The Case for Program Integrity in Medicaid Managed Care

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.