Finding Text
Condition: Required screening and valid license verification for 4 of 25 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 25 providers who received payment during the year were tested to determine
whether a required screening was performed before the provider was enrolled. For 4 of 25 providers
tested, the Department was not able to provide documentation that the required screening was
performed.
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.
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: MAD successfully provided screening and license verification for all
providers, except for MCOR providers. MCOR requests are submitted by MCOs, therefore this process
does not require providers to submit license or other credentials to enroll with New Mexico Medicaid.
MAD recently changed MCOR approval term to two years from the date of approval, thus MCORs will be
excluded from revalidation process. The program is currently working on a system memo to include
MCORs to the monthly screening process.
Responsible Person: MAD Compliance Officer and PPSB Bureau Chief.