Inspector flags 62 suspected pregnant‑woman Medicaid fraud cases; $798,000 in capitation payments identified
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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 those enrollments. He noted the $798,000 figure reflects monthly capitation paid to MCOs, not medical claims. "We identified 62 that appear to have committed fraud in getting on the program," the presenter said.
The audit team is continuing work to quantify related SNAP, WIC and TANF payments tied to these enrollments. The presenter said enrollment as a pregnant woman can trigger other benefits and that preliminary work shows some beneficiaries received additional SNAP, TANF and utility assistance after enrolling as pregnant women.
Committee members pressed how pregnancies are verified. The presenter said state policy allows self‑attestation of pregnancy unless there is reason to doubt the claim; auditors recommended additional checks for cases that meet obvious red flags, such as improbable ages or absence of prenatal claims. He said 20 criminal investigations would be opened in connection with the pregnant‑woman audit, subject to available staffing, and that other investigations are ongoing with federal partners.
Lawmakers also discussed tools to improve detection. One senator noted a software company that claims to identify anomalies; the presenter said such technology could help flag cases with zero claims or otherwise atypical patterns but that staffing shortages limit the office’s ability to follow up.
Next steps: the office will finish an interim report and continue investigations; several cases may move toward prosecution with federal partners, the presenter said.