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VideoSuccess Story: How a State Agency Used Performance Audits to Identify Medicaid Overpayments
Forensics & Litigation Services
Forensics & Litigation Services
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The Client
A state agency responsible for monitoring Medicaid spending engaged Weaver to conduct performance audits of claims billed by behavioral health and telehealth providers and reimbursed by managed care organizations (MCOs) operating within the Texas Medicaid program. The audits were designed to evaluate whether services billed to Medicaid were supported by appropriate clinical documentation and complied with applicable federal and state laws, regulations, policies and contractual requirements.
The Challenge
The engagements involved large volumes of health care claims data, extensive medical records and highly technical Medicaid billing requirements. The audits required the application of rigorous government auditing standards and statistically valid sampling methodologies capable of supporting extrapolated overpayment findings across large claim populations.
Because the findings could result in significant repayment obligations, regulatory scrutiny and potential provider disputes, the information generated by the audit had to be objective, transparent and fully defensible under Generally Accepted Government Auditing Standards (GAGAS).
The Process
To evaluate compliance with Medicaid reimbursement requirements, Weaver’s team assessed completeness of documents, coding accuracy, treatment records, service authorizations and billing support. The engagement required coordination among forensic accountants, health care reimbursement professionals and data analytics specialists to evaluate billing accuracy, identify documentation deficiencies and quantify questioned costs and overpayments.
Weaver also applied data analytics procedures to identify billing trends, anomalies and higher-risk claims requiring additional review. To support defensible overpayment findings across broader claim populations, Weaver used statistically valid sampling methodologies and RAT-STATS software to select representative claim samples and extrapolate results. All audit procedures were conducted in accordance with GAGAS and applicable Texas Administrative Code requirements.
The Deliverables
Weaver provided the client with clear, defensible findings supported by detailed documentation review, statistical sampling and transparent audit methodologies. Importantly, the overpayment findings were not disputed by the providers, allowing the matters to be resolved efficiently and reinforcing the reliability and credibility of Weaver’s audit approach.
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Success Story