Program Integrity
Medicaid audit reports involving fraud prevention, improper payments, recoveries, compliance controls, and program integrity operations.
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...
Oklahoma Focused Program Integrity Review Final Report
CMS supports Oklahoma’s efforts and encourages further improvements in program integrity. The review identified four observations for the state’s attention but no non-compliance findings that pose a r...
North Carolina’s Medicaid Control Environment, Risk Management Practices, and Governing Processes Were Assessed as Moderate Risk
Overall, the audit determined that North Carolina's Medicaid control environment, risk management practices, and governing processes operate at a moderate risk level, with three risk areas rated high ...
Performance Audit of the Health Benefits for Immigrant Seniors and Adults
The audit revealed significant discrepancies between estimated and actual enrollment and costs, issues with data accuracy and eligibility verification, and the need for improved controls to prevent in...
Performance Audit of Selected Programs and Activities of the Division of TennCare
The Division of TennCare has made progress in implementing TennCare III initiatives, unwinding renewals, and maintaining cybersecurity controls, but faces ongoing risks in behavioral health provider n...
Colorado's Program Integrity Section Reporting of Medicaid Overpayments
Colorado did not report and refund the correct Federal share of Medicaid overpayments identified by its Program Integrity Section during Oct 1, 2014 through Dec 31, 2020; 80 of 403 cases contained unr...
Additional Actions Needed to Enhance Program Integrity and Save Billions
While CMS has made significant progress in reducing improper payments and implementing GAO recommendations, ongoing efforts and additional actions are necessary to further enhance program integrity, p...
Medicaid Audit Unit—Annual Report
The audit identified an estimated $84,832,094 in capitation payments to MassHealth members residing outside Massachusetts. MassHealth has reported actions or planned actions on all four audit recommen...
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 Program Integrity Opportunities for CMS to Strengthen Use of State Auditor Findings and Collaboration
While CMS has taken steps to improve collaboration with state auditors and analyze audit findings, there remains significant room for improvement in using these findings to enhance Medicaid program ov...
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...
Proposition 56 Tobacco Tax The Department Of Health Care Services Is Not Adequately Monitoring Provider Payments Funded By Tobacco Taxes
Overall, the audit found significant control weaknesses in how Proposition 56 funds and OTP taxes were administered: DHCS did not adequately monitor supplemental payments or provider suspensions in Me...
Medicaid Program Integrity Examining the Health Care Authority’s oversight of efforts at state agencies
Medicaid is a significant public assistance program in Washington, requiring robust program integrity efforts to ensure proper use of funds. While HCA has taken steps to improve oversight, there are o...
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 ...
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
The audit concludes that inaccuracies in CDTFA’s tax rate calculation and insufficient safeguards and public disclosure across several agencies impeded program integrity, resulting in potential revenu...
Medicaid Managed Care Improvements Needed to Better Oversee Payment Risks
The GAO found that Medicaid managed care faces significant payment risks and oversight challenges. CMS's efforts to improve program integrity have been delayed and insufficient, risking continued paym...