Finding 1177689 (2025-004)

Material Weakness Repeat Finding
Requirement
N
Questioned Costs
-
Year
2025
Accepted
2026-03-10

AI Summary

  • Core Issue: Nine out of 40 providers lacked original approved Provider Participation Agreements, and five did not have evidence of eligibility re-verification within five years.
  • Impacted Requirements: Compliance with 42 CFR 455.410 and 42 CFR 455.412 regarding provider screening and license verification.
  • Recommended Follow-Up: Update controls to ensure all provider screenings and license verifications are documented and retained; complete revalidation processes by June 2026.

Finding Text

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

Corrective Action Plan

2025-004 (2024-004) Special Tests and Provisions: Provider Eligibility (Significant Deficiency in Internal Controls over Compliance) What Action(s) Will be Done: 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. Who Will Act: Bureau Chief, Provider Enrollment Services Bureau, Medical Assistance Division When Will Action(s) be Completed: Corrective actions are expected to be implemented by June 30, 2026.

Categories

Special Tests & Provisions Subrecipient Monitoring Eligibility Significant Deficiency Internal Control / Segregation of Duties

Other Findings in this Audit

  • 1177684 2025-004
    Material Weakness Repeat
  • 1177685 2025-004
    Material Weakness Repeat
  • 1177686 2025-004
    Material Weakness Repeat
  • 1177687 2025-004
    Material Weakness Repeat
  • 1177688 2025-004
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
10.551 SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM $1.02B
93.558 TEMPORARY ASSISTANCE FOR NEEDY FAMILIES $103.15M
10.646 SUMMER ELECTRONIC BENEFIT TRANSFER PROGRAM FOR CHILDREN $64.78M
93.767 CHILDREN'S HEALTH INSURANCE PROGRAM $41.19M
93.563 CHILD SUPPORT SERVICES $34.98M
10.569 EMERGENCY FOOD ASSISTANCE PROGRAM (FOOD COMMODITIES) $16.36M
10.555 NATIONAL SCHOOL LUNCH PROGRAM $6.75M
21.027 CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS $5.60M
10.561 STATE ADMINISTRATIVE MATCHING GRANTS FOR THE SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM $5.58M
93.788 OPIOID STR $5.57M
93.959 BLOCK GRANTS FOR PREVENTION AND TREATMENT OF SUBSTANCE ABUSE $4.63M
93.569 COMMUNITY SERVICES BLOCK GRANT $4.25M
93.796 STATE SURVEY CERTIFICATION OF HEALTH CARE PROVIDERS AND SUPPLIERS (TITLE XIX) MEDICAID $3.35M
93.566 REFUGEE AND ENTRANT ASSISTANCE STATE/REPLACEMENT DESIGNEE ADMINISTERED PROGRAMS $2.47M
93.778 MEDICAL ASSISTANCE PROGRAM $1.83M
10.541 CHILD NUTRITION-TECHNOLOGY INNOVATION GRANT $1.07M
10.565 COMMODITY SUPPLEMENTAL FOOD PROGRAM $988,652
93.568 LOW-INCOME HOME ENERGY ASSISTANCE $832,116
93.493 CONGRESSIONAL DIRECTIVES $803,552
10.568 EMERGENCY FOOD ASSISTANCE PROGRAM (ADMINISTRATIVE COSTS) $643,844
93.243 SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES PROJECTS OF REGIONAL AND NATIONAL SIGNIFICANCE $483,922
10.187 THE EMERGENCY FOOD ASSISTANCE PROGRAM (TEFAP) COMMODITY CREDIT CORPORATION ELIGIBLE RECIPIENT FUNDS $436,416
93.150 PROJECTS FOR ASSISTANCE IN TRANSITION FROM HOMELESSNESS (PATH) $309,844
10.560 STATE ADMINISTRATIVE EXPENSES FOR CHILD NUTRITION $300,543
10.194 COMMODITY CREDIT CORPORATION (CCC) FUNDING TO ALLEVIATE EMERGENCY SUPPLY CHAIN DISRUPTION IN THE COMMODITY SUPPLEMENTAL FOOD PROGRAM (CSFP) $293,130
93.777 STATE SURVEY AND CERTIFICATION OF HEALTH CARE PROVIDERS AND SUPPLIERS (TITLE XVIII) MEDICARE $229,916
93.958 BLOCK GRANTS FOR COMMUNITY MENTAL HEALTH SERVICES $188,666
93.829 SECTION 223 DEMONSTRATION PROGRAMS TO IMPROVE COMMUNITY MENTAL HEALTH SERVICES $147,188
93.694 SECTION 206 CONSOLIDATED APPROPRIATIONS ACT, 2024: STATE PLANNING GRANTS TO PROMOTE CONTINUITY OF CARE FOR MEDICAID & CHIP BENEFICIARIES $123,070