Audit results of Medicaid eligibility determinations system

The OIG conducted an audit of the Texas Integrated Eligibility Redesign System (TIERS), which is the system that contains records of applications processed, approved and denied. TIERS is a critical Texas Health and Human Services Commission (HHSC) system because it processes eligibility information to determine whether individuals are eligible to receive services, including Medicaid. The audit objective was to determine whether TIERS system and process controls were adequate to reasonably ensure that Medicaid eligibility determinations were accurate based on selected eligibility elements, including citizenship, residency and identification of deceased individuals.

While TIERS had system and process controls in place, those controls should be strengthened to reasonably ensure that Medicaid eligibility determinations are accurate based on selected eligibility elements. Specifically:

• Automated controls within TIERS were not always adequate to ensure all eligibility records were closed as required for applicable deceased individuals. This resulted in managed care capitation payments totaling $660,721 for individuals who were deceased.
• Controls were not always adequate to reasonably ensure that information used to determine Medicaid eligibility was accurate, complete and in alignment with Medicaid policy.

The OIG made recommendations to HHSC to identify deceased individuals and close Medicaid eligibility; ensure TIERS automated controls are sufficient, consistent and aligned with Medicaid policy; ensure access to TIERS and controls related to TIERS access is appropriate; and to recover the $660,721 managed care capitation payments for the deceased individuals.

Read the full audit and recommendations on the OIG website, ReportTexasFraud.com.