Audit finding — capitation recoupment / CMS-64 exposure
Transition Orphans
27,943
Members affected
$155.1M
Estimated exposure
7.4
Avg months at risk
$108.7M–189M
Exposure range
What this is
Members carried onto the Meridian claims platform during the vendor cutover and still receiving capitation, with no active eligibility span behind them in CBES.
Why single-system review misses this
CBES correctly shows these cases closed; Meridian correctly shows enrolled, paying members. Each system passes its own audit — only a cross-system join on the cutover window exposes payment with no eligibility.
One member, two systems
Member CAS-00000026 — the eligibility record and the payment record, on one clock. The hatched window is the seam.
CBES eligibility spanMMIS enrollment spanthe seam — capitation paid with no eligibility behind it
The exposure math, in the open
members × avg monthly capitation × avg months paid without eligibility
27,943members×$746avg per month×7.4avg months≈$155.1Mestimated exposure
Example members:CAS-00000026CAS-00000030CAS-00000047CAS-00000071CAS-00000082