Medicaid Audit Intelligence

Publishing agency

U.S. Department of Health and Human Services, Office of Inspector General

Reports attributed to this exact publisher identity in the indexed source metadata.

Evidence register

24 reports

Published
Jun 2026
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 163

Inaccurate Medicaid Managed Care Network Lists May Compromise State Oversight of Access to Maternal Health Care

We found that the network lists from Centene, Elevance, and UnitedHealthcare Medicaid plans in five States contained inaccuracies—potential ghost providers who reported not being in-network, incorrect contact information, and discrepancies with online provider directories—that…

Findings
3
Recommendations
2
Open evidence record
Source status
Original source
Published
Dec 2025
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 119

Illinois Medicaid Managed Care Capitation Payments for Incarcerated Enrollees

The audit determined that Illinois made unallowable managed care capitation payments for incarcerated enrollees during the audit period, totaling at least $9.5 million with $8.3 million Federal share, and identified failures to terminate enrollment as required. Recovered findi…

Findings
3
Recommendations
2
Open evidence record
Source status
Original source
Published
Dec 2025
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 118

Medicaid Agencies Made Millions in Unallowable Capitation Payments to Managed Care Organizations on Behalf of Deceased Enrollees

We estimate that Medicaid agencies made $207,501,380 ($138,645,710 Federal share) in unallowable capitation payments to MCOs for deceased enrollees during the audit period (July 1, 2021 – June 30, 2022).

Findings
4
Recommendations
2
Open evidence record
Source status
Original source
Published
Jul 2025
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 46

Wisconsin’s Fee-for-Service Medicaid Payments for Applied Behavior Analysis

The Wisconsin Department of Health Services’ ForwardHealth program did not provide adequate oversight of FFS Medicaid ABA payments, resulting in improper and potentially improper payments for autism-related ABA services. The program had not conducted a statewide postpayment re…

Findings
12
Recommendations
6
Open evidence record
Source status
Original source
Published
Jul 2025
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 50

Pennsylvania Capitation Payments for Enrollees With Multiple Medicaid Identification Numbers

The OIG concluded that Pennsylvania made unallowable capitation payments totaling at least $8,784,549 ($4,596,390 Federal share) for enrollees with multiple Medicaid ID numbers during the audit period (January 1, 2019 – December 31, 2022). The unallowable payments were caused…

Findings
3
Recommendations
5
Open evidence record
Source status
Original source
Published
Jul 2025
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 45

Analysis of Selected Nursing Facilities’ Use of Medicaid Reimbursement for Direct Care Compensation

The data brief concludes that there is no clear, positive correlation between higher direct care compensation and higher nursing hours per resident day (HPRD). Increases in direct care compensation are largely attributed to higher labor costs from contracting for nursing staff…

Findings
9
Recommendations
0
Open evidence record
Source status
Original source
Published
May 2025
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 57

Maryland Did Not Comply With Federal Waiver and State Requirements at 20 Adult Day Care Facilities Audited

The Maryland Department of Health did not fully comply with Federal waiver and State requirements in overseeing adult day care facilities; 253 noncompliance instances were identified across health and safety and administrative areas, with inspections insufficient to detect vio…

Findings
1
Recommendations
3
Open evidence record
Source status
Original source
Published
Apr 2025
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 51

Audit Of Ohio Adult Day Health Care Services

The Ohio Department of Medicaid did not fully comply with Federal waiver and State requirements in overseeing providers serving adults in the ADS program; inspections were insufficient to ensure a continuously safe and nonhazardous environment, placing adults at risk.

Findings
1
Recommendations
1
Open evidence record
Source status
Original source
Published
Mar 2025
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 56

North Carolina’s Medicaid Control Environment, Risk Management Practices, and Governing Processes Were Assessed as Moderate Risk

Overall, the audit determined that North Carolina's Medicaid control environment, risk management practices, and governing processes operate at a moderate risk level, with three risk areas rated high and three rated moderate; the State agency has implemented numerous controls…

Findings
7
Recommendations
11
Open evidence record
Source status
Original source
Published
Mar 2025
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 49

Texas Did Not Fully Comply With Federal Waiver And State Health, Safety, And Administrative Requirements At All 20 Adult Day Activity And Health Service Facilities Audited

The State agency did not fully comply with Federal waiver and State requirements in overseeing DAHS facilities serving people with special health care needs, and its inspections were not sufficient to ensure a safe and nonhazardous environment, leaving program participants at…

Findings
8
Recommendations
3
Open evidence record
Source status
Original source
Published
Feb 2025
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 37

Colorado Made Capitation Payments to Managed Care Organizations After Enrollees’ Deaths

The audit found that Colorado made unallowable capitation payments to Medicaid managed care organizations for deceased enrollees, resulting in significant financial losses and reporting inaccuracies. The State agency lacked adequate controls and policies to prevent and recover…

Findings
0
Recommendations
0
Open evidence record
Source status
Original source
Published
Dec 2024
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 44

Twelve Selected States Did Not Accurately Calculate the Federal Share of Medicaid Collections Subject to the Increased COVID-19 Federal Medical Assistance Percentages

Twelve of the thirteen selected States did not accurately calculate the Federal share of Medicaid collections subject to the increased COVID-19 FMAP, resulting in net underreporting of $61.8 million. CMS concurred with all four recommendations and described actions to address…

Findings
5
Recommendations
4
Open evidence record
Source status
Original source
Published
Jul 2024
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 95

California Payments for Enrollees With Concurrent Medicaid Enrollment in Another State

We estimated that the State agency incurred costs of approximately $19.9 million ($15.5 million Federal share) for August 2021 capitation payments made on behalf of enrollees who were residing and concurrently enrolled for Medicaid in another State. This amount represents pote…

Findings
5
Recommendations
2
Open evidence record
Source status
Original source
Published
Jun 2024
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 55

North Carolina Did Not Report and Return All Medicaid Overpayments for the State's Medicaid Fraud Control Unit Cases

The State agency did not report and return the Federal share of all MFCU-determined Medicaid overpayments identified for the period under review (October 1, 2019 through September 30, 2021).

Findings
5
Recommendations
3
Open evidence record
Source status
Original source
Published
May 2024
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 98

Colorado's Program Integrity Section Reporting of Medicaid Overpayments

Colorado did not report and refund the correct Federal share of Medicaid overpayments identified by its Program Integrity Section during Oct 1, 2014 through Dec 31, 2020; 80 of 403 cases contained unreported or incorrectly reported amounts, with late reporting and misused feed…

Findings
6
Recommendations
5
Open evidence record
Source status
Original source
Published
May 2024
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 99

California Improperly Claimed $52.7 Million in Federal Medicaid Reimbursement for Capitation Payments Made on Behalf of Noncitizens With Unsatisfactory Immigration Status

California improperly claimed Federal Medicaid reimbursement for capitation payments to noncitizens with UIS by applying an outdated proxy percentage that did not reflect the true costs of nonemergency services; recommends refund and coordination with CMS to determine reimburs…

Findings
4
Recommendations
2
Open evidence record
Source status
Original source
Published
Mar 2024
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 43

CMS Did Not Ensure That Selected States Complied With Medicaid Managed Care Mental Health and Substance Use Disorder Parity Requirements

CMS did not ensure that selected States complied with Medicaid managed care MH/SUD parity requirements; noncompliance was widespread across eight States, including missing parity provisions in contracts, lack of parity analyses and public posting, and restrictive practices by…

Findings
6
Recommendations
8
Open evidence record
Source status
Original source
Published
Feb 2024
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 97

Colorado Could Better Ensure That Nursing Homes Comply With Federal Requirements For Life Safety, Emergency Preparedness, And Infection Control

Colorado could better ensure that nursing homes participating in Medicare and Medicaid comply with Federal life safety, emergency preparedness, and infection control requirements. Deficiencies were observed across all 20 nursing homes audited, indicating ongoing oversight chal…

Findings
7
Recommendations
3
Open evidence record
Source status
Original source
Published
Nov 2023
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 42

Multiple States Made Medicaid Capitation Payments to Managed Care Organizations After Enrollees’ Deaths

The report concludes that improper Medicaid capitation payments to MCOs on behalf of deceased enrollees remain a persistent issue across states, with prior unallowable payments totaling about $249 million and ongoing uncollected federal shares. While CMS has made substantial p…

Findings
5
Recommendations
3
Open evidence record
Source status
Original source
Published
Oct 2023
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 41

States Face Ongoing Challenges in Meeting Third-Party Liability Requirements for Ensuring That Medicaid Functions as the Payer of Last Resort

OIG concludes that States continue to face persistent and wide-ranging challenges in meeting third-party liability requirements for Medicaid, even after the Deficit Reduction Act provisions and CMS guidance. The report notes substantial reporting errors by numerous States, lim…

Findings
15
Recommendations
8
Open evidence record
Source status
Original source
Published
Sep 2023
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 9

New York Did Not Ensure That A Managed Care Organization Complied With Requirements For Denying Prior Authorization Requests

The audit concluded that the New York State Department of Health’s oversight was ineffective in ensuring that CPHL complied with requirements for denying prior authorization requests, resulting in delays and potential adverse impacts on Medicaid enrollees' health and safety.

Findings
1
Recommendations
3
Open evidence record
Source status
Original source
Published
Nov 2022
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 88

The Centers for Medicare & Medicaid Services’ Review Contractors Generally Conducted Medicaid Fee-for-Service Claim Reviews for Selected States Under the Payment Error Rate Measurement Program in Accordance with Federal and State Requirements

CMS’s review contractors adequately conducted Medicaid FFS claim reviews for three States (Arkansas, Connecticut, and New Mexico) under the PERM program in accordance with Federal and State requirements.

Findings
5
Recommendations
1
Open evidence record
Source status
Original source
Published
Sep 2022
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 40

Nearly All States Made Capitation Payments for Beneficiaries Who Were Concurrently Enrolled in a Medicaid Managed Care Program in Two States

CMS did not concur with the recommendations. The OIG maintains that the recommendations are valid and will continue to work with States to identify opportunities to reduce the number and amount of concurrent Medicaid capitation payments. The audit highlighted that concurrent e…

Findings
7
Recommendations
1
Open evidence record
Source status
Original source
Published
Mar 2022
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 90

The Centers for Medicare & Medicaid Services’ Eligibility Review Contractor Adequately Determined Medicaid Eligibility for Selected States Under the Payment Error Rate Measurement Program

We determined that CMS’s eligibility review contractor correctly determined Medicaid eligibility for the beneficiaries associated with all 100 sampled claims. Based on our sample results, CMS’s eligibility review contractor adequately determined Medicaid eligibility for three…

Findings
3
Recommendations
0
Open evidence record
Source status
Original source