Better Medicaid managed care oversight needed to protect providers serving high-risk populations: OI

States are not doing a good job of monitoring how Medicaid managed care enterprises handle providers serving high-risk populations, according to a new government report.

Under federal law, Medicaid managed care enterprises (MCEs) cannot discriminate against providers serving high-risk populations or those needing costly treatments. To guard against this, federal law requires MCEs to sign a contract that stipulates they will not discriminate against these kinds of providers. Yet five of six states evaluated in a recent study were not monitoring MCEs’ compliance with this provision, according to a report issued yesterday by the Department of Health and Human Services Office of the Inspector General.

Furthermore, in three of those states, some of the MCE policies lacked the nondiscrimination requirement altogether, the report stated. OIG interviews with state staff members and reviews of MCE credentialing policies revealed that staff were unaware of this situation.

Lax oversight extends to the federal level, the OIG found. Centers for Medicare & Medicaid Services regional offices are supposed to ensure that state contracts under their purview contain all the federally required credentialing provisions for MCEs. The CMS offices are inconsistent in reviewing and documenting this contract information, according to the OIG report.

The trend toward managed care likely is irreversible, LeadingAge CEO and President Larry Minnix recently told McKnight’s. Minnix, who leads one of the nation’s largest long-term care provider associations, said managed care should help providers serve particularly high-risk residents, such as those dually eligible for Medicaid and Medicare. These people often have complex needs and limited financial resources. Insofar as the OIG findings cast doubt on how equitably managed care companies are treating providers primarily serving this type of population, long-term care providers may find the report troubling.

Providers also must go over managed care contracts carefully, legal experts said at the national American Health Care Association/National Center for Assisted Living conference in October.

Click here to access the complete report.