Oversight and Encounter Claim Integrity of the Comprehensive Health Care Program
Learn how the AI-generated research projects were createdOverall Conclusion
Sufficient, with exceptions.
Source Document
Audit Scope
To examine the records and procedures related to MDHHS's efforts pertaining to MHP encounter claim data, oversight of MHP-enrolled beneficiary access to medical care, and monitoring of MHP provider networks. Period covered: October 1, 2014 through May 31, 2017. Fee-for-service verification and Medicaid beneficiary eligibility verification were excluded; the Michigan Office of the Auditor General conducted fieldwork and analysis in accordance with GAO standards.
Key Findings Summary
MDHHS needs to monitor MHP encounter claim data and supporting medical records.
Activation and development of certain CHAMPS edits needed.
Oversight of BMP needs improvement.
AI-Assisted
AI Scope Summary
This performance audit assesses MDHHS's sufficiency of controls over MHP encounter claim data, beneficiary access to care, and provider-network monitoring, revealing material conditions and areas for improvement in data validation, edit activation, and BMP oversight, with conclusions that are generally 'sufficient, with exceptions' and recommendations to strengthen monitoring, claim validation, and BMP enforcement.
AI-Generated Insight
The Michigan MDHHS CHCP encounter-claim audit identifies material data integrity and BMP oversight issues, with potential future overpayments tied to unsupported claims and incomplete monitoring of BMP enrollees and CHAMPS edits.
Audit Objectives
To assess the sufficiency of MDHHS's efforts to ensure that MHPs' encounter claim data met select Medicaid program criteria.
To evaluate the sufficiency of MDHHS's oversight efforts to ensure MHP-enrolled beneficiary access to medical care.
To assess the sufficiency of MDHHS's efforts to monitor MHPs' provider networks.
Audit Findings (3)
MDHHS needs to monitor MHP encounter claim data and supporting medical records.
Activation and development of certain CHAMPS edits needed.
Oversight of BMP needs improvement.
Recommendations (3)
MDHHS implement a process to ensure MHP encounter claims are properly supported by medical records and accurately represent the medical services provided.
MDHHS activate and develop CHAMPS 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.
MDHHS improve its processes for identifying BMP candidates and ensuring that BMP enrollees are properly evaluated and monitored.