Finding Text
Condition: Required screening and valid license verification for 9 of 40 providers tested was not properly
supported by the Department's records. 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 40 out of approximately 23,500 providers who received payment during the year
were tested to determine whether a required screening was performed before the provider was enrolled.
For 9 of 40 providers tested, the Department was not able to provide documentation that the required
screening was performed. 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 2023-001; 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: The Corrective Action Plan (CAP) is currently in motion with the
transition from our previous Legacy enrollment system to the new Benefit Management Services (BMS)
System. BMS system will track license and certification expiration dates and will auto terminate accounts
with expired date. The BMS system went live on November 8, 2024, and all accounts with an expired
license and certification date have been auto terminated. The State and the new vendor will complete an
audit on all accounts with a missing license and certification information to ensure correct action is taken
for or against the account. The action will be completed by February 1, 2025.
Responsible Person: Staff Manager, Policy and Provider Services Bureau, Medical Assistance Division