Finding Text
Context:
Effect:
Cause:
US Department of Health and Human Service
Passed through the NC Dept of Health and Human Services
AL # 93.778
Finding: 2023-009
SIGNIFICANT DEFICIENCY
Eligibility
Criteria:
Condition:
Program Names: Medical Assistance
We examined 60 cases from of a total of 331,466 Medicaid claims from the Medicaid
beneficiary report provided by NC Department of Health and Human Services to redetermine
eligibility. These findings are being reported with the financial statement audit
as it relates to Medicaid administrative cost compliance audit.
For those certifications/re-certifications there was a chance that information was not
properly documented and reconciled to NC FAST and a participant could have been
approved for benefits for which they were not eligible.
Ineffective record keeping and ineffective case review process, incomplete documentation,
and incorrect application of rules for purposes of determining eligibility.
Recommendation: Files should be reviewed internally to ensure proper documentation is in place for
eligibility. Workers should be retrained on what files should contain and the importance of
complete and accurate record keeping. We recommend that all files include online
verifications, documented resources of income and those amounts agree to information in
NC FAST. The results found or documentation made in case notes should clearly indicate
what actions were performed and the results of those actions.
Section III - Federal Award Findings and Questioned Costs (continued)
In accordance with the Medicaid Manual MA-3120, the State sends notification to the
County when a participant is no longer eligible under Supplemental Security Income (SSI)
determination, the County is required to initiate the ex parte review within 5 workdays of
the date the termination appears on the SSI Termination Report, and complete the
redetermination within 4 months of the month the case appears on the SSI Termination
Report and notify the recipient about applicant's ongoing eligibility for Medicaid.
There was 2 applicant/beneficiary not reviewed timely and determined to be eligible for
Medicaid when their SSI benefits were terminated, for which the recipient was not eligible.
Questioned Costs: There was no known affect to eligibility and there were no known questioned costs.
Identification of a repeat
finding:
This is a repeat finding from the immediate previous audit, 2022-009.
Untimely Review of SSI Terminations
Context:
Effect:
Cause:
Program Name: Medical Assistance Program (Medicaid; Title XIX)
AL # 93.778
Section III - Federal Award Findings and Questioned Costs (continued)
Views of Responsible
Officials and Planned
Corrective Actions:
The County agrees with the finding. See corrective action plan.
We examined 60 cases from of a total of 331,466 Medicaid claims from the Medicaid
beneficiary report provided by NC Department of Health and Human Services to redetermine
eligibility. These findings are being reported with the financial statement audit
as it relates to Medicaid administrative cost compliance audit.
The County did not initiate ex parte review timely, therefore, no eligibility review was
completed in the required time period. The lack of follow up and certification lead to
applicants receiving Medicaid benefits for which they were not eligible.
Ineffective communication between departments within the Department of Social Services.
One area within DSS received State communications that applicants would no longer be
eligible for SSI benefits and the County needed to conduct an application process. This
information was not shared with other departments in DSS from which the recipient was
also receiving benefits.
Recommendation: Any State communications related to applicants’ benefits received by any DSS department
should be shared with all areas from which the participant receives benefits. State files
should be reviewed internally to ensure all actions have been properly closed and the
corrective action has been taken. Workers should be retrained on what process needs to be
followed when State communications are received.
Identification of a repeat
finding:
This is a repeat finding from the immediate previous audit, 2022-010.