Evidence record
Oversight Of Medicaid Quality Care
- Jurisdiction
- Louisiana
- Publishing agency
- Louisiana Legislative Auditor
- Publication date
- May 23, 2024
- Source record
- Original document linked
Findings
5
Recommendations
10
Overall conclusion
The audit found significant governance and data-use gaps in LDH’s oversight of Medicaid MCOs, including incentive design that can pay for non-improving performance, lack of data-driven identification of non-utilizing beneficiaries and preventive service gaps, fragmented complaint tracking, and inaccurate provider directories and networks, with recommendations to strengthen oversight and accountability.
Scope
The scope of the audit was to evaluate the Louisiana Department of Health’s oversight of Medicaid Managed Care Organizations (MCOs) in Louisiana, assessing whether LDH’s Quality Strategy and related governance, data analytics, and oversight practices effectively ensure that Medicaid beneficiaries receive quality care and necessary services. The audit examined LDH’s implementation and performance of its Quality Strategy (Triple Aim: Better Care, Better Health, Lower Costs) and the associated 1.0% quality withhold incentive program, including analysis of CMS/HEDIS and related quality measures reported by MCOs for calendar years 2018 through 2022. It also evaluated LDH’s use of Medicaid data to identify non-utilizers and preventive service gaps (e.g., breast and colorectal cancer screenings), the completeness and usefulness of beneficiary complaint data and LDH’s consolidated complaint-tracking capabilities, and the accuracy and validation of MCO provider directories and networks (provider directories, network adequacy reports). The analysis covers periods of 2018–2022, notes suspensions of the incentive program in 2020 and 2023 due to pandemic and added MCO, and references related appendices (Appendix B – scope and methodology; Appendix C – performance measures; Appendix D – beneficiaries with no services).
Findings (5)
Each finding has a stable link.
- F-456
LDH’s 1.0% quality withhold incentive program design allows MCOs to receive payments without improving performance; the program withheld $283.6 million between 2018 and 2022 and paid $32.2 million (11.4%) for incentivized measures where targets were met but performance declined from the prior year.
- F-457
LDH does not use Medicaid data as part of its Quality Strategy to identify beneficiaries who have not received any services or recommended services based on demographics; the audit identified 49,894 beneficiaries who appeared to be continuously enrolled 13–60 months (2018–2022) but received no services, with $720.5 million paid to MCOs to manage their care.
- F-458
LDH does not have a consolidated database of beneficiary complaints, hindering comprehensive tracking and trend analysis; the majority of complaints related to a lack of quality or access to care.
- F-459
MCO provider directories and networks are inaccurate; LDH provider directory audits showed a 49.4% median accuracy and 33.2% of providers on network adequacy reports did not provide Medicaid services (Jul 2022–Dec 2022); 6,947 (21.4%) providers were listed as out-of-state; 6,711 (20.6%) were listed with multiple provider types.
- F-460
The EQRO reviews and LDH’s data analyses do not consistently utilize comprehensive Medicaid data to assess Triple Aim outcomes, limiting ability to identify beneficiaries needing preventive services and track improvements.
Recommendations (10)
- R-418
Recommendation 1: LDH should evaluate the design of the quality withhold incentive program and implement strategies to strengthen it, including penalties for declining performance on withhold measures, reducing or eliminating payments for report-only measures, ensuring payment is tied to year-over-year improvement, and increasing the PMPM withhold rate.
Related finding F-456 - R-419
Recommendation 2: LDH should conduct analyses of Medicaid data to identify beneficiaries who receive no services over certain periods to ensure they remain eligible for Medicaid.
Related finding F-457 - R-420
Recommendation 3: LDH should conduct analyses of Medicaid data to identify beneficiaries who receive no services over certain periods to ensure MCOs conduct appropriate outreach activities.
Related finding F-457 - R-421
Recommendation 4: LDH should conduct analyses of Medicaid data to identify groups of beneficiaries who should receive certain services (e.g., mammograms, colorectal screenings) but routinely do not, to ensure outreach.
Related finding F-460 - R-422
Recommendation 5: LDH should create a database that captures complaints received and resolved by CSR staff.
Related finding F-458 - R-423
Recommendation 6: LDH should ensure consistent data across MCO complaint reports, CSR complaints, LDH management complaints, and other sources to enable a master database.
Related finding F-458 - R-424
Recommendation 7: LDH should compile a master database of all complaints and perform analyses to identify areas with highest concern for beneficiaries.
Related finding F-458 - R-425
Recommendation 8: LDH should perform routine analyses of network adequacy reports to proactively review accuracy.
Related finding F-459 - R-426
Recommendation 9: LDH should analyze Medicaid data to validate network adequacy reports (e.g., providers with no claims, multiple provider types).
Related finding F-459 - R-427
Recommendation 10: Based on network adequacy analyses, LDH should determine if additional penalties are warranted.
Related finding F-459