Medicaid Provider Enrollment Performance Audit
Learn how the AI-generated research projects were createdOverall Conclusion
The Medicaid Provider Enrollment process in North Carolina did not adequately ensure that only qualified providers were enrolled to serve Medicaid beneficiaries or to receive payments. The Division failed to monitor license suspensions/terminations, allowed providers with license limitations to stay enrolled, did not verify credentials during re-verification, and did not verify ownership information, leading to uncredentialed providers being paid and heightened fraud risk. CMS regulations and state policy require robust credential verification, timely removal of suspended/license-limit providers, and ownership disclosures; gaps persisted during SFY 2019, increasing the risk of substandard care and improper payments.
Source Document
Audit Scope
The audit covered the Medicaid Provider Enrollment process in North Carolina for state fiscal year 2019, including initial enrollment, provider re-verification every five years, and ongoing discipline checks of professional licenses. The Division of Health Benefits outsources most screening/enrollment work to General Dynamics Information Technology (GDIT) but retains ultimate responsibility; NCTracks is used for enrollment and re-verification, including a background, license, and discipline checks through LexisNexis and monthly background reports. The population consisted of approximately 90,000 Medicaid providers in SFY2019, with specific audit samples: 16,044 enrolled providers tested from 2019 approved enrollment applications; 27,334 re-verified providers tested from 2019 approved re-verification applications; 40,284 flagged providers tested for manual review; and 66 disciplined providers tested for ongoing discipline checks. Results include failures in identifying/removing suspended/terminated licenses, license limitations, incomplete credential verification, and lack of ownership verification, all contributing to potential improper payments and risks to beneficiary safety.
Key Findings Summary
Unlicensed providers served Medicaid beneficiaries and received payments: The Division did not identify and remove providers with suspended or terminated professional licenses; unlicensed providers remained enrolled and paid because disciplinary reports from licensing boards were not monitored.
Division increased risk to Medicaid program and beneficiaries by allowing providers with license limitations to remain enrolled in Medicaid: The Division allowed all providers who had professional license limitations to remain enrolled, despite potential safety concerns.
Providers without required credentials paid $11.2 million: The Division did not verify credentials during the Medicaid provider enrollment re-verification process; uncredentialed providers were re-verified, served beneficiaries, and were paid; credentials were not verified for many months/years.
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AI-Assisted
AI-Generated Insight
This report highlights systemic gaps in ongoing credential verification and ownership disclosure during Medicaid provider re-verification. The reliance on automated tools without primary source verification created backlogs and allowed uncredentialed providers to bill, while authority gaps complicated removal of providers with license limitations. Addressing these weaknesses would strengthen program integrity, reduce improper payments, and improve beneficiary safety.