An Audit Report on Medicaid Managed Care Contract Processes at the Health and Human Services Commission

The Commission has established new processes and controls related to Medicaid managed care contract management and made progress toward implementing the requirements of Senate Bill 894. It implemented a strategy for managing audit resources, followed up on negative performance audit findings, completed a risk assessment for selecting MCOs to audit, and billed MCOs for audit-related costs.

The Commission should continue to implement planned improvements such as conducting performance audits of pharmacy benefit managers, issuing corrective action plans based on AUP engagements, and monitoring MCOs based on External Quality Review Organization information.

The Commission developed a plan to monitor MCOs using EQRO information but had not yet implemented it. This includes establishing minimum performance standards for Medicaid survey results and encounter data validation.

The Commission strengthened controls over its IT systems and change management process, but should ensure consistent documentation of change authorizations and testing.

The Commission established a billing process for MCOs to reimburse audit-related services and a process to identify and transfer experience rebates, but had unresolved disputes over some rebates.

The Commission should continue to implement its performance audit plan, including audits of pharmacy benefit managers.

The Commission should implement policies for issuing corrective action plans based on AUP engagements and verify their implementation.

The Commission should develop and implement a process to resolve disputes over experience rebates claimed by MCOs.

The Commission should implement its plan to use EQRO information to enhance monitoring of MCOs and develop minimum performance standards for Medicaid survey results and encounter data validation.

The Commission should consistently follow its process to document the authorization and testing of programming changes to ARTS.