Medicaid Audit Intelligence

Public audit ledger

Medicaid audit reports

Search the complete report library and verify each record against its publishing agency and original public source.

Evidence register

188 reports

Published
Dec 4, 2024
Jurisdiction
New York
Publishing agency
Office of the New York State Comptroller, Division of State Government Accountability
Report ID
REPORT 52

Medicaid Program: Overpayments for Medicare Part C Claims

DOH oversight identified improper Medicaid payments related to Medicare Part C cost-sharing, primarily driven by provider misinterpretation of rules, incomplete CARC reporting, and system limitations. The audit results indicate substantial recoveries and opportunities to stren…

Findings
5
Recommendations
8
Open evidence record
Source status
Original source
Published
Nov 13, 2024
Jurisdiction
New York
Publishing agency
Office of the New York State Comptroller, Division of State Government Accountability
Report ID
REPORT 103

Medicaid Program: Provider Compliance With the Electronic Visit Verification Program

DOH’s EVV program showed significant control weaknesses and data quality issues, with large volumes of Medicaid payments made without matching EVV records and with low EVV-claim match rates (56% for PC and 11% for HHC). The VO pre-claim review requirement ended in January 2024…

Findings
6
Recommendations
11
Open evidence record
Source status
Original source
Published
Nov 1, 2024
Jurisdiction
New Jersey
Publishing agency
New Jersey Office of the State Auditor
Report ID
REPORT 85

Estate Recovery Audit Report

The division had adequate controls to ensure compliance with federal and state regulations and general information system controls were in place and functioning. However, outdated policies and procedures related to estate recovery led to inconsistent case processing and inadeq…

Findings
1
Recommendations
3
Open evidence record
Source status
Original source
Published
Nov 1, 2024
Jurisdiction
Ohio
Publishing agency
Ohio Auditor of State
Report ID
REPORT 22

Electronic Visit Verification Audit Ohio Department of Medicaid

The audit identified significant gaps in EVV utilization and matching, with only 44% of claims supported by EVV data in 2022. The Department has made efforts to implement EVV but faces challenges including low provider compliance, technical issues, and stakeholder engagement.…

Findings
5
Recommendations
3
Open evidence record
Source status
Original source
Published
Oct 2024
Jurisdiction
Oregon
Publishing agency
Oregon Secretary of State, Audits Division
Report ID
REPORT 87

The Oregon Eligibility System Appropriately Determines Eligibility, But Input Errors Continue to Occur

The audit found that the ONE system largely determines eligibility accurately for Medical and SNAP programs, and automated eligibility determinations are generally effective. However, input errors, manual data entry, and inconsistent override monitoring create risk for incorre…

Findings
6
Recommendations
3
Open evidence record
Source status
Original source
Published
Oct 31, 2024
Jurisdiction
Texas
Publishing agency
Texas Health and Human Services Office of Inspector General
Report ID
REPORT 147

Managed Care Pharmacy Benefit Services – Wellpoint

The Texas OIG found that the involved entities employed unallowable pricing practices to reduce prescription expenses, and Wellpoint incorrectly reported expenses on FSRs, with scope limitations due to Caremark's restricted access. The report concludes that these practices, in…

Findings
6
Recommendations
5
Open evidence record
Source status
Original source
Published
Oct 31, 2024
Jurisdiction
Texas
Publishing agency
Texas Health and Human Services Commission Office of Inspector General
Report ID
REPORT 148

Managed Care Pharmacy Benefit Services – Aetna

CaremarkPCS Health, LLC (Caremark) and Aetna Better Health of Texas Inc. (Aetna) employed unallowable pricing models to reduce prescription expenses, and Aetna incorrectly reported expenses on its financial statistical reports to HHSC.

Findings
3
Recommendations
4
Open evidence record
Source status
Original source
Published
Oct 28, 2024
Jurisdiction
Washington
Publishing agency
Office of the Washington State Auditor
Report ID
REPORT 32

Examining Washington’s Concurrent Medicaid Enrollments

The audit highlights significant financial waste due to concurrent Medicaid enrollments, emphasizing the need for improved communication, data sharing, and federal solutions to prevent unnecessary premium payments and optimize Medicaid spending.

Findings
5
Recommendations
5
Open evidence record
Source status
Original source
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