Evidence record

Oversight and Encounter Claim Integrity of the Comprehensive Health Care Program

Jurisdiction: Michigan
Publishing agency: Michigan Office of the Auditor General
Publication date: May 1, 2019
Source record: Original document linked

Open original reportOriginal source available

Findings

Recommendations

Overall conclusion

Sufficient, with exceptions.

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.

Findings (3)

Each finding has a stable link.

F-1137
MDHHS needs to monitor MHP encounter claim data and supporting medical records.
F-1138
Activation and development of certain CHAMPS edits needed.
F-1139
Oversight of BMP needs improvement.

Recommendations (3)

R-999
MDHHS implement a process to ensure MHP encounter claims are properly supported by medical records and accurately represent the medical services provided.
Related finding F-1137
R-1000
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.
Related finding F-1138
R-1001
MDHHS improve its processes for identifying BMP candidates and ensuring that BMP enrollees are properly evaluated and monitored.
Related finding F-1139