Oregon Medicaid Managed Care Medical Loss Ratio Audit
Learn how the AI-generated research projects were createdOverall Conclusion
The audit identified areas for improvement in Oregon's Medicaid managed care MLR reporting and oversight processes. While no immediate remittance was required, implementing the recommendations will enhance compliance, accuracy, and program integrity.
Source Document
Audit Scope
This audit covers the calendar year 2019 reporting period for Oregon Medicaid Managed Care, specifically evaluating the MLR reports submitted by 15 CCOs contracted with the Oregon Health Authority. The scope includes review of the methodology, supporting documentation, and oversight procedures related to MLR calculations, remittance processes, and compliance with federal and state regulations.
Key Findings Summary
CMS identified 37 instances requiring correction to the reported MLR remittance calculations across all CCOs, but none resulted in a recalculated MLR below the 85% threshold, so no remittances were due.
CMS found non-compliance with federal and state requirements in areas such as special payments, third-party vendor data, expense allocation, and quality improvement expenditures.
AI-Assisted
AI Scope Summary
The audit aimed to assess the accuracy and compliance of Oregon's Medicaid Managed Care Organizations' (CCOs) Medical Loss Ratio (MLR) reporting for 2019, ensuring that the reported data supported the calculated MLRs and that the state’s oversight mechanisms were effective.
AI-Generated Insight
This comprehensive audit underscores the importance of rigorous oversight and precise reporting in Medicaid managed care to ensure financial accountability and compliance with federal regulations. Addressing identified gaps will strengthen Oregon's program integrity and optimize resource allocation.
Audit Objectives
To determine if the Medicaid Coordinated Care Organizations (CCOs) submitted annual MLR reports to Oregon pursuant to federal requirements.
To verify if the annual MLR reporting and minimum MLR remittance calculations are supported by the underlying data and documentation.
Audit Findings (2)
CMS identified 37 instances requiring correction to the reported MLR remittance calculations across all CCOs, but none resulted in a recalculated MLR below the 85% threshold, so no remittances were due.
CMS found non-compliance with federal and state requirements in areas such as special payments, third-party vendor data, expense allocation, and quality improvement expenditures.
Recommendations (10)
Remove health-related service costs from QIA expenditures if they do not qualify as QIA.
Exclude fraud prevention activities from the MLR numerator until defined in regulation.
Monitor and reconcile special payments such as QDPs and HRAs.
Improve oversight of incentive contracts and ensure timely provider payments.
Include QDPs and SDPs in MLR calculations as required.
Monitor receipt of qualified directed payments and reconcile with MLR reports.
Update instructions to disallow non-medical costs of third-party vendors, including PBMs.
Ensure collection of underlying data from third-party vendors.
Establish and maintain contracts with subcontractors to ensure compliance.
Update reporting instructions to exclude non-Medicaid expenses and clarify allocation methodologies.