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. 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

2. Did Not Fully Implement Recommendations to Identify and Remove Providers with Suspended or Terminated Licenses

   Performance Audit Report July 2025 Medicaid Provider Enrollment Follow-Up Audit · North Carolina Office of the State Auditor · Jul 2025

3. The unallowable payments occurred because the State agency’s controls were insufficient to detect or prevent multiple Medicaid ID numbers from being assigned to 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

1. Monitor receipt of State Directed Payments (SDP) and pass-through payments and reconcile with MCPs’ MLR reports.

   Ohio Medicaid Managed Care Medical Loss Ratio Audit · Centers for Medicare & Medicaid Services, Center for Program Integrity · Jul 25, 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. Improve inter-agency communication and automated notification systems between HCA and DSHS.

   Examining Washington’s Concurrent Medicaid Enrollments · Office of the Washington State Auditor · Oct 28, 2024

• 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
• 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
• 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 of Selected Programs and Activities of the Division of TennCare
• 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
• 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
• 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
• New York Did Not Ensure That A Managed Care Organization Complied With Requirements For Denying Prior Authorization Requests
• 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
• Medicaid Residency
• Kansas Medicaid and CHIP Eligibility Determinations Audit
• Medicaid CMS Oversight and Guidance Could Improve Recovery Audit Contractor Program
• 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
• 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 Eligibility Determinations: Status on the Use of Federal Tax Information
• 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
• Audit of Medicaid Reimbursements Made to Regency Manor Rehabilitation
• Review of Medicaid Provider Reimbursements made to Crest Transportation Service