Program integrity & COmpliance

The Case for Program Integrity in Medicaid Managed Care | Part 11

In our previous post on claims denials, we presented issues with the underlying data and other variables that influence effective evaluation of prior authorization (PA) and claim denials. We also discussed a few risks associated with PA and claim denials. In this post, we offer our recommendations for states to directly address claim denial issues to improve MCO claim transparency, efficiency, and accuracy, thereby bolstering program integrity (PI) in their Medicaid health and human services programs.

5 minutes

Key Takeaways

This blog highlights the need for stronger program integrity (PI) in Medicaid Managed Care by addressing claim denial issues through improved data accuracy, transparency, and oversight. Key recommendations focus on enhancing MCO contracts, compliance monitoring, and data analytics to support better health outcomes.

  • Strategies to improve Medicaid claim transparency and oversight.
  • Address data issues, automate audits, and flag anomalies to reduce improper denials.
  • Focus on consistent, accurate data to protect vulnerable populations and improve care quality.

Part Eleven: Claims Denials Recommendations

As PI professionals, we believe most PA and claim denials are legitimate: however, some denials are simply related to data integrity or other reasons, complicating PI efforts. Examples of denial data issues include incomplete or inconsistent data, repeated denials stemming from claim adjudication issues, missing codes, and unclear denial reasons. By using reliable, tested processes designed to increase transparency and oversight of MCOs, states can improve health outcomes for members and be better stewards of taxpayer monies.

Recommendations

Ultimately, states need better data and more vigorous oversight of MCO claim and PA denial activities. Together, these recommended actions will provide insight into whether MCOs are inappropriately denying care to reduce MCO costs and protect their bottom line at the expense of the nation’s most fragile populations. We encourage states to consider:

  • MCO Contract Language. Issues with data, PI, and potential FWA can all stem from unclear contract language that does not delineate requirements and state expectations. Therefore, it is essential to develop strong contracts underpinned by compliance monitoring. Contract consultants can help develop the strong, precise language that is foundational for oversight and enforcement.
  • Compliance Oversight and Monitoring. Regular oversight and monitoring helps ensure the MCOs are compliant with their contract and state expectations. This oversight and monitoring can be supported by robust data analytics and dashboard reporting.
  • Data Analytics.  Analytics can identify a range of errors or problems with data, including missing fields, inconsistent formats, technology platform incompatibility, and more. Analytics can identify rates of denials that might seem anomalous, and outliers can be flagged for detailed review.
  • Dashboards Reporting. Interactive dashboard reporting can accurately and concisely capture and visualize data in engaging, easy-to-understand ways, providing clear communication of key insights, all in one customizable platform. Dashboards can capture numerous functional areas of MCO activities down to the level of health plan operations and performance, including quality performance measures, member enrollment and demographics, financial reporting, claims processing, PA and denials, and appeals and grievances. Using dashboard reporting can provide insight into MCO activities and offer early indications of potential issues.
  • Audits. Audits ensure a deeper dive into potentially concerning metrics found while conducting oversight and monitoring, or audits can be used as a regular monitoring tool to ensure MCO compliance with contractual obligations. When audits are performed at the plan level, be certain to focus on the accuracy and completeness of the underlying data supporting claim and PA denials. It is also important to consider the records used as the basis for MCO denials. Vague and non-specific denials can signal a problem, as can automatic denials triggered by unspecified levers or switches.
  • Subcontractor Denials. Denials determined by a subcontractor, possibly owned by the MCO itself (e.g. pharmacy benefit managers or behavioral health vendors) can differ in substance and structure from MCO denials. So apart from PA or other claim edit denials, the root cause of errors for these denials can manifest differently. This can mean data presented from different sources having different claim numbers but representing the same claim might provide unique information at each source. These variances can make uncovering trends and identifying potential issues more difficult. We recommend enhanced MCO contract language requiring rigid data integrity for MCOs and MCO subcontractors. 

Together, these approaches can ensure greater consistency and accuracy of MCO data. Complete and accurate data is the primary tool necessary to strengthen PI, combat FWA, and better serve the fragile populations served by state agencies.

Join the Benefit/Program Integrity team next time for the final post in our series as we look back at key highlights and look forward with observations about what might be on the horizon for program integrity in managed care.

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