Wilkes County officials are hoping the Wilkes Department of Social Services fares as well in an upcoming Medicaid audit as it did in 2016, when the agency made the fewest errors among 10 county DSS offices chosen at random for a similar review.
However, the stakes are higher now because Medicaid payments made for people determined ineligible for these benefits in the upcoming audits must be paid back to the state.
Explaining the new audit to the Wilkes County commissioners during their Feb. 5 meeting, Wilkes DSS Director John Blevins said the payback requirement could be costly if it involved Medicaid recipients with long hospital stays or other large medical bills.
Blevins said the state was divided into thirds for the 10-month-long Medicaid audits of all 100 county DSS offices in the next three years. A little over 30 county DSS offices will be audited each year, with Wilkes in the first round starting in early March.
He said the cycle is scheduled to be repeated, which means every county DSS office will have a Medicaid audit every three years. The auditors are retired Medicaid eligibility professionals hired by a temporary staffing agency working under a contract with the N.C. Department of Health and Human Services (DHHS).
The auditors will pull the names of 200 people—100 “negatives” (denied Medicaid) and 100 “actives” (approved for Medicaid)—from records of each county DSS office per 10-month period. That will break down to 20 people (10 negatives and 10 actives) per county agency per month.
“I’ll get a letter at the first of the month telling me the 20 cases they’re going to pull and our social workers will have five days to make sure everything they did in those cases is in the NC FAST (Families Accessing Services through Technology) system,” said Blevins. This includes scanning and downloading paper records to NC FAST.
Blevins said having an established number of Medicaid cases to review is better than some audits “where they say, ‘Oh, I found something so I need to look some more.’”
He continued, “If they find an error, I will be sent a notice and I’ll have five days to either dispute or accept it. If we dispute it, the case in question will be reviewed by a manager (with the auditors), who will decide if we are at fault.”
If a county DSS office is found at fault, it will receive an invoice from DHHS for the amount in Medicaid benefits wrongly paid and have 60 days to pay it. Blevins said there is no appeals process. If a DSS office admits fault, it will have 30 days to verify that the mistake was corrected.
The mistake could be a wrongly-approved Medicaid benefits application or a person recertified to continue receiving benefits when the person should have been rejected.
“We’re reviewing cases to make sure all the information is put in the system ahead of time, but it’s going to be a brave new world for us.”
Blevins said he’s optimistic about the outcome of the audit locally because Wilkes DSS is staffed by conscientious income maintenance caseworkers and people in other positions and also because of the outcome of the audit in 2016.
County Commissioner Gary Blevins said he couldn’t think of another agency scrutinized on such a regular basis as county DSS offices statewide.
Wilkes DSS made the fewest errors while processing Medicaid applications among the 10 county DSS offices audited in 2016. The 10 offices were chosen at random for Medicaid audits to comply with Senate Bill 14, which required that the state auditor audit a representative sample of urban and rural counties.
Legislators are motivated by the fact that the Centers for Medicare and Medicaid Services has a 3 percent statewide error rate threshold above which a state is potentially subject to receiving lower Medicaid payments and other penalties.
A report on the 2016 audit said most of the 10 sample DSS offices failed to consistently provide adequate oversight or controls for eligibility determination of new Medicaid applications and re-certifications. It also said DHHS failed to provide adequate oversight or controls over eligibility determination.
According to the report, 16,745 Wilkes residents, or 24.4 percent of the county’s 68,502 residents, were enrolled in Medicaid in 2015. Wilkes residents received $100.12 million in Medicaid benefits in 2015.
N.C. Fast is software designed to process benefit applications, determine eligibility and manage and provide digital access to data as it replaces 19 different systems in use statewide. Food stamp and Medicaid backlogs over the last five years have partly been blamed on technical problems with NC FAST, but county and state officials say the system has continued to improve.
John Blevins said the positive attitude of Hal Wilson, Wilkes DSS child protective services program manager, influenced others and helped the agency’s recent transition to the assessment portion of NC FAST go well.
“Around the end of May, we’ll have to go to full functionality (with NC FAST and child protective services) and that is expected to be more problematic. The concern is that entering information into computers takes up a lot of the social workers’ time,” he said.
Blevins added that transitioning to NC FAST is more of a challenge with child protective services than with income maintenance because of the nature of these programs.