U.S. Department of Health and Human Services
Pass-through Entity: North Carolina Department of Health and Human Services
Program Name: Medical Assistance
Federal Assistance Listing Number: 93.778
Material Weakness and Nonmaterial Noncompliance – Eligibility ...
U.S. Department of Health and Human Services
Pass-through Entity: North Carolina Department of Health and Human Services
Program Name: Medical Assistance
Federal Assistance Listing Number: 93.778
Material Weakness and Nonmaterial Noncompliance – Eligibility Finding 2024-001 – Repeat Finding
Criteria or Specific Requirement: Per Section 200.303 of the Uniform Grant Guidance, a nonfederal entity must establish and maintain effective internal control over the federal award that provides reasonable assurance that the non-federal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award.
The County should have adequate documentation for each participant that supports each eligibility determination and the information entered into NCFAST. We noted several errors related to the following compliance criteria:
a) Self-attestation wages should be compared to information in NC FAST.
b) All countable resources should be confirmed and recalculated and ensure they are computed accurately in NC FAST.
c) An OVS inquiry must be completed and agreed to information reported in NC FAST.
d) An ex parte review is required every six (6) to twelve (12) months.
e) Forced eligibility cases should maintain the proper documentation within NC FAST to support the determination for the required forced eligibility.
f) For Aged, Blind, or Disabled cases or MQB programs the Register of Deeds is required to be verified and documented in the case file
g) The caseworker should prepare and submit a DMA-5097 form in the case of incompatible income verification and self-attestation income as described in the Eligibility Review Document.
h) For countable earned and unearned income, income conversion and computation was done in accordance with policy manuals, and have to agree to amounts in NC FAST.
Condition: The following are the results of nonmaterial noncompliance noted for each criteria listed above out of the 122 program participants selected for testing:
a) There were four instances where the participants self-attest wages did not agree to the wages entered into NC FAST.
b) There were three instances where the countable resources were inaccurate within NC FAST.
c) There was one instance where the OVS query was not run at the time of the determination.
d) There were two instances where the ex parte review was not completed timely.
e)There were two instances where the support for the forced eligibility was not properly maintained in NC FAST.
f) There was one instance where the Register of Deeds support was not maintained in NC FAST.
g) There were five instances where the income was incompatible between the income verification and self-attestation income but no DMA-5097 was sent.
h) There were two instances where countable income was not properly included in NC FAST.
Lastly, there were 6 instances out of 60 program participants tested for control testing where the County did not remediate the errors identified within their internal review timely.
Context: There were 14 out of 124 unique participants tested with the errors noted above.
Questioned Costs: None noted.
Effect: By not having the required documentation in the files or information being incorrectly documented, eligibility cannot be readily substantiated and there is a risk the County could provide funding to individuals who are not eligible.
Cause: County oversight when performing reviews over applications. Additionally, the County does not have a formal process in place to ensure issues identified during the review process are appropriately corrected on a consistent and timely basis.
Recommendation: Although these issues will occur from time to time considering the volume of case files, the County should review their processes to ensure proper supporting documentation of eligibility is maintained within each case file. Additionally, Mecklenburg County should consider implementing a formal policy for the requirements of having documentation corrected within a specific timeframe once identified.
Views of Responsible Officials: Management agrees with the finding and is implementing procedures to correct this which is further discussed in the Corrective Action Plan.
Corrective Action Plan:
The County will take a multi-faceted approach to mitigating such errors in the future.
Training:
The Staff Development Unit within the Economic Services Division (ESD) will review the findings and create and deliver training to staff that determine Medicaid eligibility and their supervisors and managers to address the specific errors identified. This training will be delivered by the end of January 2025.
Responsible Individual(s): Staphon Snelling, Training and Development Manager
Anticipated Completion Date: January 31, 2025
Process Improvement:
The Economic Services Division (ESD) has trained new hires in one function of the Medicaid program, for example, processing applications or recertifications/changes. This has built a stronger foundation before they learn the second function of their assigned program. Our Supervisors and Quality and Training Specialists are working even more closely together to follow up on errors and help ensure identified challenges in training and mentoring are addressed before they are released from mentoring.
Ex parte reviews are directly assigned for Family and Children’s Medicaid and for Adult Medicaid, renewals are placed into Current for workers to get next and work as soon as possible. Family and Children’s Medicaid will provide second-function training for current employees on recertifications. Adult Medicaid has 10 currently in mentoring for recertifications. Kim Konior is responsible for monitoring ex-parte review reports and MAGI cases are being assigned out by Supervisor Collin Smith and Jannicia Austin for Adult Medicaid. Each month the Medicaid managers Kim Konior and Lynn Martin review the progress and update the Assistant Division Director on the current status and plans to continually improve in this area.
Supervisors will ensure that second party reviews are reviewed and corrected for any internal control and eligibility errors within 5 business days of receipt. Supervisors ensure that updates to the quality sampling tracking log are completed by the 20th day of the following month.
Responsible Individual(s): Kim Konior and Lynn Martin Medicaid Program Managers and Staphon Snelling, Training and Development Manager
Anticipated Completion Date: Will begin Family and Children’s Medicaid recertification training in third Quarter of FY25 (Jan 2025) and end by the end of 2nd quarter of FY 2025 (December 2025).
Quality Sampling and Accountability:
The Quality and Training Unit complete monthly quality sampling for Medicaid. Error trends are shared with the managers and their supervisors, who work collaboratively with Quality and Training staff to coordinate appropriate strategies to train and coach staff to mitigate errors moving forward.
Supervisors review specific quality sampling results with their staff. The supervisor when necessary and appropriate, address continued errors using an individual Corrective Action Plan with the worker to include refresher training, additional second party review and/or initiating the formal documentation process.
Managers review quality sampling results with supervisors quarterly to follow up on errors addressed, trainings completed and progress with individual Corrective Action Plans. Supervisors, front line, and Managers have quality measure on their workplan to ensure timely response and accountability is held. All levels are to achieve an average quality score of 80% quarterly. Note that this error was found at a much higher rate last year. We are continuing to reinforce this importance and expect the improvement that we have achieved within one year will continue to grow as we keep reinforcing quality into our everyday work culture.
Protocol for second party reviews provided 08/2024 in place for ESD. Cases will be checked by Quality and Training by the last day of each business month. Quality and Training will check and provide feedback to workers within 2 business days of the case being checked. Corrections of errors and rebuttals for QS errors should be submitted within 5 business days of feedback being provided and a response will be received within 3 business days of receipt.
The Quality Assurance team in OSI/CFAS conduct an independent evaluation and review the second party review process at the divisional level to ensure review was accurate and errors were corrected timely. This team reports out to ESD Leadership quarterly on findings.
Responsible Individual(s): Kim Konior and Lynn Martin, Medicaid Program Managers & Julio Rosales, Quality Assurance Supervisor, Staphon Snelling Training and Development Manager
Anticipated Completion Date: Currently Ongoing