Performance Audit Report July 2025 Medicaid Provider Enrollment Follow-Up Audit
Learn how the AI-generated research projects were createdOverall Conclusion
The Division of Health Benefits did not fully implement prior audit recommendations during 2023, leaving ongoing risks to patient safety and Medicaid integrity from providers with suspended licenses, license limitations, unverified credentials (including DEA), and uncorroborated ownership information. The Division also faced governance concerns regarding the monitoring of the GDIT contract and did not consistently enforce measures intended to remove ineligible providers from the Medicaid program.
Source Document
Audit Scope
The audit examined the North Carolina Department of Health and Human Services (DHHS), Division of Health Benefits (DHB) provider enrollment processes for 2023. It evaluated whether the Division identified and removed Medicaid providers with suspended or terminated licenses, identified and removed providers with license limitations that pose threats to patient safety, verified provider accreditations and credentials, and corroborated ownership information during initial enrollment and the five-year reverification cycle. The scope includes enrollment activities (initial enrollment and reverification) and ongoing discipline checks for calendar year 2023, during which auditors tested 60 of 1,674 initial enrollment applications approved in 2023, reviewed all 4,860 reverification applications approved in 2023, and obtained lists of disciplined providers from four major NC licensing boards. It also considers the Division’s oversight of the NCTracks Medicaid Management Information System and the contract with General Dynamics Information Technology (GDIT) for provider enrollment activities, including SLAs and cost considerations. The audit period is January 1, 2023, through December 31, 2023.
Key Findings Summary
Did Not Fully Implement Recommendations to Identify and Remove Providers with Suspended or Terminated Licenses
Did Not Fully Implement Recommendations to Remove Providers with Professional License Limitations That Pose Threats to Medicaid Patients
Did Not Fully Implement Recommendations to Strengthen Provider Credential Verification
View the Findings tab to see all 4 findings
AI-Assisted
AI Scope Summary
To determine whether the Division of Health Benefits implemented corrective actions from the 2021 Medicaid Provider Enrollment audit, specifically for 2023: removing providers with suspended/terminated licenses, removing providers with license limitations posing safety risks, verifying provider credentials (including DEA), and corroborating ownership information during initial enrollment and reverification.
AI-Generated Insight
This follow-up audit reveals persistent gaps in Medicaid provider integrity controls in North Carolina. Despite prior recommendations, the Division of Health Benefits continues to enroll or retain providers with license limitations or suspensions, and fails to verify DEA certifications and ownership disclosures. The findings underscore the importance of robust, timely contract and risk-management practices with the contract administrator (GDIT) and strong, auditable credential verification to protect patient safety and public funds.
Audit Objectives
Identify and remove providers from the Medicaid program who had their professional license suspended or terminated.
Identify and remove providers from the Medicaid program who had professional license limitations and who posed threats to the safety of beneficiaries.
Ensure all provider professional accreditations and credentials were verified.
Verify provider ownership information.
Audit Findings (4)
Did Not Fully Implement Recommendations to Identify and Remove Providers with Suspended or Terminated Licenses
Did Not Fully Implement Recommendations to Remove Providers with Professional License Limitations That Pose Threats to Medicaid Patients
Did Not Fully Implement Recommendations to Strengthen Provider Credential Verification
Did Not Fully Implement Recommendation to Corroborate Provider Ownership Information
Recommendations (6)
Remove all providers who have had their professional licenses suspended, terminated, or entered into Non-Practice Agreements from the Medicaid program.
Develop written policies for the continued enrollment of providers with license limitations describing acceptable license limitations and the documentation required to support enrollment decisions.
Verify that providers possess DEA certifications; ensure credential verification includes direct verification with credentialing agencies and do not rely solely on provider self-report or opt-out forms.
Corroborate ownership information for Medicaid providers by comparing provider-disclosed ownership against data from state licensure boards or other authoritative sources and conduct background checks; remove ineligible providers.
Fully implement prior audit recommendations in a timely manner to address identified internal control deficiencies.
Strengthen provider credential verification by ensuring direct verification with credentialing authorities (including DEA) during enrollment and reverification.