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Inspector flags 62 suspected pregnant‑woman Medicaid fraud cases; $798,000 in capitation payments identified
Summary
An interim audit presented to the Public Health and Welfare committee identified 62 beneficiaries who 'appear to have fraudulently applied' for pregnant‑woman Medicaid coverage; auditor estimated $798,000 in MCO capitation payments tied to those enrollments and opened criminal investigations.
An interim audit presented to the Public Health and Welfare committee on Jan. 28 identified 62 Medicaid beneficiaries who "appear to have committed fraud" by enrolling under pregnant‑woman eligibility, a state inspector told lawmakers.
The presenter said the 62 cases were found after auditors screened for atypical records — for example, beneficiaries 45 or older with no recorded prenatal claims — and calculated $798,000 in capitation payments paid to managed care organizations (MCOs) for…
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