Online provider directories of Centene, Elevance, and UnitedHealthcare Medicaid plans in five States contained inaccuracies (ghost providers, missing in-network providers, and incorrect contact information) that may impede enrollees' access to maternal health care and distort…
CMS did not consistently follow its policies and procedures for overseeing States’ CMS-64 expenditures and its processes for deferred payments and disallowed expenditures require improvements to protect Medicaid financial integrity.
We found that the network lists from Centene, Elevance, and UnitedHealthcare Medicaid plans in five States contained inaccuracies—potential ghost providers who reported not being in-network, incorrect contact information, and discrepancies with online provider directories—that…
The North Dakota State agency could improve oversight of residential providers and settings to better ensure the health and safety of participants with intellectual and developmental disabilities residing in residential habilitation settings; weaknesses in the quality manageme…
The State agency did not always claim Federal Medicaid reimbursement for clinical diagnostic laboratory services in accordance with Federal and State requirements, resulting in overpayments totaling $13.9 million (Federal share) and potentially $29.3 million (Federal share not…
CBH did not comply with Federal and State requirements for denying prior-authorization behavioral health services; none of the 100 sampled denials complied with all applicable requirements, indicating potential systemic issues in denials and potential impact on enrollee rights.
Because LHCC revised its internal policy during our audit period to ensure that written notices of adverse determinations were sent to enrollees regardless of the enrollees' inpatient status, and because we did not identify any additional concerns after the effective date of t…
Because the State agency ensured, for the sample items we reviewed, that the MCOs followed all outpatient prescription drug coverage and utilization requirements that were in place during our audit period, including prior authorizations and quantity limits, this report contain…
Although the State agency improved its controls over invoicing for rebates for physician-administered drugs, during our audit period the State agency did not comply with Federal Medicaid requirements for invoicing manufacturers for rebates for some physician-administered and p…
Colorado’s FFS Medicaid payments for Applied Behavior Analysis provided to children did not fully comply with Federal and State requirements, resulting in improper and potentially improper payments and highlighting a need for stronger governance, oversight, and guidance to pre…
The Office of Inspector General found that West Virginia did not invoice manufacturers for some rebates due on physician-administered drugs dispensed to enrollees of Medicaid managed-care organizations during the audit period, totaling $8.2 million ($6.1 million Federal share)…
For our audit period, the Maine Department of Health and Human Services’s FFS Medicaid payments for rehabilitative and community support services provided to children diagnosed with autism included improper and potentially improper payments. Improper payments totaled at least…
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…
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).
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…
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…
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…
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.
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…
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…
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…
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.
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…
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…