A Wall Street Journal analysis of Medicaid data found that health insurers collected at least $4.3 billion over three years for patients who were enrolled in other states. But insurers say the information is misleading.
The publication found that the extra payments occurred among patients who were enrolled in Medicaid in two states at the same time after moving from one state to another. The Journal said most received their health care services through one insurer in one state, but Medicaid paid insurers in both states to cover these patients. The analysis covered a three-year period from 2019 to 2021.
The Journal identified the duplicative payments using T-MSIS, a national database of Medicaid services and payments. All monthly premium payments made by enrollees in Medicaid managed care plans to insurers were identified by criteria used by the Centers for Medicare & Medicaid Services (CMS). The publication then identified each month from 2019 to 2021 in which two states made payments to insurers for the coverage of a single recipient.
According to the analysis, the biggest payouts went to the three largest Medicaid insurers: Centene, which received $620 million in duplicate payments, Elevance Health, which received $346 million, and UnitedHealth Group, which collected $298 million.
Most of the cases involved Medicaid recipients who moved from one state to another. Although recipients are supposed to cancel their coverage in the former state when they sign up for coverage in a new one, they don’t always cancel.
Insurers told the publication that it’s up to states to verify eligibility and disenroll them if necessary. They also complained that the time period that the Journal used is skewed because it included the COVID-19 pandemic, which involved emergency rules that limited disenrollments. Indeed, double payments throughout the country increased from $814 million in 2019 to $2.1 billion in 2021, the Journal found. The emergency rules were lifted in 2023.
CMS doesn’t screen for the duplicative payments and states often don’t realize Medicaid recipients have moved until their annual eligibility reviews, the Journal reported.
A UnitedHealth spokesman told the Journal that the analysis is misleading because it doesn’t account for the payments the insurer had returned to states. “Many of the duplicates are children, typically due to parental separation,” he said, and are “reconciled as part of our standard audit process.”
The Journal’s analysis follows a 2022 audit by the Department of Health and Human Services Office of Inspector General that looked at payments made by states on behalf of beneficiaries who were enrolled in a Medicaid managed care program in two states in 2019 and 2020. The OIG report found that the Medicaid program could have saved approximately $1 billion if they had identified the duplicative payments earlier. The watchdog suggested that CMS and states use T-MSIS data and appropriate reconciliation to prevent these potential payments.