Evidence record
Medicaid Managed Care Program
- Jurisdiction
- Missouri
- Publishing agency
- Missouri State Auditor
- Publication date
- November 2020
- Source record
- Original document linked
Findings
4
Recommendations
4
Overall conclusion
The audit found material weaknesses in MEDES controls that allowed improper and potentially preventable capitation payments to be issued, particularly for bypassed and out-of-state and incarcerated participants. While MEDES updates have improved functionality for new participants, they do not automatically correct past issues, and recoupment of overpayments is limited. The report emphasizes the need for stronger system controls, tracking, and timely redeterminations, as well as ongoing vendor coordination to mitigate risks in the Medicaid Managed Care program.
Scope
Scope and Methodology: The scope of the audit included evaluating (1) DSS management's procedures to ensure reliable MC encounter data, (2) DSS management's techniques to provide oversight of the program, (3) policies and procedures, and (4) other management functions and compliance requirements in place during the period July 2016 to June 2019. Due to MEDES system control limitations and complexities rising from the DSS's long-term resolution efforts in the MEDES, we also observed activity beyond June 2019 for further comprehension and to assess significance. The audit tested controls related to four main areas: 1) Eligibility Bypass, 2) Indicator Control, 3) Out-of-State Participants, 4) Incarcerated Participants. The data sources included MMIS capitation payments and encounter data, MEDES eligibility records, and data from the Missouri Department of Corrections and Missouri Department of Health and Senior Services. The audit notes the existence of MEDES updates post-2019, the participation of external factors such as the 2020 public health emergency and FMAP changes, and cross-system data flows (MMIS and MEDES). The scope encompassed July 2016 through June 2019 with additional activity for comprehension through 2020, to understand ongoing resolution efforts and potential ongoing risks.
Findings (4)
Each finding has a stable link.
- F-631
Eligibility Bypass: The Department of Social Services improperly issued capitation payments on behalf of participants whose eligibility had been activated (and remained active) in MEDES via a manual bypass process, which prevented MEDES controls from deactivating eligibility and discontinued payments when participants became ineligible.
- F-634
Incarcerated Participants: DSS not performing effective incarceration matches or using results effectively to detect, discontinue, and recoup capitation payments for incarcerated participants.
- F-632
Indicator Control: Weaknesses in the MEDES 'indicator' control and related manual tracking allowed overpayments and potentially preventable capitation payments to continue due to triggers that do not accurately reflect MHABD eligibility status.
- F-633
Out-of-State Participants: DSS improperly issued capitation payments for participants who were no longer Missouri residents due to MEDES control limitations in deactivating eligibility when participants moved out of state.
Recommendations (4)
- R-565
Strengthen the MEDES indicator control and manual tracking processes to ensure triggered indicators are reviewed promptly by eligibility specialists; implement automated notifications and systematic tracking to prevent unnecessary or delayed reviews; deactivate eligibility when appropriate.
Related finding F-632 - R-566
Enhance controls to identify and deactivate eligibility for out-of-state participants (including verifying residency and addressing out-of-state addresses) to stop improper capitation payments; verify and adjust participant records and recover overpayments where possible.
Related finding F-633 - R-567
Improve incarceration matching and use results to discontinue and recoup capitation payments for incarcerated participants; ensure reviews occur in a timely manner; continue vendor collaboration and implement systematic tracking; pursue recoupment as feasible.
Related finding F-634 - R-564
Address MEDES control limitations by completing MEDES updates and ensuring bypass participants are properly deactivated when no longer eligible; improve annual redetermination processes and pursue recovery of identified overpayments where appropriate.
Related finding F-631