Managed Care
Medicaid audit reports involving managed care oversight, capitation payments, MCO reporting, network adequacy, and encounter data.
Illinois Medicaid Managed Care Capitation Payments for Incarcerated Enrollees
The audit determined that Illinois made unallowable managed care capitation payments for incarcerated enrollees during the audit period, totaling at least $9.5 million with $8.3 million Federal share,...
Medicaid Agencies Made Millions in Unallowable Capitation Payments to Managed Care Organizations on Behalf of Deceased Enrollees
We estimate that Medicaid agencies made $207,501,380 ($138,645,710 Federal share) in unallowable capitation payments to MCOs for deceased enrollees during the audit period (July 1, 2021 – June 30, 202...
Medicaid Program: Oversight of Managed Care Provider Networks
DOH did not maintain sufficient oversight of Medicaid managed care provider networks during 2023, with data reliability and process control issues affecting the accuracy of deficiency reporting and SO...
Medicaid Program: Improper Premium Payments Made on Behalf of Managed Care Members Residing Outside the State
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Washington Medicaid Managed Care Medical Loss Ratio Audit
CMS identified eight findings requiring correction, but none resulted in an MLR recalculation below the 85% remittance threshold; the audit identified operational improvements and oversight enhancemen...
Ohio Medicaid Managed Care Medical Loss Ratio Audit
While no remittances were required based on the findings, the audit identified multiple areas for improvement in Ohio’s oversight and reporting processes to ensure compliance with federal requirements...
Medicaid Managed Care Improper Payment Estimate
The GAO report highlights that while CMS's current improper payment estimates for Medicaid managed care are near zero, they do not capture all program integrity risks. CMS has taken steps to improve o...
Managed Care Incentive Payment Program
LDH’s design and lack of oversight of the MCIP program led to the majority of MCIP funds being paid for activities that do not have a direct, measurable result for how they improve access to healthcar...
Colorado Made Capitation Payments to Managed Care Organizations After Enrollees’ Deaths
The audit found that Colorado made unallowable capitation payments to Medicaid managed care organizations for deceased enrollees, resulting in significant financial losses and reporting inaccuracies. ...
CMS Did Not Ensure That Selected States Complied With Medicaid Managed Care Mental Health and Substance Use Disorder Parity Requirements
CMS did not ensure that selected States complied with Medicaid managed care MH/SUD parity requirements; noncompliance was widespread across eight States, including missing parity provisions in contrac...
The Comprehensive Perinatal Services Program
The State has provided limited oversight of the Comprehensive Perinatal Services Program and has not meaningfully improved the program. Data limitations and insufficient oversight hinder the ability t...
Maryland Department of Health Medical Care Programs Administration Managed Care Program Audit Report
MDH’s corrective actions addressing the identified audit issues are considered sufficient to address all audit issues.
Multiple States Made Medicaid Capitation Payments to Managed Care Organizations After Enrollees’ Deaths
The report concludes that improper Medicaid capitation payments to MCOs on behalf of deceased enrollees remain a persistent issue across states, with prior unallowable payments totaling about $249 mil...
Medicaid Managed Care Contract Monitoring Follow-Up and Oversight of Health Plan Complaint and Grievance Handling Operational Audit
The audit identified deficiencies in internal controls related to ECGA reporting, data summaries, and follow-up actions, indicating a need for strengthened oversight and documentation.
New York Did Not Ensure That A Managed Care Organization Complied With Requirements For Denying Prior Authorization Requests
The audit concluded that the New York State Department of Health’s oversight was ineffective in ensuring that CPHL complied with requirements for denying prior authorization requests, resulting in del...
An Actuarial Analysis Of The Health And Human Services Commission’s Fiscal Year 2024 Medicaid Managed Care Rates Actuarial Soundness
The FY 2024 Texas Medicaid managed care capitation rates are actuarially sound overall, with no material program-wide under- or over-funding detected. Milliman identifies several recommendations to st...
Oregon Medicaid Managed Care Medical Loss Ratio Audit
The audit identified areas for improvement in Oregon's Medicaid managed care MLR reporting and oversight processes. While no immediate remittance was required, implementing the recommendations will en...
An Audit Report on the Health and Human Services Commission's Medicaid Managed Care Rate-Setting Process
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 governa...
Nearly All States Made Capitation Payments for Beneficiaries Who Were Concurrently Enrolled in a Medicaid Managed Care Program in Two States
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 con...
An Audit Report on Cook Children’s Health Plan, a Managed Care Organization
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...
An Audit Report on Blue Cross Blue Shield of Texas, a Managed Care Organization
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 ...
Medicaid Managed Care Program
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 pa...
An Audit Report on Medicaid Managed Care Contract Processes at the Health and Human Services Commission
The audit found that the Health and Human Services Commission has made significant progress in establishing processes and controls related to Medicaid managed care contract management, in compliance w...
Medicaid Managed Care Contract Processes at the Health and Human Services Commission
The Commission has made significant progress in establishing processes and controls for Medicaid managed care contract management, aligning with Senate Bill 894 requirements. However, further efforts ...