Audit 391096

2025-004 (2024-004) Special Tests and Provisions: Provider Eligibility (Significant Deficiency in Internal Controls over Compliance) Assistance Listing Number(s) Name of Federal Program Federal Agency/Pass-through Entity Award Number Award Year 93.777/93.778 Medicaid Cluster Department of Health and Human Services Multiple 2025 Condition: For 9 of 40 providers tested, the Department was unable to provide an original approved Provider Participation Agreement (PPA). However, all 9 providers had been reverified and screened within the prior five years. For 5 of 40 providers tested, the Department was unable to provide evidence that the provider’s eligibility had been reverified within the prior five years. However, all 5 of these providers did have approved original PPAs as well as current licenses. Management has made progress on the prior year finding. A program was implemented to address the transfer of screening records from the legacy system into the current MMIS system and to provide monthly screenings of providers. However, due to the timing of the corrective actions, there are certain providers remaining in the system without the required screening documentation. Criteria: 42 CFR 455.410 states that the Department must require all enrolled providers to be screened. Per 42 CFR 455.412, the Department must verify the provider’s license has not expired and is valid. Context: A sample of providers who received payment during the year were tested to determine whether a required screening was performed before the provider was enrolled. Management has made progress on the prior year finding. A program was implemented to address the transfer of screening records from the legacy system into the current MMIS system and to provide monthly screenings of providers. However, due to the timing of the corrective actions, there are certain providers remaining in the system without the required screening documentation. Cause: In certain instances, information from the legacy system was not transferred to the current MMIS. Additionally, certain providers who received single-case approvals were being excluded from the revalidation processes in place. Effect: There is no documentation to show that a provider screening and license verification were conducted to show compliance with Medicaid requirements. Questioned Cost: None. Repeat Finding: This is a repeat finding (prior year finding 2024-004; original finding 2022-003). Recommendation: We recommend that the Department review and update controls to ensure proper screening and license verification is performed for all providers and that documentation of the screening and verification is retained in all cases. Current Status/Plan of Action: Re-implementation of the recertification and revalidation processes is currently completed in the provider enrollment system. We are moving forward with the revalidation/recertification implementation. Initial provider notifications (90-day notice) will be issued in March 2026. Completion Date: June 2026 Responsible Person: Bureau Chief, Provider Enrollment Services Bureau, Medical Assistance Division