0. Corrective Action for Medicaid/NCHC QC Errors and Deficiencies
Prepared and Presented by Shara Britt, Assistant Chief
DMA Quality Assurance and Special Projects Section

1. DMA Quality Assurance Reviews
Medicaid Eligibility Quality Control (MEQC)
Monthly MEQC reviews- specific populations or certain geographic areas will begin again with FY 2016
Focused reviews –planned by state/approved by CMS or directed by CMS (currently being done for FY2014 – FY2016)
Payment Error Rate Measurement (PERM)
FY most recent PERM cycle completed for NC
FY2014-FY2016- PERM eligibility reviews postponed by CMS until FY2017 for all states
Medicaid and CHIP identified as susceptible programs

2. FY2014-FY2016 - Focused Medicaid/NCHC Reviews
CMS has given states specific sampling and review requirements
Four rounds of reviews(six-month sampling periods)
First two rounds focused on MAGI
Third round will focus on MAGI and non-MAGI
Fourth round - CMS still has to provide requirements and type of universe

3. PERM FY2013 Medicaid Error Rates
Medicaid actives- 972 cases reviewed, 31 error cases, 40 cases with deficiencies(4.56% payment error rate; 1.34% active case error rate)
Medicaid negatives –384 cases reviewed, 91 error cases, 40 cases with deficiencies (23.74% negative case error rate)
Note: Deficiencies/technical errors were required to be reported to CMS but did not factor into error rates

4. PERM FY2013 NCHC Error Rates
NCHC actives- 504 cases reviewed, 32 error cases, 11 cases with deficiencies(3.21% payment error rate; 6.34% active case error rate)
NCHC negatives –204 cases reviewed, 91 error cases, 40 cases with deficiencies (20.12% negative case error rate)
Note: Deficiencies/technical errors were required to be reported to CMS but did not factor into error rates

5. Round 1 FY Error Rates
Medicaid actives- 44 cases reviewed, 2 error cases (4.5% active case error rate)
Medicaid negatives –126 cases reviewed, 55 error cases (44% active case error rate)
NCHC actives – 5 cases reviewed, 0 error cases(0%)
NCHC negatives- 0 cases reviewed
Note: Deficiencies/technical errors were not required to be reported to CMS. No payment error rate calculated.

6. Round 2 FY2014-2016 Error/Deficiency Rates
Medicaid actives- 75 cases reviewed, 4 error cases, 26 cases with deficiencies (40% cases with errors or deficiencies)
Medicaid negatives –25 cases reviewed, 0 error cases, 15 cases with deficiencies (60% cases with errors or deficiencies)
NCHC actives – 75 cases reviewed, 9 error cases, 23 cases with deficiencies (43% cases with errors or deficiencies)
NCHC negatives- 25 cases reviewed, 0 error cases, 15 cases with deficiencies (60% cases with errors or deficiencies)

7. Review Requirements Eligibility verification and processing
Income and resource calculations
Appropriate and accurate notices
Timeliness of processing(actives and negatives)
Sanctions
Transfers to FFM for negative actions

8. Reasons for Errors/Deficiencies
Incorrect program or program classification
Citizenship/identity not verified
OVS not completed and reviewed
OVS not used for verification of income
Income of budget unit member not used
Income calculation errors
Residency not verified
Insurance information not entered into NCFAST

9. Reasons for Errors/Deficiencies
No denial or termination notice sent
Timely notice does not show 10th work day or shows incorrect date for the 10th work day
Terminated prior to 10 work days
Incorrect reasons on denial or termination notices
Timeliness of actions
Resources not verified or excess resources

10. Notification of Errors/Deficiencies
Notification of errors or deficiencies (technical errors) is sent by DMA Quality Assurance(QA) via DMA-7002, Active Case Error/Technical Error Report or DMA-7004, Negative Case Error/Technical Error Report
DMA-7001, County Department Report of Errors and Corrective Action is sent at time DMA-7002 or DMA-7004 is sent

11. Corrective Action Activities Required
County should take corrective action to correct the case
Train staff to prevent similar errors from happening
Implement monitoring activity to ensure staff are appropriately implementing the training they received
Provide followup training, if necessary
Refer client responsible errors to county Program Integrity staff
Keep records of training
Report to DMA Quality Assurance via DMA-7003, Corrective Action Report
corrective action taken on the case and information regarding training and referral to Program Integrity

12. Questions
Contact Information: