Public audit ledger
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154 reports
Milliman concluded that FY2023 capitation rates were actuarially sound, with no program-wide pattern of under- or over-funding, though improvements were recommended in several rate-setting and governance processes.
CMS did not concur with the recommendations. The OIG maintains that the recommendations are valid and will continue to work with States to identify opportunities to reduce the number and amount of concurrent Medicaid capitation payments. The audit highlighted that concurrent e…
AHCCCS did not ensure all peer specialists met qualification and supervision requirements; some peer specialists were not supervised, potentially jeopardizing the quality of peer support services. The agency should enhance oversight and monitoring of contracted health plans to…
MDHHS did not fully remediate Finding 1; a material condition still exists; Finding 2 was complied.
ReCept Pharmacy #1 properly billed for paid claims and complied with applicable contractual, Texas Administrative Code, and federal requirements for most claims tested; however, ReCept did not consistently comply with requirements for accurate claims submissions and dispensing…
Cook Children’s Health Plan accurately reported STAR Kids medical and pharmacy expenses in FY 2020 and complied with eligibility requirements for medical and pharmacy claims. However, improvements are needed in reporting shared administrative expenses, particularly those alloc…
MassHealth did not ensure that DSRIP funding was allocated to ACOs in accordance with the Massachusetts Delivery System Reform Incentive Payment Protocol (Attachment M).
The audit identified strengths in some areas but also significant weaknesses that could affect the program's integrity and compliance. The Commission has committed to implementing recommended improvements.
We determined that CMS’s eligibility review contractor correctly determined Medicaid eligibility for the beneficiaries associated with all 100 sampled claims. Based on our sample results, CMS’s eligibility review contractor adequately determined Medicaid eligibility for three…
Not effective
Moderately effective.
The Department has processes to identify and recoup improper capitation payments, but controls are not sufficiently robust to ensure all improper payments are identified and recouped. The audit identified over $118.5 million in improper capitation payments not recouped for SFY…
OHA lacks timely notification of inpatient hospital stays, which results in some claims being paid for services not provided because the Medicaid client was in the hospital; there is significant improper payments and high-risk claims related to in-home services, NEMT, and priv…
MassHealth did not administer payments to non-hospice providers for hospice-related services in compliance with applicable state and federal regulations, including ensuring that Medicaid is payer of last resort and that hospice election data and service coordination were prope…
Medicaid is a significant public assistance program in Washington, requiring robust program integrity efforts to ensure proper use of funds. While HCA has taken steps to improve oversight, there are opportunities to strengthen strategic planning, performance measurement, and o…
Health Care Services halted efforts to resolve hundreds of thousands of known Medi-Cal eligibility discrepancies during the public health emergency, leading to a growing backlog and increased risk of improper payments and federal penalties; some emergency waivers and communica…
The audit found that while the Health Plan accurately reported medical, administrative, and quality improvement expenses, its pharmacy expense reporting was flawed due to unallowable practices by the Pharmacy Benefit Manager, which could impact Medicaid costs and program integ…
The Medicaid Provider Enrollment process in North Carolina did not adequately ensure that only qualified providers were enrolled to serve Medicaid beneficiaries or to receive payments. The Division failed to monitor license suspensions/terminations, allowed providers with lice…
The audit concludes that inaccuracies in CDTFA’s tax rate calculation and insufficient safeguards and public disclosure across several agencies impeded program integrity, resulting in potential revenue losses and misallocation of Prop 56 funds intended for health and public he…
The Office of the Inspector General notes that it is not expressing an opinion on the State Comptroller’s report or its results; however, the OSC encourages CMS to consider the report and its results and work with state partners to ensure the federal share of improper Medicaid…
The audit found material weaknesses in MEDES controls that allowed improper and potentially preventable capitation payments to be issued, particularly for bypassed and out-of-state and incarcerated participants. While MEDES updates have improved functionality for new participa…
Agency controls could be enhanced to better prevent or detect potential improper Medicaid claims payments.
Moderately effective.