Finding Text
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.