 federal share) in unallowable Medicaid reimbursements in fiscal years 2013 and 2014 for TCM services. The North Dakota Department of Human Services may have also claimed more than $1.6 million ($861,916 federal share) in Medicaid reimbursement when it reported allowable and unallowable TCM services on the same claim, according to the OIG report.

One or more of the following errors was discovered on 22 of 120 sampled claims for the state agency:

• Providers claimed services (other than transportation) that did not meet the definition of allowable TCM services (15 recipient-months)
• Providers claimed unallowable transportation services (12 recipient-months)
• The provider could not produce the supporting documentation for the services provided (one recipient-month)

The OIG recommends that the North Dakota Department of Human Services take the following actions:

• Refund $349,211 to the federal government
• Work with CMS to determine what portion of the federal share of $861,916 in potentially unallowable claims may have been allowable
• Strengthen its policies and procedures surrounding TCM services