Medicaid Program: Oversight of Managed Care Provider Networks

DOH lacked sufficient oversight of managed care provider networks.

DOH did not follow its internal PNDS Review Guidance; SOAs contained inaccurate deficiencies, and deficiency statuses were not consistently updated.

Records were incorrectly labeled as 'excluded' from the network adequacy process, risking incomplete SOAs.

DOH does not provide MCOs with adequate guidance regarding the deficiency review process or out-of-network provider payments, potentially increasing Medicaid expenses.

DOH officials do not use SOA data to identify patterns or areas for improvement or provide oversight of the network adequacy process.

Improve monitoring and controls over the provider network adequacy process to ensure network deficiencies are reported timely and accurately, including issuing guidance detailing MCO responsibilities within the deficiency review process.

Develop a complete and accurate list of specialties that are excluded from the quarterly network adequacy process, including collaborating with OMH, to ensure all services are appropriately reviewed for network adequacy.

Evaluate the provider network deficiencies identified in SOAs and take steps to improve MCO provider networks.