Managed Care Oversight Improvement Initiatives


HHSC contracted with an independent consultant, Deloitte, to evaluate potential improvements to the agency’s oversight of managed care organizations in compliance with Rider 61, General Appropriations Act, 85th Legislative Session. The subsequent Rider 61(b) report completed by Deloitte outlined several opportunities for strengthening oversight of the Texas Medicaid program.

HHSC has multiple initiatives in progress related to this evaluation. We post regular updates for here.

Administrative Simplification

This initiative focuses on reducing Medicaid provider burden in two areas:

  1. Claims payments
  2. Prior authorization submissions

Completed milestones:

  • Conducted meetings with the STAR+PLUS managed care organizations to:
    • Review and begin implementation of legislation impacting prior authorization information and submissions (Q4 2019).
    • Identify how MCOs are using claims projects and how they are submitting data on the claims project deliverable.
  • Drafted MCO guidance on the directive that nursing facility daily rate claims cannot be included in claims projects.
  • Continued monitoring of any outstanding nursing facility claims projects to ensure prompt resolution.
  • Continued monitoring and prompt resolution for complaints received.

Upcoming milestones:

  • Develop provider education on core business functions such as submission of claims and prior authorizations (Q1 2020).

Complaints Process and Data Analytics

This initiative focuses on evolving the managed care member complaints process to streamline intake and tracking, more effectively leverage complaints data to identify risks and ultimately improve quality of services. This will be accomplished by:

  • Improving data collection of complaints.
  • Standardizing complaint categories used by HHSC and MCOs for more accurate trending and issue identification.
  • Documenting the current member complaints process journey, identifying ways to streamline the process and effectively communicating the new process to clients.

Completed milestones:

  • Documented the current member managed care complaints process, identified entry points and opportunities to streamline.
  • Deployed the initial phases of the new complaints process through new internal processes.
  • Published a complaints report, as required of the HHS Office of the Ombudsman, to the HHS website (Q4 FY2019).

Upcoming milestones:

  • Deploy client-facing changes to the new complaints process (Q1 FY2020).
  • Execute contract changes for complaints definitions (Q1 FY2020).
  • Finalize complaint category standardization (Q2 FY2020).

Network Adequacy and Access to Care

This initiative’s goal is to build a comprehensive strategy to ensure members have access to providers at the right time and place. We will accomplish this by:

  • Improving the accuracy of provider directories, including more robust MCO validation requirements and improvement of critical processes that impact accuracy.
  • Incentivizing the use of telemedicine services to improve access for members in underserved areas of the state.
  • Reducing administrative burdens related to network adequacy reporting and monitoring, including cross-agency coordination with the Texas Department of Insurance.
  • Integrating network adequacy reporting to include additional measures, such as appointment availability studies and targeted encounter data.

Completed milestones:

  • Legislation passed to expand the use of telemedicine and telehealth services.
  • Reviews of all proposed new medical benefits are now automatically considered for delivery through telemedicine.
  • MCOs may use telemedicine in their network adequacy corrective action plans to ensure access to underserved areas of the state.
  • MCOs must validate provider directory errors identified during appointment availability studies.

Upcoming milestones:

  • Work with MCOs to prioritize new contract requirements to strengthen provider directory accuracy (Q1 FY2020).
  • Develop a cost effectiveness methodology to evaluate telemedicine and telehealth services (Q4 FY2020).
  • Work with stakeholders to plan implementation of legislation that expands reimbursement for telemedicine and telehealth services (Q2 FY2020).
  • Develop a “proof of concept” for a network adequacy performance dashboard focused on access to prenatal care services (Q2 FY2020).
  • Work with Texas Department of Insurance to align and simplify network adequacy monitoring requirements (Q3 FY2020).
  • Implement strategies to reduce administrative burden for providers and MCOs when updating provider directory information (Q3 FY2020).
  • Conduct procurement for automated network adequacy tool and performance dashboard technology (Q4 FY2020).

Outcome-Focused Performance Management

We are bolstering our oversight tools related to comprehensive MCO on-site reviews and reporting efficiency through:

  • Improving the MCO operational review process by:
    • Expanding the scale of our biennial MCO on-site reviews to include finance and reporting, quality, pharmacy and more.
    • Streamlining review processes to minimize administrative burden.
  • Integrating managed care oversight at HHSC for more holistic assessment of MCO performance.
  • Reviewing MCO deliverables to ensure reporting requirements provide meaningful information on targeted performance.

Completed milestones:

  • Enhanced the operational review oversight process by including five additional program areas into the biannual reviews.
  • Enriched existing operational review modules and developed new ones.
  • Removed, or in the process of removing, 14 deliverables including one ad hoc report.
  • Identified 15 deliverables to be streamlined.

Upcoming milestones:

  • Introduce 11 deliverables through TexConnect (Q2 FY2020).
  • Continue to transition deliverables from other platforms, such as program-area mailboxes, to TexConnect (ongoing).
  • Incorporate changes to the Uniform Managed Care Manual which reflect streamlined deliverables (Q3 FY2020).
  • Implement the new Uniform Managed Care Manual chapter regarding operational reviews (Q1 FY2020).
  • Deliver HHSC and MCO staff training specific to enhancements of the operational review process (Q1 FY2020).
  • Implement expanded operational reviews (Q1 FY2020).

Strengthening Clinical Oversight

Strengthening clinical oversight will further ensure our most vulnerable populations receive services appropriately. Our aim is to reduce preventable denials or delays in services related to the prior authorization process. This will be accomplished by:

  • Enhancing oversight to ensure consistent, medically appropriate approval of Medicaid services.
  • Expanding staffing models to support increased scope and sample size for Utilization Review activities.
  • Developing a new, standardized prior authorization data collection tool that uses transaction-level data.
  • Using prior authorization data to identify trends and anomalies for Medicaid overall and within specific Medicaid programs.
  • Developing a structured process to trend utilization data for specific programs.

Completed milestones:

  • Gathered baseline data for prior authorization requests for private duty nursing and speech therapy.
  • Provided a prototype of the aggregate-level prior authorization deliverable to MCOs for input.
  • Developed proposals for increased sample size and services reviewed for Acute Care Unit Review and Long-term Services and Supports.
  • Gathered information to develop a standardized transaction-level prior authorization data tool with Texas Medicaid & Healthcare Partnership.
  • Obtained feedback from MCOs related to aggregated measures for prior authorization data.

Upcoming milestones:

  • Finalize aggregate-level prior authorization deliverable (Q1 FY2020).
  • Complete Uniform Managed Care Manual amendments about the new process for collecting prior authorization data from the MCOs (Q1 FY2020).
  • Initiate standardized due dates for prior authorization data files (Q2 FY2020).
  • Integrate service utilization monitoring into other oversight coordination functions (FY2020).
  • Implement member-level prior authorization data management solution for medical, dental and pharmacy services (FY2020).

Service and Care Coordination

This initiative’s goal is to improve service and care coordination within managed care. Activities include:

  • Analyzing other state Medicaid programs to assess best practices.
  • Addressing any state-level barriers that hinder MCO delivery of coordination services.
  • Simplifying terminology and definitions of service coordination and service management.
  • Identifying improvements to ensure service and care coordination is consistent within HHSC contract requirements.

Upcoming milestones:

  • Review all managed care contracts and manuals across programs for potential revisions to be in the next contract update (Q1 FY2020).
  • Update the HHS website to include an overview of service and care coordination for members within managed care programs (Q1 FY2020).
  • Develop managed care oversight tools related to service and care coordination (Q3 FY2020).
  • Develop educational tools and targeted training for MCOs and other case management entities (Q3 FY2020).

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