Purpose

To determine the extent of implementation of the seven recommendations included in our initial audit report, Improper Medicaid Payments to Eye Care Providers (Report 2015-S-6).

Background

Under federal and State regulations, providers must apply for enrollment into the Medicaid program and meet certain requirements in order to provide services to Medicaid recipients. In addition, Medicaid providers must revalidate their enrollment every five years. The enrollment and revalidating processes are intended to prevent improper payments for services rendered by providers who do not meet federal and State requirements for participation in the Medicaid program and to protect Medicaid recipients from receiving care or services from providers who are not qualified.

The initial audit report identified vulnerabilities in the Department’s provider enrollment and revalidating processes that undermine the Department’s ability to (1) ensure that only qualified providers participate in the Medicaid program and (2) prevent improper payments for services rendered by providers who do not meet federal and State requirements. As a result of these weaknesses, six eye care professionals who did not comply with the Department’s Medicaid policies for enrollment and revalidation were able to obtain Medicaid eligibility under 34 provider identification numbers without disclosing all of their apparent affiliations. We recommended that the Department: review the appropriateness of the providers’ enrollments; enhance controls over the Department’s enrollment process; monitor the appropriateness of the providers’ Medicaid claims; and recover improper payments.

Key Finding

Department officials have made progress addressing the problems identified in the initial audit. For instance, the Department has improved enrollment and revalidation procedures to verify the accuracy and completeness of ownership, control interest, and affiliation data. The Department has also established pre-payment reviews of claims for 8 of the 34 provider identification numbers, and the Office of the Medicaid Inspector General has opened investigations into the providers we identified as having received improper payments. Of the initial report’s seven audit recommendations, four were implemented and three were partially implemented.

Key Recommendation

Officials are given 30 days after the issuance of the follow-up report to provide information on any actions that are planned to address the unresolved issues discussed in this report.

Other Related Audit/Report of Interest

Department of Health: Improper Medicaid Payments to Eye Care Providers (2015-S-6)