Managed Care Oversight Improvement Initiatives


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

This initiative is focused on reducing Medicaid provider burden through administrative improvements in four areas:

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

Upcoming milestones:

  • Review and begin implementation of legislation impacting prior authorization information and submissions (Q4 2019).
  • Develop proposed provider education modules on core business functions to include claims and prior authorization submissions (Q1 2020).

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.
  • Initial deployment of the first phases of the new complaints process.

Upcoming milestones:

  • Publish a complaints report, as required of the HHS Office of the Ombudsman, to the HHS website (Q4 FY2019).
  • Execute contract changes related to complaints definitions (Q1 FY2020).
  • Deploy client-facing changes to the new complaints process (Q1 FY2020).
  • Finalize complaint category standardization (Q2 FY2020).

Network Adequacy and Access to Care

Build a comprehensive monitoring strategy to ensure members have timely access to the services they need.

  • Improve the accuracy of provider directories, including more robust MCO validation requirements and improvement 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, 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.
  • 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.
  • Legislation passed to expand the use of telemedicine and telehealth services.

Upcoming milestones:

  • Implement new contract requirements to strengthen provider directory accuracy (Q1 FY2020).
  • Develop a cost effectiveness methodology for evaluating telemedicine and telehealth services. (Q2 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 is under development (Q2 FY2020).
  • Implement strategies to reduce administrative burden for providers and managed care organizations when updating provider directory information (Q3 FY2020).
  • Conduct procurement for automated network adequacy tool and performance dashboard technology (Q4 FY2020).

Outcome-Focused Performance Management

Strengthen MCO partnerships through transparency and accountability.

  • 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.
  • Revised existing operational review modules.
  • Developed new operational review modules and deliverables.

Upcoming milestones:

  • Implement consolidation of MCO deliverables (Q3 FY2019).
  • Implement 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.

  • 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.

Completed milestones:

  • Developed proposals for increased sample size and services reviewed for Acute Care Unit Review and Long-Term Services & Supports
  • Gathered information for the development of a standardized prior authorization data collection tool
  • Obtained feedback from MCOs related to aggregated measures for prior authorization data.

Upcoming milestones:

  • Develop medical aggregated prior authorization data collection form (Q4 FY2019).
  • Complete Uniform Managed Care Manual amendments about the new process for collecting prior authorization data from the MCOs (Q4 FY2019).
  • 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 and reporting for medical, dental and pharmacy services (pending funding determination) (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:

  • Update HHSC Website to include outward facing overview of service and care coordination within Texas’ managed care programs (Q4 FY2019).
  • Develop managed care oversight tools related to service and care coordination (Q4 FY2019).
  • Review all managed care contracts and manuals across product lines for potential revisions in the next contract update (Q4 FY2019).

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