Risk & Quality Management Team: Oversight and Monitoring Unit (OMU)

% of Quality Control (QC) results found to be correct

92.0%Jan 2022

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Notes on Methodology
  • Due to the COVID-19 pandemic CMS implemented changes to auditing procedures during the second half of CY 2020. Because of this, DVHA does not have data to report on this measure for the June – December 2020 timeframe. 
  • December 2019 data is not available due to the unit switching over to a new database system.


  • Coordination of Benefits Unit (COB)
  • Health Access Eligibility & Enrollment Unit (HAEEU)
  • Long Term Care Unit (LTC)
  • DVHA Senior Management
Story Behind the Curve

This measure is important because it shows the % of audit findings found correct by the Quality Control (QC) Unit in eligibility decisions processed by HAEEU and LTC.

This data identifies weaknesses in the eligibility determinations that could result in monetary penalties from CMS.  Cases with a QC finding result of ‘Error’ are a high priority for eligibility units to fix followed by findings with “Deficiencies”.   The strategy is  to report these findings to the eligibility units in a timely manner so they will be able to create a corrective action as to how they will fix the case and avoid the error in the future.

The trendline shows the % of cases found to be "Correct" for any given sample month, meaning there were no errors or deficiencies found with the case.  Data shows there has been a fluctuation with % of cases found ‘Correct’ by QC since we first started reporting data. This could be influenced by eligibility system changes, rule changes or eligibility process changes. QC is seeing an upward trend of ‘Correct’ eligibility determinations for CY 2020. The new COVID-19 emergency rules for Medicaid, implemented by CMS in March 2020, could account for this upward trend.

Since November 2021, QC has seen a marked increase in ‘Correct’ cases.  The reasons for this increase are likely contributed to cases that have been extended correctly due to the Public Health Emergency (PHE) and the decision to suspend citing notices related to missing or repealed rules (16ANFTD), effective with the November 2021 sample through2022. These suspensions reduced the burden on QC and the Eligibility staff during the PHE. The citations for notices related to missing or repealed rules will resume in 2023 when the next Medicaid Eligibility Quality Control audit takes place.

Narrative last updated: 06/16/2022

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