November 9, 2007

Iowa Medicaid Payments for Targeted Case Management

The Iowa Department of Human Services (DHS) provides targeted case management (TCM) services to Medicaid-eligible children and adults who are pregnant; have a diagnosis of mental retardation,
developmental disability, or chronic mental illness; or are eligible under the Early and Periodic Screening, Diagnostic, and Treatment program; and meet the eligibility categories under Part B and C of the Individuals with Disabilities Education Act.

 For Federal fiscal years (FY) 2003 and 2004, the State agency claimed Medicaid reimbursement totaling $33.4 million for TCM services. The federal Office of the Inspector General (OIG) for the Department of Health and Human Services reviewed a sample of 200 TCM claims submitted in 2003 and 2004 and found that some of the claims were for improperly claimed services and others were not properly documented. Problem areas included:

• Federal reimbursement was claimed for 48 services in which the state agency failed to properly describe the nature, extent, or units of service in enough detail to show that an allowable service had been provided.

• DHS also claimed reimbursement for 12 services beyond the definition of Medicaid targeted case management services.

• DHS claimed reimbursement for 13 direct medical services that were provided to TCM recipients