Medicaid Audit Intelligence

Subject guide register

Medicaid audit topics

Use these guides to understand recurring Medicaid audit issues, the findings that support them, and the actions auditors recommend.

Active topics

  1. Managed Care

    Medicaid managed care delivers benefits through contracted health plans that receive payments to coordinate and cover enrollee services. Audit work examines how agencies set expectations, monitor plan performance, validate reported data, and protect access to care.

    64 reports

  2. Eligibility and Enrollment

    Eligibility and enrollment controls determine who qualifies for Medicaid, when coverage begins or ends, and whether beneficiary records remain accurate. Audits test determinations, renewals, residency, duplicate enrollment, and the timely processing of case changes.

    43 reports

  3. Capitation Payments

    Capitation payments are recurring amounts paid to managed care plans for each enrolled beneficiary. Audits examine rate inputs, enrollment records, duplicate or incorrect payments, reconciliations, and the recovery of amounts that should not have been paid.

    36 reports

  4. Pharmacy and PBMs

    Pharmacy benefit managers administer prescription-drug benefits on behalf of Medicaid agencies and managed care plans. Audit work considers contracting, pricing practices, claims administration, transparency, and oversight of pharmacy vendors.

    14 reports

  5. Data Quality and Reporting

    Data quality and reporting covers the completeness, accuracy, and timeliness of information used to administer and oversee Medicaid. Audits assess encounter records, federal submissions, financial reports, coding, reconciliations, and the controls that produce them.

    78 reports

  6. Program Oversight

    Program oversight is the system of governance, internal controls, contractor monitoring, audit follow-up, corrective action, and enforcement used to administer Medicaid. Audits evaluate whether agencies identify problems and ensure that responsible parties correct them.

    108 reports

  7. Rebates

    Medicaid drug rebates reduce prescription-drug costs through amounts owed by manufacturers under federal and supplemental agreements. Audits examine invoicing, collection, dispute resolution, reconciliation, and the accuracy of utilization data used to calculate rebates.

    5 reports