Follow-Up Report on Prior Audit Recommendations Oversight and Encounter Claim Integrity of the Comprehensive Health Care Program
Learn how the AI-generated research projects were createdOverall Conclusion
MDHHS did not fully remediate Finding 1; a material condition still exists; Finding 2 was complied.
Source Document
Audit Scope
Follow-up of two material conditions from the May 2019 CHCP performance audit; generally covering June 1, 2021 through May 31, 2022.
Key Findings Summary
Monitoring of Medicaid Health Plan (MHP) encounter claim data and supporting medical records needed.
Activation and development of certain CHAMPS edits needed.
AI-Assisted
AI Scope Summary
This follow-up assesses whether MDHHS has implemented corrective actions for two material conditions from the May 2019 CHCP performance audit, covering encounter claim data, medical record documentation, and CHAMPS edits during June 2021–May 2022, to inform future improvements and ensure compliance with federal and state requirements.
AI-Generated Insight
The follow-up indicates progress in tightening controls over CHAMPS and MHP encounter claims but notes a persistent material condition in ensuring medical record support for claims, guiding future audits toward documented verification processes and EDV protocol integration.
Audit Objectives
Determine whether MDHHS had taken appropriate corrective measures in response to the two material conditions noted in the May 2019 audit report.
Audit Findings (2)
Monitoring of Medicaid Health Plan (MHP) encounter claim data and supporting medical records needed.
Activation and development of certain CHAMPS edits needed.
Recommendations (2)
MDHHS implement a process to help ensure that MHP encounter claims are properly supported by medical records and accurately represent the medical services provided.
MDHHS activate and develop edits to identify and reject improper and duplicate encounter claims to help ensure the accuracy of capitation rates and the amount that the State pays to MHPs.