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OIG’s Continuing and New Reviews of the Medicaid Program: Managed Care

Posted in Department of Health and Human Services

As part of its Work Plan for Fiscal Year 2013, the Office of Inspector General (“OIG”) plans to focus on the following current and new issues in the Medicaid program: prescription drugs; home, community, and personal care services; equipment and supplies; state management and oversight; the Children’s Health Insurance Program; Medicaid data systems, controls, and claims processing; and managed care.

Managed care allows groups of providers and hospitals to organize into a network and offer beneficiaries access to high quality and cost-effective health care.  OIG’s continuing review of the Medicaid managed care program will address three new initiatives: (1) beneficiary access to Medicaid managed care; (2) the beneficiary grievances and appeals process; and (3) Medicaid managed care organizations’ identification of fraud and abuse.

States have an obligation to ensure that managed care plans maintain and monitor a network of providers that is sufficient to provide adequate access to all Medicaid services.    As an upcoming initiative, OIG will review how extensive these provider networks are for Medicaid managed care beneficiaries.  The OIG provides several factors for managed care plans to consider when establishing a network, in order to ensure that the network grants beneficiaries adequate access to Medicaid services.  These factors include: anticipated Medicaid enrollment; expected utilization of services; number and types of providers accepting new patients; and geographic location of providers and beneficiaries.

OIG will also review the extent to which states monitor Medicaid managed entities’ grievances and appeals systems.  Internal grievance procedures must be established for beneficiaries to challenge the denial of medical services.

Finally, OIG will determine the extent to which Medicaid managed care organizations have administrative and management arrangements or procedures that are designed to guard against fraud and abuse.  Such procedures include mandatory compliance plans for internal monitoring and auditing.