Criteria: Federal regulations under 42 CFR § 435.956 require states to verify eligibility factors using electronic data sources where available, and to obtain documentation for unverifiable information. Additionally, the state's Medicaid manual (Aged, Blind and Disabled manual, Family and Children Medicaid manual and the Integrated Policy manual) mandates that all eligibility determinations include cross-verification of applicant-provided data against reliable external sources to ensure accuracy and prevent improper payments. Condition: There were a total of Forty-three (43) errors found during our testing procedures: There were Three (3) errors where resources were incorrectly calculated or were not properly documented in the case file, Twelve (12) errors where required information needed for eligibility determinations were not requested or not requested timely at applications or redeterminations, One (1) error where applicants/beneficiaries not reviewed timely and determined to be eligible for Medicaid when their SSI benefits were terminated, and Twenty-seven (27) where a redetermination of eligibility was not performed in accordance with program requirements. Questioned Costs: Due to the nature of the populations provided from which the samples were chosen, we are unable to calculate questioned costs for the above mentioned potential eligibility and noncompliance errors. Context: We examined 60 cases from of a total of 520,883 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. Effect: This control deficiency increases the risk of improper Medicaid payments, potentially resulting in overpayments to ineligible beneficiaries or underpayments to those who qualify. Identification of a repeat finding: This is a repeat finding from the immediate previous audit: 2024-004, 2024-006, and 2024-007. Note: In the prior year, we reported findings separately based on the type of error was found in testing. In the current year, all errors for Medicaid eligibility determinations are reported in one finding. Cause: The deficiencies reported above appear to originate from ineffective record keeping and case review processes due to insufficient training of staff, adequate staffing, retention of experienced staff, and lack of oversight from County management, and inadequate communication between departments resulting in inconsistencies in data sharing and delayed information exchanges. Recommendation: We recommend that management enhance internal controls by: (1) Providing comprehensive training to staff on the program's eligibility requirements and procedures outlined in the State's Medicaid manuals; (2) Ensuring that there is a formal internal review process and that it is adequately completed to identify and correct errors and monitor compliance; and (3) Communicating all program or policy changes to staff clearly and timely. Views of responsible officials and planned corrective actions: The County agrees with the finding and is implementing actions to correct these issues, which are further discussed in the corrective action plan.
Criteria: Food and Nutrition Services case files to require proper documentation be contained in the case record to verify eligibility. The case file should contain a completed, signed (telephonic signature is allowable) and dated Food and Nutrition Services application (DSS-8207 or electronically generated ePASS application). The form must be signed by an adult household member (or an authorized representative), and NC FAST captures the user ID which serves as the worker’s electronic signature. Additionally, employment program participation is required for specified applicants. Eligibility criteria further outlined in Food and Nutrition Services Certification Manual, Section 305 through Section 350. Condition: There were Seven (7) cases lacking the required signature or date certifying the documentation, Nine (9) cases in which the proper documentation was not provided for the client, One (1) case in which the clock tracking time limits for receiving was not engaged in NC FAST, and One (1) case of incomplete or incorrect income verifications. Questioned Costs: While there was an affect to eligibility, there were no questioned costs. Context: We examined 60 out of 74,122 Food and Nutrition Services case files active during the fiscal year to ensure verifications used to determine eligibility were properly documented. Effect: For the active cases, there was a chance that information was not adequately documented or were not accessible NC FAST which affect general adherence to prescribed guidelines. Identification of a repeat finding: This is not a repeat finding. Cause: Ineffective record keeping and ineffective case review process, incomplete documentation, and incorrect application of rules for purposes of determining eligibility. Recommendation: 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 supporting documentation used for eligibility verification be reviewed for completeness and reconciled to the information provided in worker dictation. Views of responsible officials and planned corrective actions: The County agrees with the finding. Supervisors will perform second party reviews to ensure proper documentation is contained in files to support eligibility determinations. Workers will be retrained on what information should be maintained in case files, the importance of complete and accurate record keeping, and reserve calculations. The County finance office will also participating in the review process.