HARRISBURG, PA — A performance audit conducted by the Pennsylvania Department of the Auditor General has uncovered significant shortcomings in UPMC’s management of its Community HealthChoices (CHC) contract with the Department of Human Services (DHS), resulting in taxpayers losing $120,977 in unrecoverable funds in 2022.
The audit findings were presented by Deputy Auditor General for Audits Gordon Denlinger, highlighting that UPMC, a managed care organization, failed to provide timely updates on program participant eligibility. These errors contributed to $357,048 in overpayments from DHS, of which the state was unable to recover over $120,000 due to contractual limitations.
“UPMC is required to report to DHS whether a person has died, went to jail or is no longer eligible to be part of the program,” Denlinger explained. “DHS uses this as part of the data to set the rate it pays UPMC to provide care to people on Community HealthChoices. UPMC needs to make sure there is greater accountability in its management structure to ensure the required assessments are happening on time and regularly.”
Key Audit Findings
The performance audit revealed multiple critical concerns regarding UPMC’s oversight of its contract duties, particularly its failure to conduct participant assessments or to notify DHS of changes in eligibility. These failures undermined the proper functioning of the Community HealthChoices program, which provides long-term support and healthcare services for over 450,000 Pennsylvanians.
Specific findings included:
- Missed Assessments and Reporting Delays: UPMC did not consistently complete required participant assessments, nor did it notify DHS of eligibility changes in a timely manner.
- Payment Reconciliation Gaps: UPMC lacked robust procedures for reconciling payment inaccuracies.
- Medicare Eligibility Outreach: The organization fell short in ensuring that participants’ Medicare eligibility was accounted for, potentially impacting care coordination.
The audit, which focused on the community care segment of the HealthChoices program, emphasized that these errors have a direct financial impact on taxpayers.
Recommendations for Improvement
The audit report outlined several recommendations to address the identified issues, including procedural changes for both UPMC and DHS. Denlinger stressed the importance of weekly updates to DHS regarding participant eligibility status, as required under the contract.
Further recommendations were directed at DHS to close contractual loopholes and improve protections for public funds. “DHS can make sure Pennsylvanians get back all the money owed to them when they overpay for services by changing the contract language to close this loophole,” Denlinger stated. He also suggested that DHS require UPMC to make annual contact with all program participants to verify their eligibility.
About Community HealthChoices
The Community HealthChoices program, part of Pennsylvania’s HealthChoices system, coordinates care for individuals 21 and older who require long-term support through Medicaid and Medicare. Its services include physical health care, nursing facility care, and home- and community-based services, allowing participants to remain in their homes and communities whenever possible.
UPMC serves more than 140,000 people under the CHC program and received nearly $360 million in payments from the state last year.
Broader Implications
The findings highlight systemic challenges in overseeing publicly funded programs, where accountability and accurate data reporting are paramount. Auditor General Timothy L. DeFoor, who recused himself from this audit due to his prior connection with UPMC, has consistently advocated for transparency in state operations to protect taxpayer dollars.
This audit serves as a clear reminder of the need for effective contract management and oversight to ensure taxpayer resources are used as intended, particularly in programs that serve vulnerable populations. The Department of the Auditor General has underscored its commitment to monitoring compliance and ensuring Pennsylvanians benefit from streamlined, efficient government programs.
The next steps for implementing these recommendations and addressing audit findings now rest with both UPMC and DHS, as taxpayers await decisive action to rectify these costly lapses.
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