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.

Oversight decisions are only as reliable as the underlying data. Missing or inconsistent records can distort payment calculations, weaken program-integrity reviews, prevent comparisons across plans or states, and limit the ability to identify beneficiaries at risk.

1. State Directed Payments, Special Payments, and Risk Sharing Arrangements: SDP and risk-sharing arrangements were inconsistently treated, misclassified, and lacking clear instructions, with a need for separate line items and reconciliation oversight.

   Arizona Medicaid Managed Care Medical Loss Ratio Audit · Centers for Medicare and Medicaid Services · Jul 2026

2. A substantial number of claims related to clinical trials (32,578 claims totaling approximately $94 million for 7,447 members) lacked a corresponding attestation form.

   Oversight of Services for Medicaid Members Enrolled in Clinical Trials · Office of the New York State Comptroller, Division of State Government Accountability · Jun 4, 2026

3. Medicaid managed care plans did not list any accurate phone numbers for over one-quarter of maternal health providers.

   Inaccurate Medicaid Managed Care Network Lists May Compromise State Oversight of Access to Maternal Health Care · U.S. Department of Health and Human Services, Office of Inspector General · Jun 2026

1. Develop an ongoing process to identify and review the appropriateness of fee-for-service and encounter claims for high-risk procedures exceeding lifetime limits, such as the ones identified in this audit.

   Medicaid Program – Improper Payments for Laboratory and Related Services · Office of the New York State Comptroller Division of State Government Accountability · Jul 16, 2026

2. Expand the prisoner data match to include inmates housed in non-IDOC facilities to ensure enrollment termination before capitation payments continue.

   Illinois Medicaid Managed Care Capitation Payments for Incarcerated Enrollees · U.S. Department of Health and Human Services, Office of Inspector General · Dec 2025

3. MassHealth should implement a match criterion that focuses solely on Social Security Numbers (SSNs). Because an SSN should be unique to each individual, a targeted match criterion that only includes an SSN would reduce the prevalence of multiple IDs by 19%, based on our sample testing.

   Office of Medicaid—Review of Capitation Payments With Multiple Identification Numbers · Massachusetts Office of the State Auditor · Dec 31, 2024

• Arizona Medicaid Managed Care Medical Loss Ratio Audit
• Medicaid Program – Improper Payments for Laboratory and Related Services
• Inaccurate Medicaid Managed Care Network Lists May Compromise State Oversight of Access to Maternal Health Care
• California's Medicaid Reimbursements for Clinical Diagnostic Laboratory Services
• CMS Should Improve Its Policies and Procedures for the Oversight of States’ Reported Medicaid Expenditures to Better Protect the Financial Integrity of the Medicaid Program
• Oversight of Services for Medicaid Members Enrolled in Clinical Trials
• Comparison of Georgia Care Management Organization Encounter Data to Cash Disbursements for Amerigroup Community Care
• Missouri Medicaid Rebates for Physician-Administered and Pharmacy Drugs
• West Virginia Medicaid Managed-Care Rebates Associated With Physician-Administered Drugs
• Dental Value-Added Services—Molina Healthcare
• Dental Value-Added Services—Wellpoint
• Dental Value-Added Services—Superior HealthPlan, Inc.
• Special Investigative Unit – Blue Cross and Blue Shield
• Medicaid Program – Oversight of Health Homes
• Multiple Identification Numbers in Texas Medicaid and CHIP
• Illinois Medicaid Managed Care Capitation Payments for Incarcerated Enrollees
• Medicaid Agencies Made Millions in Unallowable Capitation Payments to Managed Care Organizations on Behalf of Deceased Enrollees
• Review of Durable Medical Equipment Providers
• Medicaid Program: Oversight of Managed Care Provider Networks
• Mississippi Did Not Report and Return All Medicaid Overpayments for the State’s Medicaid Fraud Control Unit Cases
• A Performance Audit of the Office of Inspector General of Medicaid Services: Policy Options for Improved Governance and Medicaid Oversight
• How Kentucky Failed to Prevent Over $800 Million of Medicaid Waste
• Medicaid Program: Improper Premium Payments Made on Behalf of Managed Care Members Residing Outside the State
• Washington Medicaid Managed Care Medical Loss Ratio Audit
• Medicaid Payments to MCOs for Deceased Individuals
• Pennsylvania Capitation Payments for Enrollees With Multiple Medicaid Identification Numbers
• Wisconsin’s Fee-for-Service Medicaid Payments for Applied Behavior Analysis
• Ohio Medicaid Managed Care Medical Loss Ratio Audit
• Performance Audit of Medicaid Eligibility Determinations for Long-Term Care
• Medicaid Managed Care Improper Payment Estimate
• Medicaid Program: Claims Processing Activity April 1, 2024 Through September 30, 2024
• School-Based Fee-for-Service Medicaid Reimbursements
• North Carolina’s Medicaid Control Environment, Risk Management Practices, and Governing Processes Were Assessed as Moderate Risk
• Maternal Health Outcomes
• Colorado Made Capitation Payments to Managed Care Organizations After Enrollees’ Deaths
• Special Investigative Unit Wellpoint Texas
• Performance Audit of the Health Benefits for Immigrant Seniors and Adults
• Follow-Up Assessment on a Previously Published Audit Report Managed Care Claims Submitted by Cook Children’s Home Health
• UnitedHealthcare Dental’s Financial Statistical Reports
• Twelve Selected States Did Not Accurately Calculate the Federal Share of Medicaid Collections Subject to the Increased COVID-19 Federal Medical Assistance Percentages
• Office of Medicaid—Review of Capitation Payments With Multiple Identification Numbers
• Medicaid Program: Overpayments for Medicare Part C Claims
• Summary of Results: Psychiatric and Behavioral Health Teleservices in Texas Medicaid and CHIP
• Medicaid Program: Provider Compliance With the Electronic Visit Verification Program
• Follow-Up Report on Prior Audit Recommendations Medicaid Home Help Program Michigan Department of Health and Human Services
• Estate Recovery Audit Report
• Electronic Visit Verification Audit Ohio Department of Medicaid
• The Oregon Eligibility System Appropriately Determines Eligibility, But Input Errors Continue to Occur
• Managed Care Pharmacy Benefit Services – Aetna
• Managed Care Pharmacy Benefit Services – Wellpoint
• Examining Washington’s Concurrent Medicaid Enrollments
• Without Federal Action, States Will Continue to Pay Millions of Dollars in Duplicate Medicaid Payments
• Performance Audit of Selected Programs and Activities of the Division of TennCare
• Hospice Care Claims and Fiscal Agent Contract
• Managed Care Pharmacy Encounters Paid to Omnicare Pharmacy
• Managed Care Pharmacy Encounters Paid to Meadowbrook Pharmacy
• Performance Audit Report: Pharmacy Benefit Manager Services for the Physical HealthChoices Medicaid Program in Pennsylvania
• Maryland Department Of Health Pharmacy Services Audit Report
• California Payments for Enrollees With Concurrent Medicaid Enrollment in Another State
• Medicaid Dental Benefit Program Manager - DentaQuest Informational Brief
• Cook Children’s Health Plan’s Financial Statistical Reports
• North Carolina Did Not Report and Return All Medicaid Overpayments for the State's Medicaid Fraud Control Unit Cases
• Colorado's Program Integrity Section Reporting of Medicaid Overpayments
• Evaluation Of The Colorado Recovery Audit Contractor Program
• Oversight Of Medicaid Quality Care
• Continuing Care Retirement Communities
• The Cost of Concurrent Enrollment
• Medicaid Audit Unit—Annual Report
• Medicaid Program: Claims Processing Activity October 1, 2023 Through March 31, 2024
• Medicaid Program: Improper Payments for Drugs Without a Federal Drug Rebate Agreement
• The Comprehensive Perinatal Services Program
• Maryland Department of Health Medical Care Programs Administration Managed Care Program Audit Report
• Lead Testing for Children Enrolled in Medicaid
• Maryland Department of Health Medical Care Programs Administration Audit Report
• Multiple States Made Medicaid Capitation Payments to Managed Care Organizations After Enrollees’ Deaths
• Children Enrolled in Medi‑Cal Face Challenges in Accessing Behavioral Health Care
• Maryland Department of Health – Medical Care Programs Administration Audit
• Medicaid Managed Care Contract Monitoring Follow-Up and Oversight of Health Plan Complaint and Grievance Handling Operational Audit
• States Face Ongoing Challenges in Meeting Third-Party Liability Requirements for Ensuring That Medicaid Functions as the Payer of Last Resort
• An Actuarial Analysis Of The Health And Human Services Commission’s Fiscal Year 2024 Medicaid Managed Care Rates Actuarial Soundness
• Medicaid Residency
• Office of Medicaid (MassHealth) — Review of Capitation Payments
• Medicaid Program: Maximizing Drug Rebates Under the Federal Medicaid Drug Rebate Program
• Oregon Medicaid Managed Care Medical Loss Ratio Audit
• Public Assistance Reporting Information System Alerts
• Proposition 56 Tobacco Tax The Department Of Health Care Services Is Not Adequately Monitoring Provider Payments Funded By Tobacco Taxes
• MassHealth Telehealth Review
• An Audit Report on the Health and Human Services Commission's Medicaid Managed Care Rate-Setting Process
• Nearly All States Made Capitation Payments for Beneficiaries Who Were Concurrently Enrolled in a Medicaid Managed Care Program in Two States
• Follow-Up Report on Prior Audit Recommendations Oversight and Encounter Claim Integrity of the Comprehensive Health Care Program
• Managed Care Pharmacy Claims Paid to ReCept Pharmacy #1
• An Audit Report on Cook Children’s Health Plan, a Managed Care Organization
• An Audit Report on The Health and Human Services Commission’s Oversight of the Medical Transportation Program
• Medicaid Non-Emergency Medical Transportation Services
• Medicaid and Children's Health Insurance Program Client Eligibility Determinations
• Improper Capitation Payments
• MassHealth Payments for Hospice-Related Services for Dual-Eligible Members
• Despite the COVID-19 Public Health Emergency, the Department Can Do More to Address Chronic Medi-Cal Eligibility Problems
• An Audit Report on Blue Cross Blue Shield of Texas, a Managed Care Organization
• Proposition 56 Tobacco Tax State Agencies’ Weak Administration Reduced Revenue by Millions of Dollars and Led to the Improper Use and Inadequate Disclosure of Funds
• Medicaid Managed Care Program
• Analysis of Selected Medicaid Claims Data
• Administration of Medicaid Payments to Nursing Facilities for Long-Term Care
• Improper Billing of Services Within the Medicaid Behavioral Health Program
• Oversight and Encounter Claim Integrity of the Comprehensive Health Care Program
• An Audit Report on Medicaid Managed Care Contract Processes at the Health and Human Services Commission
• Medicaid Managed Care Contract Processes at the Health and Human Services Commission
• Medicaid Managed Care Improvements Needed to Better Oversee Payment Risks
• Performance Audit of Medicaid Managed Care Organizations for Fiscal Year 2016