10 tips for working with MCOs to advance Medicaid program integrity

Lane EdenburnHave you turned to managed care organizations (MCOs) to reduce Medicaid costs and improve patient care? If so, you probably know how difficult it is to know for sure whether your MCOs are doing all they can to reduce fraud, waste and abuse.

In May 2015, CMS proposed a new rule that MCOs strengthen their Medicaid program integrity (PI) processes. The public comment period for this rule ended July 27, and as of September 28, CMS had not yet issued the final rule.

To make the most of the new rule, if approved, you’ll need to more closely monitor your MCOs. With that in mind, we’ve developed the following best practices for working with MCOs to advance program integrity.

10 tips for working with MCOs

  1. Review the CMS proposal and start planning how you will integrate it into your processes.
  2. Require providers serving only MCO beneficiaries to enroll with your state so you can vet them and integrate them into your auditing process.
  3. Collaborate with your MCOs to develop efficient processes for fraud referral and auditing and determine how you will monitor their efforts. Develop a culture of cooperation, including regularly scheduled meeting and ongoing communication.
  4. Encourage or even require your MCOs to share claims, provider data and other relevant information.
  5. Partner with your MCOs to determine processes for the collective application of predictive analytics and other tools that reduce or prevent fraud, waste and abuse.
  6. Establish national and state-specific benchmarks for particular services. Compare your MCOs’ data submissions to these benchmarks.
  7. Require monthly reports, emphasizing data transparency and data normalization across MCOs.
  8. Rewrite your MCO contracts to clearly delineate responsibilities for fraud, waste and abuse activities, including state authority to investigate and act against providers if MCOs won’t.
  9. Monitor the underutilization of services, which not only impacts quality of care but also constitutes fraud.
  10. Make sure you have the resources to handle an increase in MCO fraud referrals.

To learn more about how your state can work with MCOs to coordinate program integrity, please read “Medicaid PI units: Best practices for working with MCOs

— Lane Edenburn

About the author

Lane Edenburn is vice president, government program integrity solutions, at Optum.

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