Determination Audit (REDA) Office of Compliance and Program - PowerPoint PPT Presentation

NC Department of Health and Human Services NC Medicaid Recipient Eligibility Determination Audit (REDA) Office of Compliance and Program Integrity December 2019 NCDHHS Division of Health Benefits | Recipient Eligibility Determination Audit (REDA) I December 2019 1

Vision • Ensure benefits are provided only to those individuals eligible for Medicaid and NC Health Choice benefits • Identify and eliminate ineligible individuals from receiving Medicaid and NC Health Choice benefits NCDHHS Division of Health Benefits | Recipient Eligibility Determination Audit (REDA) I December 2019 2

Background - Session Law 2017-57 Medicaid Accuracy Standards Strategic Planning County Audit Process R ecipient Auditors and Audit Preparation Case Findings E ligibility Rebuttal Process D etermination Corrections Process A udit Reporting Process Recoupment Methodology Joint Accuracy Improvement Plan Responsibilities & Review Process Let's Talk Internal Controls

Background Performance Audit 2017 • Office of the State Auditor (OSA) conducted a Medicaid eligibility determination in 10 selected counties • Report noted eligibility determinations were not consistently performed and error rates were significant in some counties • Findings enacted NC Session Law 2017-57 Section 11H.22., Audit of County Medicaid Determinations: • Develop accuracy and quality assurance standards • Develop an audit plan to review and evaluate the counties' performance in relation to the standards NCDHHS Division of Health Benefits | Recipient Eligibility Determination Audit (REDA) I December 2019 4

Session Law 2017-57 Components Audit of County Medicaid "§ 108A-70.46 Determinations Medicaid Eligibility Determination "§ 108A-70.47 Processing Accuracy Standards "§ 108A-70.48 Quality Assurance "§ 108A-70.49 Corrective Action Temporary Assumption of Medicaid "§ 108A-70.50 Eligibility Administration "§ 108A-70.51 Reporting NCDHHS Division of Health Benefits | Recipient Eligibility Determination Audit (REDA) I December 2019 5

Medicaid Accuracy Standards • Eligible applicants are approved 96.8% of the time • Eligible applicants are not denied, withdrawn or terminated 96.8% of the time • The eligibility determination process is free of technical errors, that do not change the outcome of the eligibility determination, 90% of the time NCDHHS Division of Health Benefits | Recipient Eligibility Determination Audit (REDA) I December 2019 6

Accuracy Rate Approach • Number of cases cited in error divided by the number of cases reviewed (per accuracy standard) • Monthly stats provided to allow county to conduct policy training for improvement over the annual audit reporting cycle • Annual accuracy rate provided at the completion of the REDA audit NCDHHS Division of Health Benefits | Recipient Eligibility Determination Audit (REDA) I December 2019 7

Best Practices Unit Meetings Flash Cards on Silo with Policy Error Prone Work Training Areas Groups Prepare Learning Questions Peer-to-Peer Gateway prior to Reviews Policy Training OST Visits

Strategic Plan Development • Developed and tested audit workbook and reporting process • Results shared with Medicaid Eligibility Services (MES) and Operational Support Team (OST) for input • OCPI/QA conducted a Quality Assurance Training for County DSS staff (August 2018) • Collaborations: ➢ County DSS Director’s Association ➢ Economics Program Committee ➢ NC FAST (access, training and document management) ➢ Operational Support Team ➢ Medicaid Eligibility Services NCDHHS Division of Health Benefits | Recipient Eligibility Determination Audit (REDA) I December 2019 9

County Audit Process Sample Methodology Options Considered: 1. Pull one sample annually for accuracy rate percentage 2. Pull quarterly sample for accuracy rate percentage 3. Pull monthly sample for accuracy rate percentage Option 3 selected Monthly sample will provide the County DSS proactive opportunity to improve their annual accuracy rate NCDHHS Division of Health Benefits | Recipient Eligibility Determination Audit (REDA) I December 2019 10

County Audit Process – Cont’d • NC FAST generates a random sample of cases monthly • Twenty cases (10 active & 10 negative) consisting of: • Combination MAGI/Non-MAGI • Application Approvals • Denials/Withdrawals • Redeterminations • Terminations NCDHHS Division of Health Benefits | Recipient Eligibility Determination Audit (REDA) I December 2019 11

County Audit Process - Cont’d • List of cases will be provided to County DSS Director and identified staff • Upon receiving the list of cases, Counties have 5 workdays to upload to NC FAST all verification and/or documentation used in the eligibility determination proc ess IMPORTANT: Counties must ensure ALL verification and/or documentation is uploaded to NC FAST within the initial 5 workday time period NCDHHS Division of Health Benefits | Recipient Eligibility Determination Audit (REDA) I December 2019 12

County Audit Process - Cont’d Per Centers for Medicare & Medicaid Services (CMS) directive, no actions should be taken on cases selected for testing prior to case review • The County DSS should not take any action, on cases selected for the audit, until the DMA-7002CA is provided with audit findings • Reporting Process for Errors Cited • Counties will be given 5 workdays to refute error findings • State will make final decision on error findings cited • Counties will have 20 calendar days to provide verification of case correction NCDHHS Division of Health Benefits | Recipient Eligibility Determination Audit (REDA) I December 2019 13

County Audit Process - Cont’d A total of 200 cases for each County DSS 20,000 cases reviewed over 3 year audit plan Cycle 1 Cycle 2 Cycle 3 Calendar Year 2019 Calendar Year 2020 Calendar Year 2021 30 Counties 35 Counties 35 Counties County Prioritization Criteria Prior Single Audit Compliance results SFYs 2016 & 2017 NCDHHS Division of Health Benefits | Recipient Eligibility Determination Audit (REDA) I December 2019 14

County Cycle Assignment Alleghany Northampton Gates Vance Currituck Ashe Rockingham Surry Caswell Granville Stokes Warren Person Hertford Halifax Watauga Wilkes Alamance Yadkin Forsyth Bertie Mitchell Avery Guilford Franklin Orange Caldwell Nash Durham Yancey Alexander Davie Edgecombe Madison Tyrrell Davidson Iredell Wake Martin Washington Dare Burke Randolph Chatham Wilson Buncombe Catawba Rowan Pitt McDowell Beaufort Swain Haywood Johnston Greene Hyde Lincoln Rutherford Lee Cabarrus Montgomery Graham Henderson Harnett Wayne Gaston Jackson Polk Moore Cleveland Stanly Lenoir Craven Mecklenburg Cherokee Macon Transylvania Cumberland Pamlico Clay Sampson Anson Hoke Jones Richmond Duplin Union Onslow Scotland Carteret Robeson Bladen Pender Columbus New Hanover Brunswick Cycle 1 Cycle 2 Cycle 3 NCDHHS Division of Health Benefits | Recipient Eligibility Determination Audit (REDA) I December 2019 15

County Cycle Assignment NCDHHS Division of Health Benefits | Recipient Eligibility Determination Audit (REDA) I December 2019 16

County Cycle Assignment NCDHHS Division of Health Benefits | Recipient Eligibility Determination Audit (REDA) I December 2019 17

County Cycle Assignment NCDHHS Division of Health Benefits | Recipient Eligibility Determination Audit (REDA) I December 2019 18

QUESTIONS

Auditors and Audit Preparation • Auditors • OCPI’s Quality Assurance Analysts (QAA) • Auditors consisting of temporary staff who are retired and former employees of The State of NC and County DSS • All QAA and auditors have access to NC FAST and various other eligibility systems • All QAA and auditors possess an extensive knowledge of NC FAST, Medicaid policy & Eligibility monitoring NCDHHS Division of Health Benefits | Recipient Eligibility Determination Audit (REDA) I December 2019 20

Auditors and Audit Preparation – Cont’d Audit Tools • Reporting documents prepared by auditors • DMA-7002CA (Case Findings Report) • DMA-7001CA (County Department Error Response) • DMA-7005CA (Case Correction Verification) • During the audit process, OCPI/QA staff conducts monthly random quality checks on the auditor’s accuracy NCDHHS Division of Health Benefits | Recipient Eligibility Determination Audit (REDA) I December 2019 21

Case Findings Correct Case • DMA-7002CA Case Findings Report • Auditor sends DMA-7002CA to County DSS, OCPI/QA Staff and OST • No further action required on the case NCDHHS Division of Health Benefits | Recipient Eligibility Determination Audit (REDA) I December 2019 22

Case Findings Error Case • DMA-7002CA Case Findings Report, DMA-7001CA County Department Error Response & DMA- 7005CA Case Correction Verification • Auditor sends DMA-7002CA, DMA-7001CA & DMA- 7005CA to County DSS, OCPI/QA Staff and OST • County DSS has 5 workdays to respond to the auditor with a concurrence or rebuttal using the DMA-7001CA NCDHHS Division of Health Benefits | Recipient Eligibility Determination Audit (REDA) I December 2019 23