Medicaid Audit Intelligence

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Medicaid audit reports

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Evidence register

154 reports

Published
Oct 18, 2024
Jurisdiction
Oregon
Publishing agency
Oregon Secretary of State, Audits Division
Report ID
REPORT 91

Without Federal Action, States Will Continue to Pay Millions of Dollars in Duplicate Medicaid Payments

The audit concludes that without federal action, states will continue to pay millions of dollars in duplicate Medicaid payments; stronger data sharing and real-time enrollment data are needed; Do Not Pay and improved PARIS controls could reduce improper payments.

Findings
9
Recommendations
7
Open evidence record
Source status
Original source
Published
Oct 14, 2024
Jurisdiction
Tennessee
Publishing agency
Tennessee Comptroller of the Treasury, Division of State Audit
Report ID
REPORT 70

Performance Audit of Selected Programs and Activities of the Division of TennCare

The Division of TennCare has made progress in implementing TennCare III initiatives, unwinding renewals, and maintaining cybersecurity controls, but faces ongoing risks in behavioral health provider network adequacy, HCBS transition data issues, and MMIS modernization complexi…

Findings
5
Recommendations
6
Open evidence record
Source status
Original source
Published
Aug 28, 2024
Jurisdiction
Texas
Publishing agency
Texas Health and Human Services Commission Office of Inspector General
Report ID
REPORT 149

Managed Care Pharmacy Encounters Paid to Omnicare Pharmacy

Omnicare Pharmacy (Omnicare) filled and dispensed prescriptions for Texas Medicaid members; however, Omnicare did not consistently comply with certain requirements for dispensing medication, confirming medication delivery, providing instructions for use, and accurately submitt…

Findings
6
Recommendations
3
Open evidence record
Source status
Original source
Published
Aug 23, 2024
Jurisdiction
Texas
Publishing agency
Texas Health and Human Services Commission Office of Inspector General
Report ID
REPORT 150

Managed Care Pharmacy Encounters Paid to Meadowbrook Pharmacy

Meadowbrook Pharmacy filled and dispensed prescriptions for Texas Medicaid and CHIP members; however, Meadowbrook did not consistently comply with certain requirements for dispensing refills, accurately submitting claims, providing instructions for use, and maintaining support…

Findings
6
Recommendations
4
Open evidence record
Source status
Original source
Published
Aug 21, 2024
Jurisdiction
Pennsylvania
Publishing agency
Pennsylvania Department of the Auditor General
Report ID
REPORT 65

Performance Audit Report: Pharmacy Benefit Manager Services for the Physical HealthChoices Medicaid Program in Pennsylvania

The audit identifies three findings with 17 recommendations. DHS generally disagreed with Finding 1 and agreed with Finding 2; PerformRx generally agrees with Finding 3. The auditors note ongoing concerns about spread pricing, data integrity, and contract monitoring, and reser…

Findings
3
Recommendations
13
Open evidence record
Source status
Original source
Published
Aug 9, 2024
Jurisdiction
Maryland
Publishing agency
Maryland Office of Legislative Audits
Report ID
REPORT 83

Maryland Department Of Health Pharmacy Services Audit Report

MDH’s pharmacy services program exhibits governance and control weaknesses across manual claims processing, provider licensure verification, program audits, and MADAP rebates, leading to substantial overpayments and potential noncompliance with regulations. A cybersecurity fin…

Findings
5
Recommendations
9
Open evidence record
Source status
Original source
Published
Jul 2024
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 95

California Payments for Enrollees With Concurrent Medicaid Enrollment in Another State

We estimated that the State agency incurred costs of approximately $19.9 million ($15.5 million Federal share) for August 2021 capitation payments made on behalf of enrollees who were residing and concurrently enrolled for Medicaid in another State. This amount represents pote…

Findings
5
Recommendations
2
Open evidence record
Source status
Original source
Published
Jul 31, 2024
Jurisdiction
Louisiana
Publishing agency
Louisiana Legislative Auditor
Report ID
REPORT 58

Medicaid Dental Benefit Program Manager - DentaQuest Informational Brief

The informational brief presents a comprehensive analysis of DentaQuest’s performance as the Medicaid dental benefit program manager, highlighting ongoing concerns with network adequacy, claims processing and denials, provider credentialing, and contract compliance, while noti…

Findings
10
Recommendations
0
Open evidence record
Source status
Original source
Published
Jul 23, 2024
Jurisdiction
Texas
Publishing agency
Texas Health and Human Services Commission Office of Inspector General
Report ID
REPORT 151

Cook Children’s Health Plan’s Financial Statistical Reports

Cook Children’s Health Plan (CCHP) had a process for preparing financial statistical reports (FSRs), which included controls related to removing unallowable expenses and identifying the appropriate FSR sections for reporting allowable expenses. However, CCHP did not always suf…

Findings
5
Recommendations
4
Open evidence record
Source status
Original source
Published
Jun 2024
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 55

North Carolina 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 the period under review (October 1, 2019 through September 30, 2021).

Findings
5
Recommendations
3
Open evidence record
Source status
Original source
Published
May 2024
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 98

Colorado's Program Integrity Section Reporting of Medicaid Overpayments

Colorado did not report and refund the correct Federal share of Medicaid overpayments identified by its Program Integrity Section during Oct 1, 2014 through Dec 31, 2020; 80 of 403 cases contained unreported or incorrectly reported amounts, with late reporting and misused feed…

Findings
6
Recommendations
5
Open evidence record
Source status
Original source
Published
May 2024
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 99

California Improperly Claimed $52.7 Million in Federal Medicaid Reimbursement for Capitation Payments Made on Behalf of Noncitizens With Unsatisfactory Immigration Status

California improperly claimed Federal Medicaid reimbursement for capitation payments to noncitizens with UIS by applying an outdated proxy percentage that did not reflect the true costs of nonemergency services; recommends refund and coordination with CMS to determine reimburs…

Findings
4
Recommendations
2
Open evidence record
Source status
Original source
Published
May 24, 2024
Jurisdiction
Colorado
Publishing agency
Colorado Office of the State Auditor
Report ID
REPORT 78

Evaluation Of The Colorado Recovery Audit Contractor Program

HCPF’s Medicaid Recovery Audit Contractor program generally adheres to federal and state requirements but requires stronger contract oversight and program management to ensure efficient operation, reduce overpayments, and improve provider billing and education.

Findings
7
Recommendations
3
Open evidence record
Source status
Original source
Published
May 23, 2024
Jurisdiction
Louisiana
Publishing agency
Louisiana Legislative Auditor
Report ID
REPORT 59

Oversight Of Medicaid Quality Care

The audit found significant governance and data-use gaps in LDH’s oversight of Medicaid MCOs, including incentive design that can pay for non-improving performance, lack of data-driven identification of non-utilizing beneficiaries and preventive service gaps, fragmented compla…

Findings
5
Recommendations
10
Open evidence record
Source status
Original source
Published
Apr 16, 2024
Jurisdiction
Federal
Publishing agency
U.S. Government Accountability Office
Report ID
REPORT 27

Additional Actions Needed to Enhance Program Integrity and Save Billions

While CMS has made significant progress in reducing improper payments and implementing GAO recommendations, ongoing efforts and additional actions are necessary to further enhance program integrity, prevent fraud, and realize substantial cost savings.

Findings
5
Recommendations
5
Open evidence record
Source status
Original source
Published
Apr 1, 2024
Jurisdiction
Kansas
Publishing agency
Kansas Office of the Medicaid Inspector General
Report ID
REPORT 81

Continuing Care Retirement Communities

The audit identifies significant non-compliance with state statutes governing CCP registrations and continuum-of-care verification, resulting in substantial revenue losses to the Quality Care Assessment fund and increased reliance on State General Funds. It recommends substant…

Findings
7
Recommendations
7
Open evidence record
Source status
Original source
Published
Mar 2024
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 43

CMS Did Not Ensure That Selected States Complied With Medicaid Managed Care Mental Health and Substance Use Disorder Parity Requirements

CMS did not ensure that selected States complied with Medicaid managed care MH/SUD parity requirements; noncompliance was widespread across eight States, including missing parity provisions in contracts, lack of parity analyses and public posting, and restrictive practices by…

Findings
6
Recommendations
8
Open evidence record
Source status
Original source
Published
Mar 26, 2024
Jurisdiction
Rhode Island
Publishing agency
Rhode Island Office of the Auditor General
Report ID
REPORT 92

Medicaid Capitation Paid for Members Residing in Other States

Rhode Island Medicaid paid approximately $38.4 million in capitation payments to MCOs for members who were not residing in Rhode Island, indicating noncompliance with state and federal residency requirements; controls over residency verification were not fully effective, but P…

Findings
3
Recommendations
3
Open evidence record
Source status
Original source
Published
Mar 13, 2024
Jurisdiction
Federal
Publishing agency
Ohio Auditor of State
Report ID
REPORT 16

The Cost of Concurrent Enrollment

The audit highlights significant financial waste due to unmanaged concurrent Medicaid enrollment across states, emphasizing the need for technological improvements, better inter-state communication, and proactive identification processes to safeguard public funds.

Findings
7
Recommendations
5
Open evidence record
Source status
Original source
Published
Mar 1, 2024
Jurisdiction
Massachusetts
Publishing agency
Massachusetts Office of the State Auditor
Report ID
REPORT 73

Medicaid Audit Unit—Annual Report

The audit identified an estimated $84,832,094 in capitation payments to MassHealth members residing outside Massachusetts. MassHealth has reported actions or planned actions on all four audit recommendations (three fully implemented and one in progress). Follow-up post-audit s…

Findings
1
Recommendations
4
Open evidence record
Source status
Original source
Published
Feb 2024
Jurisdiction
Federal
Publishing agency
U.S. Department of Health and Human Services, Office of Inspector General
Report ID
REPORT 97

Colorado Could Better Ensure That Nursing Homes Comply With Federal Requirements For Life Safety, Emergency Preparedness, And Infection Control

Colorado could better ensure that nursing homes participating in Medicare and Medicaid comply with Federal life safety, emergency preparedness, and infection control requirements. Deficiencies were observed across all 20 nursing homes audited, indicating ongoing oversight chal…

Findings
7
Recommendations
3
Open evidence record
Source status
Original source
Published
Feb 2024
Jurisdiction
New York
Publishing agency
Office of the New York State Comptroller, Division of State Government Accountability
Report ID
REPORT 53

Medicaid Program: Claims Processing Activity October 1, 2023 Through March 31, 2024

The audit concluded that eMedNY reasonably ensured that Medicaid claims were submitted by approved providers, processed in accordance with Medicaid requirements, and resulted in correct payments. However, the audit identified a number of improper payments across several catego…

Findings
9
Recommendations
10
Open evidence record
Source status
Original source
Published
Feb 23, 2024
Jurisdiction
New York
Publishing agency
Office of the New York State Comptroller
Report ID
REPORT 171

Medicaid Program: Improper Payments for Drugs Without a Federal Drug Rebate Agreement

The audit found that the Department’s oversight of Medicaid drug payments and the capitation rate adjustment process were inadequate, resulting in a substantial amount of improper MCO payments for drugs from manufacturers without an NDRA; the Department should revise the rate…

Findings
4
Recommendations
4
Open evidence record
Source status
Original source