The issue of improper Medicaid payments has surfaced after an audit of North Carolina’s Department of Health and Human Services (DHHS) revealed that the department failed to properly conduct Medicaid provider credentials verifications and other key measures. The irregularity reported is to the tune of $ 1.64 million dollars, with thousands of patients got treatment by suspended providers as DHHS failed to see only qualified providers received reimbursement.
- According to audit, the NC Department of Health and Human Services’ (Department) Division of Health Benefits (Division) is responsible for screening and enrolling Medicaid providers in accordance with CMS requirements. The Division outsources most of the provider enrollment process to General Dynamics Information Technology – GDIT (Contractor), although the Division has ultimate responsibility.
- The process involved sampling provider applications for Medicaid enrollment and applications for re-verification and conducting tests on disciplined providers who should have been removed from Medicaid enrollment.
- “Because of the test nature and other inherent limitations of an audit, together with limitations of any system of internal and management controls, this audit would not necessarily disclose all performance weaknesses or lack of compliance,” the report noted.
- The report identified four major areas in which the DHHS failed to ensure that only qualified providers were receiving Medicaid reimbursement. In some cases the providers whose licenses had been suspended or terminated, The department also permitted providers who had license limitations to continue receiving payments from Medicaid. While third party failed to re-verify the credentials and the Department could not follow their work.
- More specifically, 69 percent of the sampled providers that had been disciplined (18 providers) were not removed from the Medicaid program, meaning that they could continue to deliver care to beneficiaries and receive Medicaid reimbursement. Three disciplined providers were not removed in a timely fashion, with the DHHS waiting months before removing disciplined providers from Medicaid enrollment in two separate cases.
- As a result, around 2,400 beneficiaries received care from suspended or terminated providers, placing patients at risk. The North Carolina Medicaid program paid out at least $1.64 million to unlicensed providers.