Medicaid Managed Care Contract Monitoring Follow-Up and Oversight of Health Plan Complaint and Grievance Handling Operational Audit
Learn how the AI-generated research projects were createdOverall Conclusion
The audit identified deficiencies in internal controls related to ECGA reporting, data summaries, and follow-up actions, indicating a need for strengthened oversight and documentation.
Source Document
Audit Scope
This audit focused on Medicaid Managed Care contract monitoring follow-up and oversight of health plan complaint and grievance handling, examining activities from July 2021 through January 2023, with testing of ECGA reports and related compliance actions from July 2021 through January 2023 and management actions through July 2023.
Key Findings Summary
Agency controls over Medicaid Managed Care health plan complaint, grievance, and appeal data reports and the preparation of compliance action forms need improvement, including lack of CCU Supervisor quality review documentation, incomplete reporting of noncompliance issues, and inconsistent use of Compliance Action forms.
AI-Assisted
AI Scope Summary
Building on this report's findings, future Medicaid audits could emphasize verifying that ECGA Data Summary Reports receive documented supervisory review, that all noncompliance issues are captured in Compliance Action forms, and that data reporting across all health plans matches contract requirements.
AI-Generated Insight
This report highlights weaknesses in the Agency's oversight of ECGA reporting and follow-up actions, underscoring the need for formal supervisory review, complete documentation of noncompliance issues, and consistent use of Compliance Action forms to support accountable decision-making.
Audit Objectives
Evaluate management’s performance in establishing and maintaining internal controls, including controls designed to prevent and detect fraud, waste, and abuse, and in administering responsibilities in accordance with applicable laws, administrative rules, contracts, grant agreements, and other guidelines.
Examine internal controls designed and placed into operation to promote and encourage the achievement of management’s control objectives in the categories of compliance, economic and efficient operations, the reliability of records and reports, and the safeguarding of assets, and identify weaknesses in those internal controls.
Determine whether management had corrected, or was in the process of correcting, Finding 2 disclosed in our report No. 2018-002.
Identify statutory and fiscal changes that may be recommended to the Legislature pursuant to Section 11.45(7)(h), Florida Statutes.
Our audit also included steps to determine whether management had corrected, or was in the process of correcting, all applicable deficiencies noted in our report No 2021-198 (Findings 1 and 5 through 8).
Audit Findings (1)
Agency controls over Medicaid Managed Care health plan complaint, grievance, and appeal data reports and the preparation of compliance action forms need improvement, including lack of CCU Supervisor quality review documentation, incomplete reporting of noncompliance issues, and inconsistent use of Compliance Action forms.
Recommendations (1)
Enhance policies and procedures to require supervisory review of ECGA Data Summary Reports and ensure that Compliance Action forms are prepared for all noncompliance issues noted in accordance with Agency policies and procedures.