Review of Medicaid Claims for School-Based Health Services in New Jersey, (A-02-03-01003)

The Office of the Inspector General (OIG) sought to determine whether federal Medicaid payments for school-based health services claimed by school health providers in New Jersey were in compliance with federal and state requirements. Of the 150 school-based claims in the statistical sample, 109 did not comply with federal laws and regulations, state statute, or the Medicaid state plan.

The OIG estimated that $51,262,909 in federal Medicaid funding was unallowable. The OIG recommended that the state:

• Refund $51,262,909 to the federal government,
   
• Work with CMS to resolve $1,046,786 in set-aside claims,
   
• Provide proper and timely guidance on federal Medicaid criteria to its school health providers,
   
• Reinforce the need for school health providers to comply with federal and state requirements, and
   
• Improve its monitoring of school health providers? claims to ensure compliance with federal and state requirements.

In its written comments, New Jersey officials asserted that the state was currently unable to agree with the recommended financial adjustment of $51,262,909 but agreed to work with the Centers for Medicare and Medicaid Services to resolve all issues concerning the $1,046,786 in set-aside claims. The state also described procedural improvements addressing the three remaining recommendations.