Guam Medicaid Audit Questions $241M in Provider Payments
Summary
A three-year performance audit by Guam's territorial auditor found the island's Medicaid program paid $399.6 million to healthcare providers between fiscal 2020 and 2022, then questioned $241.1 million of it -- 60 cents of every dollar -- because a dozen providers had gone eight to ten years without the revalidation federal law requires every five, and four off-island providers had never been revalidated at all. The audit found no confirmed fraud; it found a program that kept paying providers whose eligibility to be paid had lapsed, sometimes for a decade, without anyone checking.
How a five-year check became eight to ten
Federal regulation -- 42 CFR § 455.414⧉ -- requires state and territorial Medicaid agencies to revalidate every provider's enrollment at least once every five years, confirming licenses, ownership, and other eligibility facts are still current. OPA's audit found 12 Medicaid providers whose enrollment agreements had gone unrevalidated for roughly eight to ten years -- accounting for $233.8 million of the questioned total -- and four off-island providers, approved between 2008 and 2016, whose revalidations had come due between 2013 and 2021 and were never filed at all, accounting for a further $7.25 million. DPHSS kept disbursing payments to both groups the entire time. A separate 10 providers had revalidations filed late, 146 to 535 days past their due dates -- delays the audit flagged but did not attach a dollar figure to. Two more providers had no enrollment agreement on file, past or current, and were listed as "non-participating" in DPHSS's own records, yet still collected $8,500 in Medicaid payments during the period.
View data as table
| 12 providers unrevalidated 8-10 years | 233,814,049 | Providers whose federally required five-year revalidation had lapsed by roughly eight to ten years, per the audit's own sample. |
|---|---|---|
| 4 off-island providers never revalidated | 7,251,018 | Providers approved 2008-2016, due for revalidation 2013-2021, with no revalidation ever filed. |
A finding built on 13% of the providers
The audit's dollar figures rest on a review of 28 of Guam's 218 participating Medicaid providers -- 13% of the total -- selected because their files raised the most concern, not a random or full-population sample. OPA also found DPHSS lacked a provider enrollment checklist until June 2023, meaning auditors "cannot ascertain the effectiveness of the screening, evaluation and approval process" for any provider approved before that date -- which covers the entire FY2020-2022 window this audit examined. On-island hospital care was the single largest slice of the $399.6 million Guam paid providers over the three years, at $209.0 million (52%), with the remainder split across pharmacy, physician and clinic services, dental, dialysis, and smaller categories.
View data as table
| Total paid to 218 providers | 399,581,308.4 | |
|---|---|---|
| Questioned (lapsed or missing revalidation) | 241,065,067 | 60% of every dollar Guam's Medicaid program paid providers over the three fiscal years -- from a sample covering 13% of providers. |
The next installment found no dollars, but the same paperwork gap
OPA's Medicaid review is a three-part series, and Part II⧉, published February 2026, turned to the other side of the program: whether the roughly 35,381 people a year who received a combined $400.7 million in Medicaid benefits in fiscal 2023-2024 had their own eligibility properly documented. That audit found the same kind of gaps -- missing application forms, absent signatures, late notices of eligibility decisions -- but assigned $0 in questioned costs across every finding, because the benefits at issue could have been legitimately owed from prior years and the auditors couldn't rule that out. A third installment, covering Medicaid billings and provider payments directly, was still pending as of Part II's publication.
- Guam's Medicaid program paid $399.6 million to providers over three fiscal years, and its own auditor questioned $241.1 million of it -- 60 cents of every dollar -- almost entirely because provider enrollments had gone unrevalidated for years past the federal five-year requirement, not because of confirmed fraud.
- Twelve providers drove nearly all of it: $233.8 million in payments to providers unrevalidated for eight to ten years, plus $7.25 million to four off-island providers never revalidated since their original approval a decade or more earlier.
- The finding rests on a 13% sample. Auditors reviewed 28 of 218 participating providers, chosen because their files raised concern -- meaning the $241.1 million figure describes what a targeted review found, not a full accounting of the remaining 87%.
- DPHSS agreed with all nine of the audit's recommendations and submitted corrective action plans, but a follow-on 2026 audit of the same Medicaid program found the underlying documentation and processing gaps persisting in a different corner of the system -- client eligibility files -- a year later.
"Questioned costs" is the audit's own classification, defined in the report as costs flagged "because of an alleged violation of a provision; costs not supported by adequate documentation; or a finding that the expenditure of funds for the intended purpose is unnecessary or unreasonable." The audit does not conclude that Medicaid services described in these payments were not actually delivered, and DPHSS disputed none of the underlying dollar figures in its management response. All figures describe DPHSS's Medicaid provider program specifically, for fiscal years 2020 through 2022 (Part I's audit scope); the Part II figures cited for context cover a different population -- Medicaid clients, not providers -- and a different two-year window, fiscal 2023-2024.
Sources(2) ▾
- Guam Office of Public Accountability (OPA), Department of Public Health & Social Services -- Medicaid Program -- Provider Eligibility, Part I (OPA Report No. 25-03) (2025-02-01) — Part I of a three-part performance audit series on Guam's Medicaid program, covering fiscal years 2020-2022 (October 1, 2019 through September 30, 2022). Focuses on whether the Department of Public Health & Social Services' (DPHSS) Medicaid provider database was accurate and whether provider enrollment, screening, and revalidation followed federal and local law. Read directly from the publisher's PDF via pdftotext -layout after direct download (no login required); the cover page states only the publication month, not an exact day, so 'date' above is set to the 1st of that month as a placeholder for sorting. Wayback Machine's Save Page Now returned a server error (520) on the one capture attempt made this iteration; the 'capture' field below points to the same direct publisher URL as 'url' rather than an archived copy. opaguam.org · original document
- Guam Office of Public Accountability (OPA), Department of Public Health & Social Services -- Medicaid Program -- Client Eligibility, Part II (OPA Report No. 26-01) (2026-02-01) — Part II of the same three-part audit series, covering client (beneficiary) eligibility for fiscal years 2023-2024. Used here only for the series' follow-on status: what the next installment found (or didn't find) in dollar terms, and confirmation that a third part -- provider billings and payments -- was still pending as of this report. Cover page states only the publication month; 'date' set to the 1st as a placeholder. Wayback's Save Page Now returned a server error (520) on the one capture attempt made this iteration; 'capture' points to the same direct publisher URL as 'url'. opaguam.org · original document
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Guam's Office of Public Accountability (OPA) -- the territory's independent, legislative-branch audit office -- has questioned $241.1 million⧉ in Medicaid provider payments the Department of Public Health & Social Services (DPHSS) made between fiscal years 2020 and 2022, out of $399.6 million paid to 218 participating providers over that period. Questioned costs, in audit language, are payments the auditor flags as violating a rule, lacking required documentation, or otherwise not clearly justified -- not necessarily fraud or services never rendered. Here the rule was a federal one: providers must have their Medicaid enrollment revalidated at least once every five years, and DPHSS kept paying a dozen providers whose revalidation had lapsed by eight to ten years.