Maryland's Medicaid agency still hasn't checked $430.7M in claims
Summary
After a 2023 audit flagged the gap, Maryland's Medical Care Programs Administration told legislative auditors it would start reviewing denied Medicaid claims -- including $287 million in duplicates -- before using that data to set what the state pays private managed-care insurers, by March 2024. As of October 2025, per the state's own legislative auditors, it still hadn't. The same audit found two more repeat problems from the prior review, both still unresolved: $7.8 million in payments for enrollees who were incarcerated, and $13.8 million in newborn-delivery payments never investigated.
A promise made in 2023, still broken in 2025
Of the $430.7 million in denied claims MCPA never reviewed, auditors found $287 million -- 124,500 claims, including $203.8 million from 2024 alone -- were specifically denied because they duplicated a previously submitted claim. The audit calls this pool 'questionable,' not confirmed improper, precisely because MCPA never checked it. The prior audit, dated December 2023, flagged this same failure to exclude ineligible claims from the state's capitation-rate calculations. MDH's response at the time committed to reviewing denied claims by March 2024. Auditors checked back: as of October 2025, MCPA 'had not performed any such reviews.'
View data as table
| 2024 | 324,621,813 |
|---|---|
| 2023 | 89,005,336 |
| 2022 | 17,088,705 |
Not the only repeat finding
The same audit surfaced two more problems the prior review had already flagged, with sharper repeat evidence than a raw dollar figure. Matching state incarceration records against Medicaid enrollment, auditors found 2,452 people were enrolled with a managed-care organization while incarcerated -- whose health costs generally fall to the corrections system rather than an MCO -- producing $7.8 million in confirmed improper payments. Of those 2,452 people, 508 had also been individually flagged in the prior audit; MCPA told auditors it hadn't changed its matching process since then. Separately, MCPA still hadn't investigated 768 potentially improper newborn-delivery payments worth $13.8 million from 2022-2023. At auditors' request, MCPA checked a small, non-random sample of 20 of those claims and confirmed a quarter of the dollars -- $88,900 of $352,000 -- had in fact been paid improperly.
The clearest sign nothing changed: as of October 2025, MCPA still hadn't investigated 605 of the 625 newborn-delivery claims specifically identified as potentially improper in the prior audit -- about 97% of what was flagged the first time remained untouched two audit cycles later.
View data as table
| Still uninvestigated | 96.8% |
|---|---|
| Investigated | 3.2% |
The takeaway
- A specific promise, dated and broken. MDH told auditors in response to the 2023 audit that MCPA would review denied claims by March 2024. As of October 2025 -- 19 months later -- it still hadn't, leaving $430.7 million in claims, including $287 million in flagged duplicates, unreviewed.
- This isn't a one-off gap -- it's a pattern, and the audit has the receipts. Three of the four findings in the prior audit recurred unresolved in this one. 508 of the 2,452 people flagged this time for improper incarcerated-enrollee payments were already flagged last time; 605 of 625 newborn-delivery claims flagged last time are still uninvestigated.
- MDH agreed with the findings -- again. The department's official response, included in the audit, agreed with the recommendations -- the same posture it took after the 2023 audit, before three of that audit's own findings went uncorrected.
This piece covers three of the four findings in the Maryland Office of Legislative Audits' report on MCPA's Managed Care Program (MCPA-MCO26, dated January 14, 2026), covering April 1, 2022 through May 15, 2025. It does not cover the audit's fourth finding, involving $18.7 million in payments to a state university under a rate-setting interagency agreement -- a separate matter not detailed here, though notably the same university is the vendor MCPA relies on elsewhere in this audit to help calculate capitation rates and screen newborn-delivery claims. This is a fiscal compliance audit, not a fraud investigation, and the report does not allege criminal wrongdoing.
This piece follows the audit's own, non-uniform terminology rather than flattening it: the $7.8 million incarcerated-enrollee figure and the $88,900 newborn-delivery subset are both confirmed 'improper payments' by the auditors; the $13.8 million newborn-delivery pool is only 'potentially improper'; and the $430.7 million and $287 million denied/duplicate-claims figures were never characterized as improper at all, since MCPA never reviewed them -- the audit calls that population 'questionable.' In its response, MDH separately claimed to have since completed validation reviews resolving most newborn-delivery claims from 2022-2024 (98-98.7% validated by its account), a corrective-action claim not independently confirmed by auditors against the specific $13.8 million cohort this piece covers.
Sources(1) ▾
- Office of Legislative Audits, Department of Legislative Services, Maryland General Assembly, Maryland Department of Health, Medical Care Programs Administration -- Managed Care Program (Audit Report MCPA-MCO26) (2026-01-14) — The Maryland General Assembly's independent legislative audit of the state's Medicaid managed care program (HealthChoice), covering April 1, 2022 through May 15, 2025. This piece draws on Findings 1-3 -- denied/duplicate claims never reviewed, improper payments for incarcerated enrollees, and uninvestigated newborn-delivery payments -- and the audit's own comparison to its December 14, 2023 preceding report showing all three as repeat, uncorrected findings. dls.maryland.gov · original document
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Maryland's Medical Care Programs Administration (MCPA) never reviewed 807,165 Medicaid managed-care claims, totaling $430.7 million, that the state's own claims system denied between 2022 and 2024, according to a Maryland Office of Legislative Audits report⧉. MCPA uses this expenditure data -- including denied claims it never checked -- to help calculate what the state pays private insurers to cover 1.1 million Medicaid recipients. After a 2023 audit flagged the same gap, MDH promised a fix by March 2024. It never happened.