Managed Care Oversight Improvement Initiatives

Background

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

HHSC has several focused initiatives for improving managed care oversight. We post regular updates for these initiatives to this page.

Administrative Simplification

Established in February 2019, this initiative is focused on reducing Medicaid provider burden through administrative improvements in four areas:

  • Claims payments
  • Eligibility information
  • Enrollment processes
  • Prior authorization submissions

Activities and milestones are in development for this new initiative.

Complaints Process and Data Analytics

More effectively leverage complaints data to identify risks, increase program transparency and more efficiently identify potential problems in the Medicaid program or opportunities for improved MCO contract oversight.

  • Improve data collection and system processes used to trend and analyze managed care member complaints.
  • Standardize complaint categories used by HHSC and MCOs for more accurate trending of complaints-related data to more quickly identify potential problems within managed care.
  • Document the current journey through the complaints process and identify how to streamline and effectively communicate the process for clients.

Completed milestones:

  • Document the current HHS member managed care complaints process, identifying entry points and opportunities to streamline.

Upcoming milestones:

  • Initial deployment of the new complaints process, including staff-facing changes (Q2 FY2019).
  • Publish a complaints report, as required of the HHS Office of the Ombudsman, to the HHS website (Q3 FY2019).
  • Finalize complaint category standardization (Q3 FY2019).
  • Execute contract changes related to complaints definitions (Q1 FY2020).
  • Deploy client-facing changes to the new complaints process (Q1 FY2020).

Network Adequacy and Access to Care

Build a comprehensive monitoring strategy to ensure client access to services.

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

Completed milestones:

  • All reviews of proposed new medical benefits now automatically consider the delivery of services through telemedicine.
  • Network adequacy monitoring allows MCOs to include telemedicine as part of their corrective action plans when network adequacy standards are not being met.
  • MCOs are required to validate provider directory errors identified during appointment availability studies.

Upcoming milestones:

  • A network adequacy performance dashboard using access to prenatal care services as a proof-of-concept is under development (Q3 FY2019).

Outcome-Focused Performance Management

Strengthen MCO partnerships through transparency and accountability.

Activities include:

  • Improve the MCO operational review process, including adding new modules to more accurately assess the full range of MCO performance.
  • Streamline review processes to minimize administrative burden.
  • Integrate managed care oversight across various functions to ensure oversight activities produce holistic assessments of MCO performance.
  • Review MCO deliverables to ensure reporting requirements provide meaningful information on targeted performance.

Completed milestones:

  • Identified enhanced program area processes and expectations related to the operational review process.

Upcoming milestones:

  • Revise existing operational review modules, develop new operational review models and analyze deliverables (Q2 FY2019).
  • Implement consolidation of MCO deliverables (Q3 FY2019).
  • Make changes to the Uniform Managed Care Manual and HHSC and MCO staff training (Q4 FY2019).
  • Implement expanded operational reviews (Q1 FY2020).

Strengthening Clinical Oversight

Strengthen the oversight of utilization management practices to include prior authorization policies and processes used by MCOs. Activities include:

  • Develop a new, standardized prior authorization data collection tool and process that will use member-level data.
  • Identify trends and anomalies for Medicaid services using prior authorization data and focus on trends within specific Medicaid programs.
  • Develop a structured process to trend utilization data for specific programs.
  • Enhance oversight to ensure consistent, medically appropriate approval of Medicaid services.
  • Expand staffing model to allow for increased scope and sample size for Utilization Review activities.

Upcoming milestones:

  • Gather information for the development of a standardized prior authorization data collection tool (Q3 FY 2019).
  • Complete Uniform Managed Care Manual amendments about the new process for collecting prior authorization data from the MCOs (anticipate Q4 FY2019).
  • Initiate the standardized due dates for prior authorization data files (anticipate Q2 FY2020).

Service and Care Coordination

This initiative is focused on improvements related to service and care coordination within managed care. Activities include:

  • Analyze other state Medicaid programs to assess best practices for care coordination within Texas’ managed care programs.
  • Address any state-level barriers that hinder MCO delivery of care coordination services.
  • Simplify terminology and clarify definitions of service coordination and service management activities across product lines.
  • Identify possible improvements to ensure service coordination and service management is consistent within HHSC contract requirements.

Upcoming milestones:

  • Analyze other state Medicaid programs to assess best practices for care coordination within Texas’ managed care programs (Q3 FY2019).
  • Develop managed care oversight activities related to service and care coordination (Q3 FY2019).
  • Review all managed care contracts and manuals across product lines for potential revisions in the next contract update (Q4 FY2020).

Email questions or feedback to: MedicaidManagedCare@hhsc.state.tx.us.

Presentations

Deloitte Presentation Rider 60 and 61a (PDF)

Deloitte Presentation Rider 61bcd (PDF)

Rider 60 Addendum Q&A (PDF)