US Department of Health and Human Services
Passed through the NC Department of Health and Human Services
Program Name: Medical Assistance Program (Medicaid; Title XIX)
AL #: 93.778
Finding: 2024-001 Inaccurate Information Entry
SIGNIFICANT DEFICENCY
Eligibility
Criteria:
Condition:
Questioned Costs:
There were 2 errors discovered during our procedures that inaccurate information
was entered when determining eligibility.
There was no known affect to eligibility and there were no known questioned costs.
In accordance with 42 CFR 435, documentation must be obtained as needed to
determine if a recipient meets specific standards, and documentation must be
maintained to support eligibility determinations. In accordance with 2 CFR 200,
management should have an adequate system of internal controls procedures in
place to ensure an applicant is properly determined or redetermined for benefits.Context:
Effect:
Identification of a
repeat finding:
Cause:
Recommendation:
Views of responsible
officials and planned
corrective actions:
US Department of Health and Human Services
Passed through the NC Department of Health and Human Services
Program Name: Medical Assistance Program (Medicaid; Title XIX)
AL #: 93.778
Finding: 2024-002 Untimely Review of SSI Terminations
SIGNIFICANT DEFICENCY
Eligibility
Criteria: In accordance with the Medicaid Manual MA-3120, the State sends notification to
the County when a participant is no longer eligible under a SSI determination. The
County has a certain time period to initiate an ex-parte review to determine whether
the recipient qualifies for Medicaid under any other coverage group, such as
Family and Children's Medicaid, North Carolina Health Choice for Children, Work
First Family Assistance, or Medicaid for the Aged, Blind and Disabled.
This is a repeat finding from the immediate previous audit, 2023-001.
Section III. Federal Award Findings and Questioned Costs (continued)
We examined 60 cases from of a total of 1,127,837 Medicaid claims from the
Medicaid beneficiary report provided by NC Department of Health and Human
Services to re-determine eligibility. These findings are being reported with the
financial statement audit as it relates to Medicaid administrative cost compliance
audit.
For those certifications/re-certifications there was a chance that information was
not properly documented and reconciled to NC FAST and a participant could have
been approved for benefits for which they were not eligible.
Ineffective record keeping and ineffective case review process, incomplete
documentation, and incorrect application of rules for purposes of determining
eligibility.
Files should be reviewed internally to ensure proper documentation is in place for
eligibility. Workers should be retrained on what files should contain and the
importance of complete and accurate record keeping. We recommend that all files
include online verifications, documented resources of income and those amounts
agree to information in NC FAST. The results found or documentation made in
case notes should clearly indicate what actions were performed and the results of
those actions.
The County agrees with the finding. Please refer to the corrective action plan for
details.
Context:
Effect:
Identification of a
repeat finding:
Cause:
Recommendation:
Views of responsible
officials and planned
corrective actions:
US Department of Health and Human Services
Passed through the NC Department of Health and Human Services
Program Name: Medical Assistance Program (Medicaid; Title XIX)
AL #: 93.778
Finding: 2024-002 Untimely Review of SSI Terminations
SIGNIFICANT DEFICENCY
Eligibility
Criteria: In accordance with the Medicaid Manual MA-3120, the State sends notification to
the County when a participant is no longer eligible under a SSI determination. The
County has a certain time period to initiate an ex-parte review to determine whether
the recipient qualifies for Medicaid under any other coverage group, such as
Family and Children's Medicaid, North Carolina Health Choice for Children, Work
First Family Assistance, or Medicaid for the Aged, Blind and Disabled.
This is a repeat finding from the immediate previous audit, 2023-001.
Section III. Federal Award Findings and Questioned Costs (continued)
We examined 60 cases from of a total of 1,127,837 Medicaid claims from the
Medicaid beneficiary report provided by NC Department of Health and Human
Services to re-determine eligibility. These findings are being reported with the
financial statement audit as it relates to Medicaid administrative cost compliance
audit.
For those certifications/re-certifications there was a chance that information was
not properly documented and reconciled to NC FAST and a participant could have
been approved for benefits for which they were not eligible.
Ineffective record keeping and ineffective case review process, incomplete
documentation, and incorrect application of rules for purposes of determining
eligibility.
Files should be reviewed internally to ensure proper documentation is in place for
eligibility. Workers should be retrained on what files should contain and the
importance of complete and accurate record keeping. We recommend that all files
include online verifications, documented resources of income and those amounts
agree to information in NC FAST. The results found or documentation made in
case notes should clearly indicate what actions were performed and the results of
those actions.
The County agrees with the finding. Please refer to the corrective action plan for
details.Condition:
Questioned Costs:
Context:
Effect:
Cause:
Recommendation:
Views of responsible
officials and planned
corrective actions:
Program Name: Medical Assistance Program (Medicaid; Title XIX)
AL #: 93.778
The County did not initiate ex-parte review timely, therefore, no eligibility review
was completed in the required time period. The lack of follow up and certification
lead to applicants receiving Medicaid benefits for which they were not eligible.
The County agrees with the finding. Please refer to the corrective action plan for
details.
Any State communications related to applicants/beneficiaries should be shared with
all areas from which the participant receives benefits. State files should be
reviewed internally to ensure all actions have been properly closed and the
corrective action has been taken. Workers should be retrained on what process
needs to be followed when State communications are received.
SIGNIFICANT DEFICENCY: Finding 2024-001 and 2024-002 also apply to State requirements and State
Awards.
Section IV. State Award Findings and Questioned Costs
Ineffective communication between departments within the Department of Social
Services. One area within DSS received State communications that applicants
would no longer be eligible for SSI benefits and the County needed to conduct an
ex-parte review. This information was not shared with other departments in DSS
from which the recipient was also receiving benefits.
There was no known affect to eligibility and there were no known questioned costs.
We examined 60 cases from of a total of 1,127,837 Medicaid claims from the
Medicaid beneficiary report provided by NC Department of Health and Human
Services to re-determine eligibility. These findings are being reported with the
financial statement audit as it relates to Medicaid administrative cost compliance
audit.
There were 2 applicants/beneficiaries not reviewed timely and determined to be
eligible for Medicaid when their SSI benefits were terminated.
Section III. Federal Award Findings and Questioned Costs (continued)
US Department of Health and Human Services
Passed through the NC Department of Health and Human Services
Program Name: Medical Assistance Program (Medicaid; Title XIX)
AL #: 93.778
Finding: 2024-001 Inaccurate Information Entry
SIGNIFICANT DEFICENCY
Eligibility
Criteria:
Condition:
Questioned Costs:
There were 2 errors discovered during our procedures that inaccurate information
was entered when determining eligibility.
There was no known affect to eligibility and there were no known questioned costs.
In accordance with 42 CFR 435, documentation must be obtained as needed to
determine if a recipient meets specific standards, and documentation must be
maintained to support eligibility determinations. In accordance with 2 CFR 200,
management should have an adequate system of internal controls procedures in
place to ensure an applicant is properly determined or redetermined for benefits.Context:
Effect:
Identification of a
repeat finding:
Cause:
Recommendation:
Views of responsible
officials and planned
corrective actions:
US Department of Health and Human Services
Passed through the NC Department of Health and Human Services
Program Name: Medical Assistance Program (Medicaid; Title XIX)
AL #: 93.778
Finding: 2024-002 Untimely Review of SSI Terminations
SIGNIFICANT DEFICENCY
Eligibility
Criteria: In accordance with the Medicaid Manual MA-3120, the State sends notification to
the County when a participant is no longer eligible under a SSI determination. The
County has a certain time period to initiate an ex-parte review to determine whether
the recipient qualifies for Medicaid under any other coverage group, such as
Family and Children's Medicaid, North Carolina Health Choice for Children, Work
First Family Assistance, or Medicaid for the Aged, Blind and Disabled.
This is a repeat finding from the immediate previous audit, 2023-001.
Section III. Federal Award Findings and Questioned Costs (continued)
We examined 60 cases from of a total of 1,127,837 Medicaid claims from the
Medicaid beneficiary report provided by NC Department of Health and Human
Services to re-determine eligibility. These findings are being reported with the
financial statement audit as it relates to Medicaid administrative cost compliance
audit.
For those certifications/re-certifications there was a chance that information was
not properly documented and reconciled to NC FAST and a participant could have
been approved for benefits for which they were not eligible.
Ineffective record keeping and ineffective case review process, incomplete
documentation, and incorrect application of rules for purposes of determining
eligibility.
Files should be reviewed internally to ensure proper documentation is in place for
eligibility. Workers should be retrained on what files should contain and the
importance of complete and accurate record keeping. We recommend that all files
include online verifications, documented resources of income and those amounts
agree to information in NC FAST. The results found or documentation made in
case notes should clearly indicate what actions were performed and the results of
those actions.
The County agrees with the finding. Please refer to the corrective action plan for
details.
Context:
Effect:
Identification of a
repeat finding:
Cause:
Recommendation:
Views of responsible
officials and planned
corrective actions:
US Department of Health and Human Services
Passed through the NC Department of Health and Human Services
Program Name: Medical Assistance Program (Medicaid; Title XIX)
AL #: 93.778
Finding: 2024-002 Untimely Review of SSI Terminations
SIGNIFICANT DEFICENCY
Eligibility
Criteria: In accordance with the Medicaid Manual MA-3120, the State sends notification to
the County when a participant is no longer eligible under a SSI determination. The
County has a certain time period to initiate an ex-parte review to determine whether
the recipient qualifies for Medicaid under any other coverage group, such as
Family and Children's Medicaid, North Carolina Health Choice for Children, Work
First Family Assistance, or Medicaid for the Aged, Blind and Disabled.
This is a repeat finding from the immediate previous audit, 2023-001.
Section III. Federal Award Findings and Questioned Costs (continued)
We examined 60 cases from of a total of 1,127,837 Medicaid claims from the
Medicaid beneficiary report provided by NC Department of Health and Human
Services to re-determine eligibility. These findings are being reported with the
financial statement audit as it relates to Medicaid administrative cost compliance
audit.
For those certifications/re-certifications there was a chance that information was
not properly documented and reconciled to NC FAST and a participant could have
been approved for benefits for which they were not eligible.
Ineffective record keeping and ineffective case review process, incomplete
documentation, and incorrect application of rules for purposes of determining
eligibility.
Files should be reviewed internally to ensure proper documentation is in place for
eligibility. Workers should be retrained on what files should contain and the
importance of complete and accurate record keeping. We recommend that all files
include online verifications, documented resources of income and those amounts
agree to information in NC FAST. The results found or documentation made in
case notes should clearly indicate what actions were performed and the results of
those actions.
The County agrees with the finding. Please refer to the corrective action plan for
details.Condition:
Questioned Costs:
Context:
Effect:
Cause:
Recommendation:
Views of responsible
officials and planned
corrective actions:
Program Name: Medical Assistance Program (Medicaid; Title XIX)
AL #: 93.778
The County did not initiate ex-parte review timely, therefore, no eligibility review
was completed in the required time period. The lack of follow up and certification
lead to applicants receiving Medicaid benefits for which they were not eligible.
The County agrees with the finding. Please refer to the corrective action plan for
details.
Any State communications related to applicants/beneficiaries should be shared with
all areas from which the participant receives benefits. State files should be
reviewed internally to ensure all actions have been properly closed and the
corrective action has been taken. Workers should be retrained on what process
needs to be followed when State communications are received.
SIGNIFICANT DEFICENCY: Finding 2024-001 and 2024-002 also apply to State requirements and State
Awards.
Section IV. State Award Findings and Questioned Costs
Ineffective communication between departments within the Department of Social
Services. One area within DSS received State communications that applicants
would no longer be eligible for SSI benefits and the County needed to conduct an
ex-parte review. This information was not shared with other departments in DSS
from which the recipient was also receiving benefits.
There was no known affect to eligibility and there were no known questioned costs.
We examined 60 cases from of a total of 1,127,837 Medicaid claims from the
Medicaid beneficiary report provided by NC Department of Health and Human
Services to re-determine eligibility. These findings are being reported with the
financial statement audit as it relates to Medicaid administrative cost compliance
audit.
There were 2 applicants/beneficiaries not reviewed timely and determined to be
eligible for Medicaid when their SSI benefits were terminated.
Section III. Federal Award Findings and Questioned Costs (continued)