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Series: Audits of Medicaid Reimbursement for Clinical Laboratory Services

Announced on  | Last Modified on  | Series Number: SRS-A-25-002
Status
Active
Agency
Centers for Medicare and Medicaid Services

OBJECTIVE

Outpatient clinical diagnostic laboratory tests encompass tests performed in a physician’s office, by an independent laboratory, or by a hospital laboratory, and provide information for the diagnosis, prevention, or treatment of disease or for the assessment of a medical condition. Medicaid reimbursement for outpatient clinical diagnostic laboratory services performed in a physician’s office, by an independent laboratory, or by a hospital laboratory, generally may not exceed the amount set in the Medicare clinical laboratory fee schedule. Our objective is to determine whether selected States claimed Federal Medicaid reimbursement for outpatient clinical diagnostic laboratory services in accordance with the payment limits set in Federal and State requirements.

There are 8 projects in this series.

Project titles will remain unpublished until projects are complete and reports are posted.

ACTIVE PROJECTS IN THIS SERIES (6)

Project OAS-25-01-004 • Announced on Oct 15, 2024

Project OAS-25-06-095 • Announced on Apr 28, 2025

Project OAS-25-05-120 • Announced on Jun 26, 2025

Project OAS-26-04-005 • Announced on Oct 6, 2025

Project OAS-26-01-034 • Announced on Jan 13, 2026

Project OAS-26-01-089 • Announced on Apr 14, 2026

COMPLETED PROJECTS IN THIS SERIES (2)

Audit of Georgia's Medicaid Reimbursements for Clinical Laboratory Services

Project OAS-25-01-084 • Completed on July 24, 2026

Audit of California's Medicaid Reimbursement for Clinical Laboratory Services

Project OAS-25-01-076 • Completed on June 8, 2026

TIMELINE

  • October 15, 2024
    Series Number SRS-A-25-002 Assigned
  • October 15, 2024
    Project Announced

    Project OAS-25-01-004

  • February 18, 2025
    Project Announced

    Audit of California's Medicaid Reimbursement for Clinical Laboratory Services - OAS-25-01-076

  • March 10, 2025
    Project Announced

    Audit of Georgia's Medicaid Reimbursements for Clinical Laboratory Services - OAS-25-01-084

  • April 28, 2025
    Project Announced

    Project OAS-25-06-095

  • June 26, 2025
    Project Announced

    Project OAS-25-05-120

  • October 6, 2025
    Project Announced

    Project OAS-26-04-005

  • January 13, 2026
    Project Announced

    Project OAS-26-01-034

  • April 14, 2026
    Project Announced

    Project OAS-26-01-089

  • June 8, 2026
    Project Complete - OAS-25-01-076

    Audit of California's Medicaid Reimbursement for Clinical Laboratory Services complete. This audit resulted in 4 recommendations.

  • July 24, 2026
    Project Complete - OAS-25-01-084

    Audit of Georgia's Medicaid Reimbursements for Clinical Laboratory Services complete. Report Published

  • Today
    6 Audits In-Progress
  • Est FY2028
    Estimated Fiscal Year for Series Completion

2 REPORT PUBLISHED

California Made at Least $13.9 Million More in Medicaid Reimbursements for Clinical Diagnostic Laboratory Services Than Was Allowed by Federal and State Requirements (OAS-25-01-076)

26-A-01-071.01 to CMS - Open Unimplemented
Update expected on 12/07/2026
We recommend that the State agency refund $7,576,103 to the Federal Government.

26-A-01-071.02 to CMS - Open Unimplemented
Update expected on 12/07/2026
We recommend that the State agency work with CMS to determine whether potential overpayments of $16,477,416 (Federal share) complied with Federal and State requirements and refund the Federal share of any overpayments to the Federal Government.

26-A-01-071.03 to CMS - Open Unimplemented
Update expected on 12/07/2026
We recommend the State agency review payments made after our audit period to identify any additional overpayments and refund the Federal share to the Federal Government. Additionally, the State agency should clearly identify any additional overpayments refunded as having been made in accordance with this recommendation.

26-A-01-071.04 to CMS - Open Unimplemented
Update expected on 12/07/2026
We recommend that the State agency evaluate and strengthen its existing policies and procedures for reviewing and updating rates in its claims processing system to ensure that the amounts claimed for clinical diagnostic laboratory services do not exceed the amount that would be paid under the Medicare program or the amounts allowed by State requirements.

View in Recommendation Tracker

Georgia Claimed at Least $26.1 Million More in Medicaid Reimbursements for Clinical Diagnostic Laboratory Services Than Was Allowed by Federal and State Requirements (OAS-25-01-084)

Georgia did not always claim Federal Medicaid reimbursement for clinical diagnostic laboratory services in accordance with Federal and State requirements.

  • For 648,412 of 13,603,258 services, Georgia paid providers more than they would have been paid under the Medicare program or more than the amounts allowed by State requirements.
  • Additionally, for 1,910,462 professional and 618,412 hospital outpatient lines of service, Georgia potentially paid providers more than they would have paid under the Medicare program or the amounts allowed by State requirements.

As a result, the Federal reimbursement that Georgia claimed exceeded the rates allowed by the Federal and State requirements by $26.1 million ($18.5 million Federal share) and potentially exceeded the rates allowed by Federal and State requirements by an additional $4.4 million ($3.1 million Federal share).

Recommendations are updated each month and may not immediately be available for recently completed projects.
Work Plan Type
Office of Audit Services
HHS Agencies
Centers for Medicare and Medicaid Services
Issue Areas
Laboratories Financial Stewardship
Target Groups
-
Financial Groups
Medicaid