CORRECTIVE ACTION PLAN FOR AUDIT FINDING
AUDIT FINDING 2022-061
Finding: U.S. Department of Health and Human Services Children's Health Insurance Program (CHIP), 93.767 Medicaid Cluster: State Medicaid Fraud Control Units, 93.775; State Survey and Certification of Health Care Providers and Suppliers...
CORRECTIVE ACTION PLAN FOR AUDIT FINDING
AUDIT FINDING 2022-061
Finding: U.S. Department of Health and Human Services Children's Health Insurance Program (CHIP), 93.767 Medicaid Cluster: State Medicaid Fraud Control Units, 93.775; State Survey and Certification of Health Care Providers and Suppliers (Title XVIII) Medicare, 93.777 Medical Assistance Program (Medicaid; Title XIX), 93.778 Eligibility Material Weakness in Internal Control over Compliance
Title 42 Public Health section 435.403 State Residence provides that the State must provide Medicaid to eligible residents of the State, including residents who are absent from the State, except in cases where another state has determined that the person is a resident there for purposes of Medicaid.
The Medicaid State Plan provides that the State has an eligibility determination system for data matching through the Public Assistance Reporting Information System (PARIS). The information that is requested is to be exchanged with states and other entities legally entitled to verify Title XIX applications and individuals eligible for covered Title XIX services consistent with applicable PARIS agreements. The State will transmit and receive data quarterly (February, May, August, and November).
The State enrolls beneficiaries on a mandatory basis into managed care entities (managed care organizations and/or primary care case managers) in the absence of certain allowable waivers. The State contracts with managed care organizations and reimburses them for capitation payments.
PARIS data was not utilized by the Division of Health Care Financing and Policy (DHCFP) or the Division of Welfare and Supportive Services (DWSS) to monitor residency changes to determine when managed care benefits needed to be terminated because the beneficiary was a resident of another state for Medicaid purposes.
DHCFP and DWSS did not have internal controls in place to effectively communicate the PARIS data between the two agencies to ensure managed care benefits were terminated when appropriate.
Individuals are enrolled in Medicaid (and CHIP) plans in multiple states and benefits are not being terminated timely. Therefore, the State of Nevada is paying capitation payments to managed care organizations, when the benefits should have been terminated.
Projected questioned costs are $12,743,890 for Medicaid and $186,062 for CHIP.
No sampling was used. The PARIS data was obtained and examined in total. The PARIS data included 56,892 participants with dual enrollment. Of those 56,892 participants, 9,722 participants were enrolled in another state after the State of Nevada. The projected questioned costs were estimated by performing the following:
• Identifying individuals who enrolled in another state after they had enrolled in Nevada (termination date for Nevada).
• Estimating a weighted average capitation payment based on demographics that determine the payment amount.
• Applying the weighted average capitation payments from the termination date through June 30, 2022 to determine the total projected questioned costs.
• The total projected questioned costs were then allocated between Medicaid and CHIP using participant counts in each plan between the ages of 0-18. Participants older than 18 were allocated to Medicaid. The allocated projected questioned costs were then multiplied by a weighted average Federal Medical Assistance Percentage (FMAP) to determine the final projected federal questioned costs.
Recommendation: We recommend DHCFP and DWSS implement internal controls to effectively communicate the PARIS data between each other and to ensure managed care benefits are terminated when appropriate.
Agency Response
Does the Agency Agree with Finding?: Yes
Additional Comments: None.
Corrective Action Taken or To Be Taken Action:
The Division is in the process of updating its policies and procedures for its Public Assistance Reporting Information System (PARIS) data matching process, which occurs on a quarterly basis (i.e., once every February, May, August, and November). Currently, the process is primarily a manual caseworker process conducted by caseworker staff at DWSS. However, in many states; this activity is an automated process and considered a program-integrity function of the Medicaid program rather than an eligibility function. Nevada agrees with this practice and intends to implement an automated process, while transitioning the PARIS data matching process to its program-integrity unit at the Division.
To do this, the Division will be procuring a vendor to establish a Surveillance and Utilization Review section (SUR) data system, which will include the PARIS data matching process, with new federal funds from the American Rescue Plan Act (ARPA). DHCFP has started the Request for Proposal (RFP) process for this new SUR Data System. DHCFP anticipates a contract start date of January 1, 2024 and an estimated implementation date of December 31, 2024.
By automating and streamlining this process in the future, Nevada Medicaid aims to increase the state's capacity to act more quickly on eligibility redeterminations that stem from a PARIS data match finding. In return, this will allow the program to adjust enrollment and payments to managed care plans, more quickly. This adjustment process is fully automated in the Division's Medicaid Management Information System (MMIS) which was certified by CMS in May of 2019.
Date of Completion or Estimated Completion:
December 31, 2024
Department or Agency Responsible for Corrective Action Plan
Agency: Contact:
Department of Healthcare Financing and Policy
Russ Steele, Audit Manager 1000 E William St., Suite 110 Carson City, NV 89701
(775) 684-3609
rsteele@dhcfp.nv.gov
Signature of Sandie Ruybalid, Deputy Administrator