In a recent performance audit, the department exposed fiscal discrepancies within UPMC's management of the Community HealthChoices contract. According to a report by the Department of the Auditor General, over $350,000 of taxpayer money was squandered in 2022, with $120,000 rendered unrecoverable due to contractual constraints. Deputy Auditor General for Audits Gordon Denlinger led the audit, which pointed to UPMC's failures in updating participant information as the primary cause of financial losses.
"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. Due to UPMC's lax approach in informing the Pennsylvania Department of Human Services (DHS) of changes in participant statuses, DHS was inaccurately billed, resulting in significant overpayment. Conversely, DHS has been advised to enhance contract terms to avoid such losses in future endeavors, as detailed by the Department of the Auditor General.
The audit did not merely focus on past discrepancies but also laid out recommendations for UPMC and DHS to tackle issues of accountability and efficiency. UPMC has been urged to reform its payment reconciliation process, increase Medicare eligibility outreach, and commit to regular weekly status updates, as the contract stipulates. Meanwhile, DHS's role in recouping expenditures extends to closing loopholes within their contract language and assuring annual participant contact to verify changes in circumstances.
The Community HealthChoices program, a crucial segment of HealthChoices that intersects physical, behavioral, and community care, is designed to foster independence among Pennsylvania residents via Medicaid and Medicare. Encompassing over 450,000 individuals, the program aims to shift the experience of health care away from institutional settings and towards community presence. Despite the noble intentions, UPMC, which coordinated care for over 140,000 people last year, was found wanting in its administrative duties.
Notably, Auditor General DeFoor recused himself from the audit due to past professional ties with UPMC, where he served as an auditor and fraud investigator.
