Improper Medicaid payments to ineligible recipients cost Virginia anywhere from $18 million to $263 million in 2009 and “major investments” are needed to shore up the system, according to a new state audit.

The audit also found that some Virginians eligible for care were erroneously turned down — as much as 25 percent of all denials and cancellations — which could have limited access to medical care for needy citizens.