The Secretary of State recently released a performance audit on the Oregon Health Authority: Oregon Health Authority Should Improve Efforts to Detect and
Prevent Improper Medicaid Payments. This audit received a lot of media exposure, in part due to an Audit Alert released in May, some months before the scheduled audit release date. Unsurprisingly, this led to more than a little pressure. How did our 4 person audit team (Ian Green, Wendy Kam, Kathy Davis, and Eli Ritchie) approach this audit, stay cool under fire and make sure their conclusions were sound? I sat down with the lead auditor, Ian Green, to find out more.

You led the OHA, Improper Medicaid Payments audit. What are your strategies when you’re faced with a complex agency and a complex topic?

When we started this audit, we knew we’d be looking at improper payments. Even that’s such a big topic, we knew we’d need to scope it down where we could. So we got as much information as we could from all levels – hundreds of interviews with officials and analysis, looking at agency documentation, research on best practices, all of that.

What methods did you use to identify improper payments?

Our primary focus was to look at process issues, but we did attempt to find some improper payments. We used audit software to analyze large data sets. We did a lot of data matching and looked for results that were outliers. For instance, we checked to see if providers were getting duplicate reimbursements. It’s a complex system, so providers and billers might make errors that should be caught before payments are set out. Another example was checking to see if there were people enrolled in the Oregon Health Plan who shouldn’t be – like if someone had moved out of state.

 What challenges did you face doing this audit, and what strategies did you use to address them?

One challenge was the sheer amount of data. We looked at over two hundred million records.  There was so much data that running tests could take a very long time. My team would run a script and leave it overnight to finish. We had to be very careful about how we set up our tests. Since we kept everything scripted out, each time we got new information, we could just update that script. That kept the testing sustainable, which is very important given all the last minute information we received.

To address the complexity of the topic, we separated our approach into three subtopics: prevention, detection, and recovery. Each person on the team focused on one area, and we’d meet to discuss weekly. That helped make sure we covered all the information while still working together closely.

Another challenge was trying to get complete data. We’d request data and be told we had it all. And then we’d find out it was incomplete. That meant we had to continue reworking our analysis constantly. Without scripting, it would have been extremely time-consuming to perform this work manually.

What was the hardest thing about completing this audit in the public eye?

It’s a very sensitive topic. We knew that we’d get a lot of scrutiny. But we did what we always do, which is to work really hard to make sure all our conclusions are accurate and well-supported, and put all our work through a thorough quality assurance process.

 Is there anything you wish non-audit folks knew about the audit process?

Generally, there’s a public perception that an audit should find everything that might be going wrong. Auditors look at a higher level to see if there are controls in place to prevent something from going wrong. If we’re concerned, we may do deeper testing to see what’s actually happening. For instance, we looked at processes to manage improper payments. Our goal wasn’t to find all of the improper payments being made. Our testing helped measure the effect of the processes that are currently in place.

Anything else?

It was a big audit. We’ve been excited to see important changes happening, even while we were still working on the audit. The Oregon Health Authority is working to address weaknesses in their processes and being more transparent. That’s a really good outcome, from our perspective.

 

Check out the audit here: http://sos.oregon.gov/audits/Documents/2017-25.pdf