Corrective Action Plan: The Department agrees with the Auditor’s recommendation to strengthen internal controls over utilization reviews of hospital claims to ensure claims are processed accurately and timely through the Ohio Medicaid Enterprise System Fiscal Intermediary (FI) module. The Department...
Corrective Action Plan: The Department agrees with the Auditor’s recommendation to strengthen internal controls over utilization reviews of hospital claims to ensure claims are processed accurately and timely through the Ohio Medicaid Enterprise System Fiscal Intermediary (FI) module. The Department is addressing the system edits that caused delays and ineffective processing of take-back claims. The recoupment process is in place; however, hospital recoupments are temporarily paused while necessary system testing and provider training are completed. The Department intentionally halted recoupments because system issues prevented hospitals from resubmitting corrected claims after a recoupment occurred. The Department is working with system vendors to update system logic so hospital claims can be processed correctly. The changes are currently in the testing phase, and, once validated, will be implemented statewide. As of February 20, vendors have deployed two system fixes. A hospital provider is now testing claims and confirming these fixes resolved the issues. During testing, an opportunity was identified to clarify requirements for hospital providers and is developing a simplified process document to support them. It is important to note that Surveillance Utilization Reviews (SURS) vendor findings may reflect billing or coding errors that do not always result in incorrect payment. A finding may indicate an overpayment, an underpayment, or no change. When a billing error is identified, hospitals may be permitted to re-bill with corrected information so that the proper payment can be made. Recouping claims before the system logic is corrected could create a financial hardship for hospitals that delivered medically necessary services to eligible individuals. The Department has a monitoring process in place. After final testing and acceptance, the SURS team will send the appropriate files to the vendor for processing. Once the FI vendor processes the file, SURS will receive claim status information and will track these claims to ensure accurate reprocessing. When take-back processing is resumed, recoupments will be staggered to help avoid financial hardship for providers. Anticipated Completion Date for Corrective Action: July 2026 Contact Person Responsible for Corrective Action: Megan Powell Audit Remediation Manager 50 West Town Street, Suite 400, Columbus, Ohio 43215 614-752-3844 megan.powell@medicaid.ohio.gov