But human error, through employee overrides of the computer systems and manual data entry, could result in people inappropriately being issued or denied coverage, the auditors wrote.
Oregon's Medicaid program costs $9.3 billion annually, with the state paying $1.2 billion and the federal government covering the remainder. The program, known as the Oregon Health Plan, provides health coverage to more than 1 million low-income Oregonians.
The two computer systems reviewed in the audit handle the majority of Oregon's Medicaid eligibility decisions and payments to health care providers. A new system known as ONE determines eligibility for many Medicaid applicants, and it transfers that information to the Medicaid Management Information System. That system enrolls Medicaid clients with, and send payments to, the state's 16 coordinated care organizations, provider networks established to serve Oregon's Medicaid population.
"If they do not function correctly, Medicaid clients may be inappropriately approved or denied for Medicaid benefits, and payments to providers may be in error," auditors wrote.
Auditors found the ONE computer system "appropriately validated the Social Security number and citizenship status of applicants over 99.7 percent of the time." The system also verifies applicants' reported income against available federal and state records.
However, applicants' eligibility also depends upon information the system cannot automatically reconcile or verify, such as wage stubs provided by applicants and the people who live in a household. The manual input of that information, along with the ability of caseworkers to override the systems' eligibility decisions, creates more room for error.
When auditors reviewed a small sample of 30 eligibility decisions, 23 percent had data input errors; in one case, the error resulted in someone who wasn't qualified for Medicaid being enrolled in the program. That person had initially received coverage as an individual, but a second application "added members to the client's household and reported a new income level that would have made the client no longer eligible for Medicaid benefits," auditors wrote. This resulted in "inappropriate capitated payments" to a coordinated care organization totaling $1,778 over four months, according to the audit.
In a response to the audit, Oregon Health Authority's Chief Financial Officer Mark Fairbanks wrote that "we generally agree with the report's findings and recommendations." Fairbanks said the agency will develop a quality assurance plan by July to reduce data input errors and system overrides that can lead to incorrect eligibility decisions.
In the course of this review, state auditors learned the Oregon Health Authority had accumulated a backlog of annual Medicaid eligibility checks and had no idea whether thousands of enrollees were still eligible for the benefits they were receiving. An audit of the agency's handling of that issue is now underway.
©2017 The Oregonian (Portland, Ore.) Distributed by Tribune Content Agency, LLC.
