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.

Managed care places substantial public spending and day-to-day service decisions with outside plans and their contractors. Weak contract monitoring, incomplete encounter data, or inaccurate financial reporting can conceal improper payments and make it difficult to determine whether enrollees received required care.

1. DOH did not provide adequate guidance to providers and MCOs, nor did it effectively monitor claims for certain laboratory procedures to ensure Medicaid paid only for necessary services; weaknesses in the eMedNY system edits designed to prevent improper fee-for-service laboratory payments contributed to a total of $21.6 million in improper payments.

   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. Provider Incentives/Alternative Payment Models and Contracts: Although leading practices for PI/APM were not federal or state requirements during the audit period, CMS observed contracts with timing issues, missing or unavailable contracts, and misclassification of certain PI/APM payments, requiring improved documentation and oversight.

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

3. Claims with the Q0 modifier (4,813 claims totaling nearly $4 million) indicated investigational services; most were encounter claims; MCOs generally had guidance and system edits, but none performed a risk assessment of clinical trial claims or tracked costs between Medicaid and sponsors.

   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

1. Ensure the MCO identified in this report takes corrective actions to prevent erroneously paying voided Health Home claims due to retroactive rate changes.

   Medicaid Program – Oversight of Health Homes · Office of the New York State Comptroller, Division of State Government Accountability · Jan 20, 2026

2. Implement a process by 2026 to recoupuplicate enrollment payments from CCOs for recipients who live out of state (target date Mar 31, 2026).

   Without Federal Action, States Will Continue to Pay Millions of Dollars in Duplicate Medicaid Payments · Oregon Secretary of State, Audits Division · Oct 18, 2024

3. Review the $44.5 million in missed rebates and invoice manufacturers, as appropriate; where rebates cannot be sought due to missing NDCs or invalid procedure code and NDC combinations on physician-administered drug claims paid by MCOs, follow up with MCOs for proper drug information or seek recovery directly from MCOs for the missed rebates.

   Medicaid Program: Maximizing Drug Rebates Under the Federal Medicaid Drug Rebate Program · Office of the New York State Comptroller, Division of State Government Accountability · Apr 5, 2023

• Arizona Medicaid Managed Care Medical Loss Ratio Audit
• Medicaid Program – Improper Payments for Laboratory and Related Services
• Inaccurate Medicaid Managed Care Provider Directories May Limit Enrollees’ Access to Maternal Health Care
• Inaccurate Medicaid Managed Care Network Lists May Compromise State Oversight of Access to Maternal Health Care
• Medicaid Managed Care Behavioral Health Service Denials in Philadelphia by Community Behavioral Health
• 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
• Medicaid Managed Care Behavioral Health Services Denials in Louisiana
• Selected Diabetes and Weight Loss Drugs Were Dispensed to Michigan Medicaid Managed Care Enrollees in Accordance With Federal and State Requirements
• 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.
• Follow-Up Assessment on a Previously Published Audit Report Managed Care Pharmacy Claims Paid to Encore Pharmacy #1
• Special Investigative Unit – Blue Cross and Blue Shield
• Medicaid Program – Oversight of Health Homes
• 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
• Medicaid Program: Oversight of Managed Care Provider Networks
• New Jersey Did Not Ensure That Some Medicaid Personal Care Assistant Services Provided Under the Personal Preference Program Met Federal and State Requirements
• 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
• Ohio Medicaid Managed Care Medical Loss Ratio Audit
• 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
• Managed Care Incentive Payment Program
• 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
• Office of Medicaid—Review of Capitation Payments With Multiple Identification Numbers
• 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
• 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
• California Improperly Claimed $52.7 Million in Federal Medicaid Reimbursement for Capitation Payments Made on Behalf of Noncitizens With Unsatisfactory Immigration Status
• Oversight Of Medicaid Quality Care
• Additional Actions Needed to Enhance Program Integrity and Save Billions
• CMS Did Not Ensure That Selected States Complied With Medicaid Managed Care Mental Health and Substance Use Disorder Parity Requirements
• Medicaid Capitation Paid for Members Residing in Other States
• 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
• 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
• New York Did Not Ensure That A Managed Care Organization Complied With Requirements For Denying Prior Authorization Requests
• An Actuarial Analysis Of The Health And Human Services Commission’s Fiscal Year 2024 Medicaid Managed Care Rates Actuarial Soundness
• Poor Accountability and Transparency Harm Medicaid Patients and Independent Pharmacies
• Medicaid Residency
• Office of Medicaid (MassHealth) — Review of Capitation Payments
• Medicaid CMS Oversight and Guidance Could Improve Recovery Audit Contractor Program
• Medicaid Program: Maximizing Drug Rebates Under the Federal Medicaid Drug Rebate Program
• Oregon Medicaid Managed Care Medical Loss Ratio Audit
• Proposition 56 Tobacco Tax The Department Of Health Care Services Is Not Adequately Monitoring Provider Payments Funded By Tobacco Taxes
• 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
• Arizona Health Care Cost Containment System—Review of Selected Behavioral Health Services
• 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
• Office Of Medicaid (MassHealth)—Massachusetts Delivery System Reform Incentive Payment Program
• An Audit Report on The Health and Human Services Commission’s Oversight of the Medical Transportation Program
• Medicaid Non-Emergency Medical Transportation Services
• Improper Capitation Payments
• Medicaid Program Integrity Examining the Health Care Authority’s oversight of efforts at state agencies
• An Audit Report on Blue Cross Blue Shield of Texas, a Managed Care Organization
• Medicaid Provider Enrollment Performance Audit
• Medicaid Program: Improper Medicaid Payments for Individuals Receiving Hospice Services Covered by Medicare
• Medicaid Managed Care Program
• Analysis of Selected Medicaid Claims Data
• 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