AUDIT: Medicaid Patients Left Vulnerable to Fraudulent, Potentially Dangerous Behavior from Medicaid Providers

A new performance auditfrom the North Carolina Office of the State Auditor (OSA) found patient safety vulnerabilities in North Carolina's Medicaid program.



The vulnerabilities stem from the North Carolina Department of Health and Human Services (DHHS) allowing Medicaid providers with license limitations, suspensions, or other credential issues to remain on the Medicaid program. The audit was conducted to determine if DHHS implemented fixes for similar issues found in a 2021 audit. Ultimately, this audit found DHHS "failed to fully remedy the issue, leaving North Carolina's Medicaid system and taxpayers vulnerable to fraudulent and potentially dangerous behavior."

Several providers that posed a risk to low-income Medicaid patients but remained in the Medicaid program were identified in the audit:

• Provider A: Treated 21 Medicaid patients and received $1,311 in payments despite being under a Non-Practice Agreement for practicing medicine while abusing alcohol.
• Provider B: Treated 14 Medicaid patients and received $5,415 in payments despite being under a Non-Practice Agreement for inappropriately prescribing controlled substances and medications to friends and romantic partners.
• Provider C: Billed Medicaid for services provided to 78 Medicaid patients, including 21 female patients, despite a license limitation restricting the physician from treating female patients.
• Provider D: Remained active in the Medicaid program despite having their Moderate Sedation permit suspended for administering general anesthesia without a permit.
• Provider E: Remained active in the Medicaid program despite having a license limitation prohibiting the physician from prescribing controlled medications following a DEA raid.

"When you go to the doctor, you shouldn't have to worry about whether your physician is in good standing with the professional medical community," said State Auditor Dave Boliek. "Medical suspensions and license limitations are serious prohibitions that need to be treated as such. To ensure Medicaid patients have safety and trust with their physicians, it's important that the government promptly addresses the Medicaid provider issues found in our latest report."

The audit listedsix recommendations for DHHS to take, including removing "all providers from the Medicaid program who have professional license limitations that pose threats to the safety of patients." It also highlighted the $1.5 billion contract DHHS has with General Dynamics Information Technology to perform provider enrollment functions. OSA noted that DHHS "should improve monitoring of the $1.5 billion GDIT contract so that the state's interest is protected and to ensure the effective and efficient use of taxpayer funds."