Medicaid Audit Intelligence

Public audit ledger

Medicaid audit reports

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Evidence register

154 reports

Published
Jan 20, 2026
Jurisdiction
New York
Publishing agency
Office of the New York State Comptroller, Division of State Government Accountability
Report ID
REPORT 172

Medicaid Program – Oversight of Health Homes

DOH did not adequately oversee Medicaid Health Homes to ensure appropriate care and payments, including delays in redesignation reviews, noncompliance with policies, and lack of baseline measurements, with $19.7 million in payments lacking proper MAPP-based support; the agency…

Findings
4
Recommendations
7
Open evidence record
Source status
Original source
Published
Jan 12, 2026
Jurisdiction
Texas
Publishing agency
Texas Health and Human Services Commission Office of Inspector General
Report ID
REPORT 142

Multiple Identification Numbers in Texas Medicaid and CHIP

AES had processes and controls to prevent and detect the creation of multiple IDs and associated overpayments, but improvements can be made to further limit the creation of multiple IDs for Texas Medicaid and CHIP members.

Findings
1
Recommendations
5
Open evidence record
Source status
Original source
Published
Dec 2025
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 119

Illinois Medicaid Managed Care Capitation Payments for Incarcerated Enrollees

The audit determined that Illinois made unallowable managed care capitation payments for incarcerated enrollees during the audit period, totaling at least $9.5 million with $8.3 million Federal share, and identified failures to terminate enrollment as required. Recovered findi…

Findings
3
Recommendations
2
Open evidence record
Source status
Original source
Published
Dec 2025
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 118

Medicaid Agencies Made Millions in Unallowable Capitation Payments to Managed Care Organizations on Behalf of Deceased Enrollees

We estimate that Medicaid agencies made $207,501,380 ($138,645,710 Federal share) in unallowable capitation payments to MCOs for deceased enrollees during the audit period (July 1, 2021 – June 30, 2022).

Findings
4
Recommendations
2
Open evidence record
Source status
Original source
Published
Oct 30, 2025
Jurisdiction
Massachusetts
Publishing agency
Massachusetts Office of the State Auditor
Report ID
REPORT 122

Review of Durable Medical Equipment Providers

MassHealth did not fully ensure that DME was not ordered by excluded providers or for deceased members, as evidenced by three identified findings and associated overpayments; ongoing post-payment and data-lag issues necessitate strengthened controls and more comprehensive deat…

Findings
3
Recommendations
6
Open evidence record
Source status
Original source
Published
Oct 22, 2025
Jurisdiction
New York
Publishing agency
Office of the New York State Comptroller, Division of State Government Accountability
Report ID
REPORT 123

Medicaid Program: Oversight of Managed Care Provider Networks

DOH did not maintain sufficient oversight of Medicaid managed care provider networks during 2023, with data reliability and process control issues affecting the accuracy of deficiency reporting and SOAs, incomplete communication with MCOs, and potential cost exposure due to in…

Findings
5
Recommendations
3
Open evidence record
Source status
Original source
Published
Sep 2025
Jurisdiction
Mississippi
Publishing agency
Office of Inspector General, U.S. Department of Health and Human Services
Report ID
REPORT 167

Mississippi Did Not Report and Return All Medicaid Overpayments for the State’s Medicaid Fraud Control Unit Cases

The State agency did not report and return the Federal share of all MFCU-determined Medicaid overpayments identified for FYs 2021 through 2023. The audit identified underreporting across multiple categories, with 12 cases reported and returned (totaling $290,584) compared with…

Findings
5
Recommendations
5
Open evidence record
Source status
Original source
Published
Sep 2025
Jurisdiction
Federal
Publishing agency
Office of Inspector General, U.S. Department of Health and Human Services
Report ID
REPORT 168

Most Children Enrolled in Medicaid Did Not Receive Timely Suicide-Related Followup Care

Timely followup care after pediatric suicidal thoughts or behaviors is not consistently achieved across states; about half of cases did not have a followup visit within 7 days and 21 percent had none within 60 days; shortages of behavioral health providers and difficulties con…

Findings
5
Recommendations
2
Open evidence record
Source status
Original source
Published
Sep 2025
Jurisdiction
New Jersey
Publishing agency
Office of Inspector General, U.S. Department of Health and Human Services
Report ID
REPORT 166

New Jersey Did Not Ensure That Some Medicaid Personal Care Assistant Services Provided Under the Personal Preference Program Met Federal and State Requirements

New Jersey did not ensure that the State agency adequately monitored and ensured compliance by its MCOs and fiscal intermediary with Federal and State requirements for PPP PCA services; as a result, the program was vulnerable to misuse of Federal funds and the health and safet…

Findings
5
Recommendations
2
Open evidence record
Source status
Original source
Published
Sep 25, 2025
Jurisdiction
Utah
Publishing agency
Utah Office of the Legislative Auditor General
Report ID
REPORT 125

A Performance Audit of the Office of Inspector General of Medicaid Services: Policy Options for Improved Governance and Medicaid Oversight

The report concludes that Utah’s OIG has not adequately fulfilled its Medicaid oversight mandate and suffers from governance, reporting, and performance weaknesses, with risk-based planning and proactive oversight largely missing; it recommends policy options including structu…

Findings
9
Recommendations
10
Open evidence record
Source status
Original source
Published
Sep 17, 2025
Jurisdiction
Kentucky
Publishing agency
Kentucky Auditor of Public Accounts
Report ID
REPORT 120

How Kentucky Failed to Prevent Over $800 Million of Medicaid Waste

Concurrent capitation payments across state lines resulted in substantial waste (over $800 million) during 2019–2022 due to gaps in residency determination, PARIS/T-MSIS data usage, and contract obligations with MCOs; remedies include stronger leadership, proactive data sharin…

Findings
9
Recommendations
9
Open evidence record
Source status
Original source
Published
Aug 2025
Jurisdiction
Federal
Publishing agency
Centers for Medicare & Medicaid Services
Report ID
REPORT 121

Washington Medicaid Managed Care Medical Loss Ratio Audit

CMS identified eight findings requiring correction, but none resulted in an MLR recalculation below the 85% remittance threshold; the audit identified operational improvements and oversight enhancements to ensure compliance with federal MLR requirements.

Findings
8
Recommendations
6
Open evidence record
Source status
Original source
Published
Aug 21, 2025
Jurisdiction
Nebraska
Publishing agency
Nebraska Auditor of Public Accounts
Report ID
REPORT 126

Medicaid Payments to MCOs for Deceased Individuals

The DHHS procedures for identifying deaths, updating records, and recouping post-death Medicaid payments were found to be insufficient to prevent improper disbursements to MCOs. While some adjustments and recoupments have begun, there are notable opportunities to strengthen in…

Findings
7
Recommendations
4
Open evidence record
Source status
Original source
Published
Jul 2025
Jurisdiction
North Carolina
Publishing agency
North Carolina Office of the State Auditor
Report ID
REPORT 66

Performance Audit Report July 2025 Medicaid Provider Enrollment Follow-Up Audit

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 uncorroborat…

Findings
4
Recommendations
6
Open evidence record
Source status
Original source
Published
Jul 2025
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 46

Wisconsin’s Fee-for-Service Medicaid Payments for Applied Behavior Analysis

The Wisconsin Department of Health Services’ ForwardHealth program did not provide adequate oversight of FFS Medicaid ABA payments, resulting in improper and potentially improper payments for autism-related ABA services. The program had not conducted a statewide postpayment re…

Findings
12
Recommendations
6
Open evidence record
Source status
Original source
Published
Jul 2025
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 45

Analysis of Selected Nursing Facilities’ Use of Medicaid Reimbursement for Direct Care Compensation

The data brief concludes that there is no clear, positive correlation between higher direct care compensation and higher nursing hours per resident day (HPRD). Increases in direct care compensation are largely attributed to higher labor costs from contracting for nursing staff…

Findings
9
Recommendations
0
Open evidence record
Source status
Original source
Published
Jul 2025
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 50

Pennsylvania Capitation Payments for Enrollees With Multiple Medicaid Identification Numbers

The OIG concluded that Pennsylvania made unallowable capitation payments totaling at least $8,784,549 ($4,596,390 Federal share) for enrollees with multiple Medicaid ID numbers during the audit period (January 1, 2019 – December 31, 2022). The unallowable payments were caused…

Findings
3
Recommendations
5
Open evidence record
Source status
Original source
Published
Jul 25, 2025
Jurisdiction
Federal
Publishing agency
Centers for Medicare & Medicaid Services
Report ID
REPORT 11

Ohio Medicaid Managed Care Medical Loss Ratio Audit

While no remittances were required based on the findings, the audit identified multiple areas for improvement in Ohio’s oversight and reporting processes to ensure compliance with federal requirements and enhance program integrity.

Findings
3
Recommendations
11
Open evidence record
Source status
Original source
Published
Jul 16, 2025
Jurisdiction
Illinois
Publishing agency
Illinois Office of the Auditor General
Report ID
REPORT 35

Performance Audit of Medicaid Eligibility Determinations for Long-Term Care

The audit identified significant delays, data inaccuracies, and reporting deficiencies in Illinois' Medicaid long-term care eligibility process. While some system enhancements have been implemented, issues remain with timeliness, data integrity, and reporting practices. The ag…

Findings
7
Recommendations
6
Open evidence record
Source status
Original source
Published
Jun 26, 2025
Jurisdiction
Federal
Publishing agency
U.S. Government Accountability Office
Report ID
REPORT 12

Medicaid Managed Care Improper Payment Estimate

The GAO report highlights that while CMS's current improper payment estimates for Medicaid managed care are near zero, they do not capture all program integrity risks. CMS has taken steps to improve oversight through audits and reviews, but additional measures and data improve…

Findings
5
Recommendations
4
Open evidence record
Source status
Original source
Published
Jun 18, 2025
Jurisdiction
New York
Publishing agency
Office of the New York State Comptroller, Division of State Government Accountability
Report ID
REPORT 54

Medicaid Program: Claims Processing Activity April 1, 2024 Through September 30, 2024

The audit concluded that eMedNY reasonably ensured Medicaid claims were submitted by approved providers, processed in accordance with Medicaid requirements, and paid correctly overall. However, improvements were needed in the processing of certain claim types, with over $11.5…

Findings
6
Recommendations
7
Open evidence record
Source status
Original source
Published
May 2025
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 57

Maryland Did Not Comply With Federal Waiver and State Requirements at 20 Adult Day Care Facilities Audited

The Maryland Department of Health did not fully comply with Federal waiver and State requirements in overseeing adult day care facilities; 253 noncompliance instances were identified across health and safety and administrative areas, with inspections insufficient to detect vio…

Findings
1
Recommendations
3
Open evidence record
Source status
Original source
Published
May 30, 2025
Jurisdiction
Federal
Publishing agency
Centers for Medicare & Medicaid Services
Report ID
REPORT 13

Oklahoma Focused Program Integrity Review Final Report

CMS supports Oklahoma’s efforts and encourages further improvements in program integrity. The review identified four observations for the state’s attention but no non-compliance findings that pose a risk.

Findings
1
Recommendations
5
Open evidence record
Source status
Original source