A new audit from Guam’s Medicaid program reveals $241.1 million in questionable payments due to lax oversight, outdated records, and noncompliance with federal and local regulations, according to the Office of Public Accountability.

The audit, conducted on the Department of Public Health and Social Services Medicaid Program, examined $399.6 million in payments made between Fiscal Year 2020 through Fiscal Year 2022 to 218 healthcare providers. Key findings highlighted significant deficiencies in 28 out of the total 215 Medicaid providers eligibility screening, revalidation, and recordkeeping.

Major Findings:

  • Outdated or Missing Provider Revalidations
    • Some providers had not been revalidated for 8-10 years, despite federal requirements mandating updates every five years.
  • Payments to Ineligible Providers
    • At least 12 providers received $233.8 million despite outdated credentials, while off-island providers collected $7.3 million without proper revalidation.
  • Lack of Proper Documentation
    • Some providers lacked required licenses or official enrollment agreements, yet still received Medicaid payments.
  • Disorganized Recordkeeping
    • Missing files, illegible documents, and a lack of a centralized database made it difficult to track provider compliance.

The OPA warns that these issues increase the risk of fraud and financial waste, potentially allowing unqualified or fraudulent providers to remain in the system. The report also emphasizes that the lack of proper oversight could impact the quality of healthcare services for Medicaid recipients.

Senator Sabrina Salas Matanane, Chairperson of the Committee on Health and Veterans Affairs, expresses concerns over the findings. Stating that a larget sample size of Medicaid providers would have likely revealed more questionable costs.

“The audit reviewed only a sample of just 28 out of 218 Medicaid providers. I am convinced that a larger sample would have highlighted even more questionable costs,” Matanane said.

And while the audit did not confirm intentional fraud, the senator notes that it reveals systemic issues.

“Our outdated technology and recordkeeping practices have hampered progress not only at the Department of Public Health but also at institutions like Guam Memorial Hospital and the Guam Office of Veterans Affairs. This situation underlines the urgent need to upgrade our systems, improve our procedures, and ensure we fully comply with local and federal regulations.”

Matanane also warns that these deficiencies could jeopardize future Medicaid funding, especially given federal cost-cutting efforts. In her comments she also announces plans to hold an informational briefing with DPHSS in the coming weeks to discuss the audit’s findings and the department’s corrective action plan.

DPHSS acknowledges the deficiencies and has provided OPA with an action plan to implement corrective measures. However, no formal public response from DPHSS was included in the report.

The audit is the first in a three-part series examining the Medicaid program’s operation.