HD12 - Interim Report: Fraud and Error in Virginia's Medicaid Program


Executive Summary:
House Joint Resolution 127 (2010) directs JLARC to identify opportunities to reduce waste, inefficiency, fraud, and abuse in Medicaid.

In FY 2009, Virginia had known improper Medicaid payments of $38.9 million, which consisted of roughly equal amounts of fraud and error. In addition, up to $50.3 million in potential fraud or error was avoided by blocking improper claims before they were paid.

Errors in eligibility determination and delays in eligibility redeterminations likely result in improper Medicaid payments because some ineligible Virginians receive Medicaid-funded services.

Local departments of social services and the Department of Medical Assistance Services (DMAS) may not be fully investigating and prosecuting recipient fraud.

While the State’s Medicaid Fraud Control Unit has reported over $700 million in recoveries from FYs 2005 to 2009, DMAS has received only $49 million.

The report includes recommendations to improve local department compliance with eligibility determination and redetermination requirements, encourage more fraud control activity at the local level, and give DMAS more flexibility to investigate claims prior to payment.