Every system passes its own audit. The seams don’t.
Three systems — county eligibility, a claims platform midway through a vendor transition, and a monthly Medicare COB file — each internally consistent. Reconciled against each other, they surface 41,463 affected members and $337.7M in estimated exposure.
Exposure by break class
Estimated dollars at risk per discrepancy class — click a bar for the member-level evidence.
The six break classes
Each one invisible to single-system review. Each one found by reconciling the seams.
Transition Orphans
Members carried onto the Meridian claims platform during the vendor cutover and still receiving capitation, with no active eligibility span behind them in CBES.
Dual/COB Mismatch
Members flagged dual-eligible in CBES who are missing from the Medicare COB file, or present with effective dates that don't reconcile — Medicaid paying primary where Medicare should be.
Aid Category Conflicts
CBES and MMIS carry different aid categories for the same member and span, so capitation pays from the wrong rate cell. Small dollars per member, huge member counts.
Point-in-Time Reconstruction Failure
Members whose current record looks compliant, but whose span history contains overlapping or retroactively edited spans with no audit trail — the state cannot reproduce what eligibility was on a given past date.
Eligibility Span Drift
Member exists in both systems, but enrollment spans disagree by more than 30 days — MMIS keeps paying past the CBES termination, or starts paying before approval.
County Transfer Gaps
Member moved counties; the old county terminated, the new county's span started late, and MMIS kept paying under the stale county code the whole time.
Members can appear in more than one break class; the headline figure of 41,463 counts unique members.