Medicaid audits play a critical role in ensuring healthcare organizations meet compliance, quality, and contractual requirements, and this episode of Compliance Deconstructed breaks down what providers and health plans need to know. Hosts Jessica Zeff, Lorie Davis, and Elvan Baker explore how ECRO and ISCA audits function within Medicaid programs and why understanding them is essential for operational success.

Throughout this in-depth conversation, your hosts explain that ECRO audits, conducted by External Quality Review Organizations, focus on evaluating the quality of care, member services, and adherence to state and federal Medicaid standards.

ISCA audits concentrate on internal systems capability, including data integrity, IT security, and the reliability of systems used to manage Medicaid services and member information.

You will learn that Medicaid audit processes vary by state, with some states conducting comprehensive annual reviews and others using staggered or rotating audit schedules. Lorie, Jessica, and Elvan emphasize the importance of knowing state-specific requirements and timelines to ensure audit readiness and avoid compliance gaps.

The conversation also highlights the importance of contracts, protocols, and staff preparation in successful audit outcomes. By understanding contractual obligations, educating staff on their roles, and practicing audit readiness through mock interviews and data reviews, organizations can approach ECRO and ISCA audits with greater confidence and clarity.

Key Takeaways

• ECRO audits evaluate quality of care, member services, and compliance with Medicaid requirements.
• ISCA audits assess the security, accuracy, and capability of internal data and IT systems.
• Medicaid audit structures and timelines vary by state and require careful review.
• State contracts define the standards and protocols used during ECRO and ISCA audits.
• Staff education and role clarity are essential for accurate and effective audit responses.
• Proactive preparation, including mock audits and data reviews, supports stronger compliance outcomes.

Learn more about Healthcare Compliance and discover how Simply Compliance can help your company at simplycomplianceconsulting.com.