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. Errors in reporting templates and inconsistencies in data submission were identified, including misreporting taxes, QIA expenses, and risk corridor settlement amounts.

   Ohio Medicaid Managed Care Medical Loss Ratio Audit · Centers for Medicare & Medicaid Services, Center for Program Integrity · Jul 25, 2025

2. Issues with the Integrated Eligibility System (IES) affecting internal controls and data completeness.

   Performance Audit of Medicaid Eligibility Determinations for Long-Term Care · Office of the Auditor General (Illinois) · Jul 16, 2025

3. Session notes did not support CPT codes billed (79 enrollee-months).

   Wisconsin’s Fee-for-Service Medicaid Payments for Applied Behavior Analysis · Office of Inspector General, Department of Health and Human Services · Jul 2025

1. Use the Zero SSN report consistently and update it monthly, in accordance with the State agency’s policy and procedures, to prevent the issuance of multiple Medicaid ID numbers for the same enrollee.

   Pennsylvania Capitation Payments for Enrollees With Multiple Medicaid Identification Numbers · Office of Inspector General, Department of Health and Human Services · Jul 2025

2. MassHealth should investigate and resolve all instances where its data matches indicate that a member has been assigned more than one member ID.

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

3. MassHealth should revise its policies and procedures regarding its data matches for member eligibility. Specifically, MassHealth should require that all members flagged by data matches submit documentation to substantiate that they reside in Massachusetts. If the member does not provide this documentation, MassHealth should either pause this member’s coverage or move the member to its fee-for-service model until it can determine whether the member’s coverage should be terminated.

   Medicaid Audit Unit—Annual Report · Office of the State Auditor (Massachusetts) · Mar 1, 2024

• 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
• North Carolina’s Medicaid Control Environment, Risk Management Practices, and Governing Processes Were Assessed as Moderate Risk
• Colorado Made Capitation Payments to Managed Care Organizations After Enrollees’ Deaths
• Performance Audit of the Health Benefits for Immigrant Seniors and Adults
• 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
• Follow-Up Report on Prior Audit Recommendations Medicaid Home Help Program Michigan Department of Health and Human Services
• Electronic Visit Verification Audit Ohio Department of Medicaid
• Examining Washington’s Concurrent Medicaid Enrollments
• Performance Audit Report: Pharmacy Benefit Manager Services for the Physical HealthChoices Medicaid Program in Pennsylvania
• Medicaid Dental Benefit Program Manager - DentaQuest Informational Brief
• North Carolina Did Not Report and Return All Medicaid Overpayments for the State's Medicaid Fraud Control Unit Cases
• Oversight Of Medicaid Quality Care
• The Cost of Concurrent Enrollment
• Medicaid Audit Unit—Annual Report
• Medicaid Program: Claims Processing Activity October 1, 2023 Through March 31, 2024
• The Comprehensive Perinatal Services Program
• Lead Testing for Children Enrolled in Medicaid
• 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
• 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
• Oregon Medicaid Managed Care Medical Loss Ratio Audit
• MassHealth Telehealth Review
• Nearly All States Made Capitation Payments for Beneficiaries Who Were Concurrently Enrolled in a Medicaid Managed Care Program in Two States
• 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
• MassHealth Payments for Hospice-Related Services for Dual-Eligible Members
• An Audit Report on Blue Cross Blue Shield of Texas, a Managed Care Organization
• Improper Billing of Services Within the Medicaid Behavioral Health 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