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

Why OIG Did This Audit

• Prior OIG audits found that some States did not always claim Federal Medicaid reimbursement for clinical diagnostic laboratory services in accordance with Federal and State requirements. Specifically, the States submitted claims that exceeded the amounts that would have been paid under the Medicare program or the amounts allowed by State requirements.
• We performed data analysis that indicated certain States, including Georgia, are at risk for noncompliance with Federal and State requirements.
• This audit examined Georgia's fee-for-service Medicaid payments for clinical diagnostic laboratory services provided during calendar years 2019 through 2023.

What OIG Found

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).

What OIG Recommends

We made five recommendations to Georgia, including that it refund $18.5 million to the Federal Government related to professional and hospital outpatient services, conduct a self-review of the 2,528,874 lines of service to determine whether potential overpayments of $3.1 million complied with Federal and State requirements, and review payments made after our audit period to identify additional overpayments to refund to the Federal Government. The full recommendations are in the report.

Georgia concurred with all five recommendations.