Partnership + Accountability + Impact
Myers and Stauffer provides meaningful careers where our associates know their work truly makes a difference in the lives of others. Janae Jensen, CPA and Senior Manager at our Kansas City office, shares her perspective about helping clients identify transparency within health plan reporting and calculation to help those most vulnerable.
“In the Medicaid managed care space, our state clients contract with private insurance companies to help manage the care of their Medicaid population(s). This privatization requires a vast amount of federal oversight, which holds states accountable for the health care needs of their at-risk beneficiaries, even if a private company provides those services. In other words, the buck stops with the state.
Myers and Stauffer has the opportunity to play a critical role in collaborating with states on various needs related to oversight and federally mandated audits. One growing practice area for our managed care engagement team is auditing (examining) the Medicaid medical loss ratio (MLR) reporting by health plans.
There is a federal minimum MLR requirement that 85 percent of capitation payments contracted health plans receive from Medicaid agencies must be spent on health care costs and activities to improve health outcomes for Medicaid members. Meaning, for every important dollar of Medicaid funding paid to health plans, at least 85 cents must be dedicated health care services for members, with the remaining 15 cents going toward administrative expenses. This safeguard limits the ability of a health plan to retain excessive Medicaid funding for profit or other misuses.
There is great satisfaction when our team identifies new issues affecting MLR reporting. Our expertise allows us to aid clients in pulling the curtain back on what is transpiring behind the aggregate amounts rolling into a health plan’s MLR reporting and calculation.
For example, we have identified health plans that are health-system owned where provider incentive payments were targeted, offered, and paid only to its own related-party providers. We have also encountered biased metrics used in determining payments that were not equitable between related and non-related providers, making it easier on parties related to the health plan.
Another controversial topic is disproportionate executive compensation. The risk is that corporate compensation costs could trickle down into a local health plan’s cost, which Medicaid funding ultimately reimburses. One way we bring value to our clients is by shining a light on these areas of reporting, which can lead to greater transparency and immediate action by the client requesting revisions to state financial reporting instructions that prohibit such situations going forward.
Although these audits are financial in nature, the results of our work go beyond the numbers themselves. By working with our clients, we are investing time in oversight that helps ensure Medicaid funding goes to its intended purpose: providing essential health care services to the most fragile and critical in-need populations across the country. I appreciate and value the partnership we develop with our clients to hold health plans accountable for regulatory compliance and oversight. This effort ultimately benefits those who receive services through the Medicaid managed care delivery system.” – Janae Jensen, CPA
Get to Know Janae
Janae provides experience in Medicaid auditing, managed care oversight, and consulting engagements for state health care agencies. She oversees multiple Medicaid managed care contracts with services ranging from medical loss ratio examinations, administrative expense reviews, development of financial reporting guidance, contract compliance, risk adjustment reviews, and External Quality Review (EQR)-Protocol 5. Janae additionally has extensive experience with disproportionate share hospital payment calculations and examinations, as well as hospital and nursing facility cost report attest engagements in many states.
Positive Impacts
Myers and Stauffer is proud to help our clients serve those who are most vulnerable. Our staff feel empowered to know that their hard work and dedication each day makes a difference. We believe it and so do the millions of individuals helped by the clients we serve. We will release new stories each month highlighting associates and their stories. Follow along with our LinkedIn, Twitter, and Instagram for more information.
