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Series: Medicaid School-Based Costs Claimed Based on Contingency Fee Contractor Coding

Announced on  | Last Modified on  | Series Number: W-00-24-31529
Status
Active
Agency
Centers for Medicare and Medicaid Services

OBJECTIVE

Several State Medicaid agencies retain consultants to assist with preparing Medicaid claims for school-based activities. Consultants often are paid a contingency fee based on the percentage of Federal funds reimbursed to the State. During a prior review, we found that one consultant developed unsupported time studies that it used to develop payment rates for school-based health services. Based on those rates, the State claimed unallowable Federal funds. Consultants developed time studies using a similar methodology in many other States. We will initiate a multiple State review with a roll-up report to CMS to determine whether consultants developed school-based Medicaid rates based on unsupported time studies and unallowable costs in these States

There are 2 projects in this series.

COMPLETED PROJECTS IN THIS SERIES (2)

Wisconsin Medicaid School-Based Time Study Coding and Cost Allocation

Project A-02-24-01020 • Completed on September 30, 2026

Pennsylvania

Project A-02-21-01011 • Completed on March 11, 2024

TIMELINE

  • March 3, 2021
    Series Number W-00-24-31529 Assigned
  • March 3, 2021
    Project Announced

    Pennsylvania - A-02-21-01011

  • March 11, 2024
    Project Complete - A-02-21-01011

    Pennsylvania has been marked as complete. This audit resulted in 6 recommendations.

  • October 17, 2024
    Project Announced

    Wisconsin Medicaid School-Based Time Study Coding and Cost Allocation - A-02-24-01020

  • September 30, 2026
    Project Complete - A-02-24-01020

    Wisconsin Medicaid School-Based Time Study Coding and Cost Allocation complete. Report Published

  • Today
    0 Audit In-Progress
  • Est FY2027
    Estimated Fiscal Year for Series Completion

2 REPORT PUBLISHED

Pennsylvania Improperly Claimed $551 Million in Medicaid Funds for Its School-Based Program (A-02-21-01011)

24-A-02-046.01 to CMS - Open Unimplemented
Update expected on 10/08/2026
We recommend that the Pennsylvania Department of Human Services refund $182,565,445 to the Federal Government related to moments that could not be supported as Medicaid-eligible health services or Medicaid administrative activities.

24-A-02-046.02 to CMS - Open Unimplemented
Update expected on 10/08/2026
We recommend that the Pennsylvania Department of Human Services refund $368,870,827 to the Federal Government or provide documentation that can reasonably support its allocation of health services costs to Medicaid without using unverifiable IEP ratios.

24-A-02-046.03 to CMS - Open Unimplemented
Update expected on 10/08/2026
We recommend that the Pennsylvania Department of Human Services ensure that its contractor collects sufficient information so that the State agency can validate the contractor's coding of RMTS moments.

24-A-02-046.04 to CMS - Open Unimplemented
Update expected on 10/08/2026
We recommend that the Pennsylvania Department of Human Services ensure that school districts verify that providers are appropriately licensed before they provide health services to students.

24-A-02-046.05 to CMS - Open Unimplemented
Update expected on 10/08/2026
We recommend that the Pennsylvania Department of Human Services develop an accurate, supportable method to identify Medicaid costs that can be verified with source documents.

24-A-02-046.06 to CMS - Open Unimplemented
Update expected on 10/08/2026
We recommend that the Pennsylvania Department of Human Services revise its RMTSs to include the first month of the school year.

View in Recommendation Tracker

Wisconsin May Have Improperly Claimed $455 Million in Medicaid Reimbursement for Its School-Based Program (A-02-24-01020)

Wisconsin may have improperly claimed an estimated $454.9 million in Federal Medicaid reimbursement for its school-based program.

  • We estimate that Wisconsin improperly claimed at least $67 million based on unsupported RMTS coding and services provided by unlicensed providers.
  • Wisconsin may have improperly claimed an additional $387.9 million because it could not provide documentation to support ratios used to allocate costs to Medicaid.
  • Wisconsin may have claimed additional unallowable costs because the RMTSs did not sample moments during the beginning of the school year.
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
Contracts Financial Stewardship
Target Groups
-
Financial Groups
Medicaid