Washington, D.C. - Puerto Rico’s Department of Health claimed reimbursements for more than $7 million in Medicaid funds made on behalf of participants who were dead or potentially dead.

A report by the U.S. Department of Health’s Office of Inspector General (OIG) recommends the federal government to ask the Puerto Rico government to refund the money paid in capitation payments, which are payments to providers for each patient enrolled in a health plan.

The OIG selected a stratified random sample of 105 capitation payments between April 1, 2018, and September 30, 2020, and confirmed that only three of those participants were not dead.

The OIG found that in 90 cases, “the associated enrollees were deceased prior to the month covered by the capitation payment.” In the remaining 12 cases, participants were dead but the OIG could not confirm “the enrollee’s month and year of death.”

”These unallowable and potentially unallowable payments occurred because DOH´s controls were not sufficient to identify the deceased enrollees. Also, DOH lacked a process to ensure that ASES identified and made adjustments to correct unallowable payments,” the OIG report states.

The OIG estimates that the Department of Health claimed at least $6,979,822 in unallowable Federal Medicaid funds and $885,123 in potentially unallowable Federal Medicaid funds.

The OIG used different sources to conduct the audit, including, among others, the Death Master File (DMF) and the Puerto Rico Demographic Registry.

In its comments, the U.S. Department of Health DOH “partially concurred” with the OIG´s recommendation to refund the money.

According to the OIG, the government of Puerto Rico, through ASES, “has recovered more than $580,000 in capitation payments.”