Program Oversight

Program oversight is the system of governance, internal controls, contractor monitoring, audit follow-up, corrective action, and enforcement used to administer Medicaid. Audits evaluate whether agencies identify problems and ensure that responsible parties correct them.

A finding has limited value if an agency cannot track corrective action or enforce its requirements. Oversight audits test whether responsibilities are clear, monitoring is sustained, known deficiencies are resolved, and public funds remain protected after problems are identified.

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. DOH did not always receive an attestation form before members participated in a clinical trial.

   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. Weaknesses in the State agency’s quality management system limited the effectiveness of oversight, with staffing shortages and recent changes in administrative leadership contributing to noncompliance.

   North Dakota Could Better Ensure That Providers Fully Comply With Federal Waiver and State Health, Safety, and Administrative Requirements at 44 Residential Settings · U.S. Department of Health and Human Services Office of Inspector General · Jun 2026

1. Enhance oversight and monitoring processes to verify that risk corridor amounts for subcontracted health plans are appropriately reflected within the MLR Reporting Templates.

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

2. Take steps to support States in holding Medicaid managed care plans accountable for the accuracy of their online provider directories.

   Inaccurate Medicaid Managed Care Provider Directories May Limit Enrollees’ Access to Maternal Health Care · Office of Inspector General, U.S. Department of Health and Human Services · Jun 2026

3. CMS should take steps to support States in holding Medicaid managed care plans accountable for the accuracy of the network lists used for assessing network adequacy.

   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

• Arizona Medicaid Managed Care Medical Loss Ratio Audit
• Medicaid Program – Improper Payments for Laboratory and Related Services
• North Dakota Could Better Ensure That Providers Fully Comply With Federal Waiver and State Health, Safety, and Administrative Requirements at 44 Residential Settings
• 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
• California's Medicaid Reimbursements for Clinical Diagnostic Laboratory Services
• Medicaid Managed Care Behavioral Health Service Denials in Philadelphia by Community Behavioral Health
• 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
• 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
• Efforts to Monitor Established Service Level Agreements for the Medicaid Pharmacy Benefits Manager Contract
• Department of Human Services Investigations of Alleged Kickbacks in the Early Intensive Developmental and Behavioral Intervention Program
• Performance Audit Report School Services Program
• Colorado Made at Least $77.8 Million in Improper Fee-for-Service Medicaid Payments for Applied Behavior Analysis Provided to Children
• 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.
• Maine Made at Least $45.6 Million in Improper Fee-for-Service Medicaid Payments for Rehabilitative and Community Support Services Provided to Children Diagnosed With Autism
• 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
• 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
• Most Children Enrolled in Medicaid Did Not Receive Timely Suicide-Related Followup Care
• Mississippi Did Not Report and Return All Medicaid Overpayments for the State’s Medicaid Fraud Control Unit Cases
• 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
• Performance Audit Report July 2025 Medicaid Provider Enrollment Follow-Up Audit
• Pennsylvania Capitation Payments for Enrollees With Multiple Medicaid Identification Numbers
• Wisconsin’s Fee-for-Service Medicaid Payments for Applied Behavior Analysis
• Analysis of Selected Nursing Facilities’ Use of Medicaid Reimbursement for Direct Care Compensation
• 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
• Maryland Did Not Comply With Federal Waiver and State Requirements at 20 Adult Day Care Facilities Audited
• Oklahoma Focused Program Integrity Review Final Report
• Audit Of Ohio Adult Day Health Care Services
• School-Based Fee-for-Service Medicaid Reimbursements
• North Carolina’s Medicaid Control Environment, Risk Management Practices, and Governing Processes Were Assessed as Moderate Risk
• Texas Did Not Fully Comply With Federal Waiver And State Health, Safety, And Administrative Requirements At All 20 Adult Day Activity And Health Service Facilities Audited
• 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
• 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
• Department of Medical Assistance Services Report on Audit for the Year Ended June 30, 2024
• 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
• California Improperly Claimed $52.7 Million in Federal Medicaid Reimbursement for Capitation Payments Made on Behalf of Noncitizens With Unsatisfactory Immigration Status
• Colorado's Program Integrity Section Reporting of Medicaid Overpayments
• Evaluation Of The Colorado Recovery Audit Contractor Program
• Oversight Of Medicaid Quality Care
• Additional Actions Needed to Enhance Program Integrity and Save Billions
• Continuing Care Retirement Communities
• 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
• The Cost of Concurrent Enrollment
• Medicaid Audit Unit—Annual Report
• Colorado Could Better Ensure That Nursing Homes Comply With Federal Requirements For Life Safety, Emergency Preparedness, And Infection Control
• 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
• New York Did Not Ensure That A Managed Care Organization Complied With Requirements For Denying Prior Authorization Requests
• Medicaid Correspondence Performance Audit
• Medicaid Program Integrity Opportunities for CMS to Strengthen Use of State Auditor Findings and Collaboration
• 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
• Kansas Medicaid and CHIP Eligibility Determinations Audit
• 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
• Public Assistance Reporting Information System Alerts
• The Centers for Medicare & Medicaid Services’ Review Contractors Generally Conducted Medicaid Fee-for-Service Claim Reviews for Selected States Under the Payment Error Rate Measurement Program in Accordance with Federal and State Requirements
• 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
• 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
• The Centers for Medicare & Medicaid Services’ Eligibility Review Contractor Adequately Determined Medicaid Eligibility for Selected States Under the Payment Error Rate Measurement Program
• 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
• Timely Notification of Inpatient Hospital Stays Could Help Reduce Improper Medicaid 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
• 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
• 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 Program: Improper Medicaid Payments for Individuals Receiving Hospice Services Covered by Medicare
• Medicaid Home Help Program
• Medicaid Managed Care Program
• Analysis of Selected Medicaid Claims Data
• Administration of Medicaid Payments to Nursing Facilities for Long-Term Care
• Medicaid Eligibility Determinations: Status on the Use of Federal Tax Information
• 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
• Department of Social Services Prescription Drug Oversight
• Medicaid Managed Care Improvements Needed to Better Oversee Payment Risks
• Performance Audit of Medicaid Managed Care Organizations for Fiscal Year 2016
• Audit of Medicaid Reimbursements Made to Regency Manor Rehabilitation
• Review of Medicaid Provider Reimbursements made to Crest Transportation Service