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• 2014 Managed Care Transparency Report

  Details:

  August 31, 2016

  • Legislative & Governmental Relations
  • Medicaid
  • Managed Care

  Managed Care 1.0 Amerigroup Healthy Blue Community Health Solutions LaCare AmeriHealth Caritas Louisiana Healthcare Connections UnitedHealthcare Community Plan This report is the third in a series produced by the Louisiana Department of Health to satisfy statutory reporting requirements intended to ensure the following outcomes are being achieved by Medicaid managed care programs:  improved care coordination with patient-centered medical homes for Medicaid recipients;  improved health outcomes and quality of care;  increased emphasis on disease prevention and the early diagnosis and management of chronic conditions;  improved access to Medicaid services;  improved accountability with a decrease in fraud, abuse and wasteful spending; and  a more financially stable Medicaid program. The first and second reports included 23 measures as outlined in Act 212 of the 2013 Regular Legislative Session. The first report, submitted to the Legislature on January 2, 2014, covered July 2012 through June 2013 (State Fiscal Year 2013). The second report, submitted to the Legislature on December 31, 2014, covered January 2013 through December 2013 (Calendar Year 2013). The Department shifted the reporting periods, from State Fiscal Year (SFY) in the first report to Calendar Year (CY) in the second report, duplicating six months of the first report (January 2013 through June 2013). The shift in reporting periods provided for complete claims data given Act 212’s requirement of annual transparency report submission by January 1 and Medicaid’s timely filing policy which allows providers 365 days from the date of service to file a claim for payment. Act 158 of the 2015 Regular Legislative Session modified reporting requirements for the transparency report, adding three new measures and clarifying the reporting period. This third report includes 26 measures, and it covers July 2013 through June 2014 (State Fiscal Year 2014), duplicating six months of the second report (July through December 2013). All measures are reported on a fiscal year basis, except the following measures which are reported on a calendar year basis per the contract between the Department and the health plans:  Section 7 – Medical Loss Ratio  Section 8 – Health Outcomes  Section 9 – Member and Provider Satisfaction Surveys  Section 10 – Audited Financial Statements  Section 25 – Medicaid Drug Rebates Act 158 provides sufficient time for complete claims reporting for a state fiscal year by shifting the due date for report submission from January 1 to June 30. This report covers the original contracting period for the Medicaid managed care program (beginning February 1, 2012) which includes physical and basic behavioral health services provided by both fullrisk managed care organizations, called prepaid health plans and referred to in this document as managed care organizations (MCOs), and plans serving as primary care case management (PCCM) entities, referred to as shared savings health plans. Information included in this report was collected from multiple sources. The Medicaid Management Information System (MMIS) and the Management Administrative Reporting Subsystem (MARS Data Warehouse) are maintained by the Medicaid program’s contracted fiscal intermediary, which in State Fiscal Year 2014 was Molina Healthcare. The MMIS contains detailed recipient and provider information and the MARS Data Warehouse contains claims payment information. The state administrative system, called ISIS, is maintained by the Office of Technology Services within the Division of Administration and contains information on payments to health plans. The provider registry is maintained by Molina and contains information submitted by the health plans or their contracted providers. The provider registry is updated weekly with new information overwritten onto older information, which limits the utility of the data to point-in-time information. To the greatest extent possible, the data originate from state systems rather than the health plans. Where unavailable from state sources, data were collected from the health plans, sourced from either routine reporting deliverables or ad hoc reports requested specifically for this purpose. Data included in this report were independently validated by Myers and Stauffer, an audit contractor of the Department. Myers and Stauffer reviewed for reasonability the data extraction code or process that the health plans or the Department used to generate data. For data originating from the MARS Data Warehouse or the MMIS, Myers and Stauffer generated its own data for each health plan and compared its results to the results the Department produced. For data originating from the health plans, Myers and Stauffer reviewed plan responses to a survey developed by Myers and Stauffer to document the process the plans used to generate the data, as well as policies and procedures in place to collect, track and report data. Where Myers and Stauffer found inconsistencies above or below the 10 percent variance threshold established by the Department, they made recommendations to the Department and/or the health plan to improve the method used to collect data. See Appendix 14.IX for the survey instrument. To ensure maximum reliability, subject matter experts within the Department and Myers and Stauffer also reviewed the data. In some cases, the health plans also reviewed data pulled on their plans by the Department for reasonability. In addition, health plans’ internal policies and procedures for collection of data were validated by the Department’s contracted external quality review organization (EQRO), Island Peer Review Organization (IPRO), in conjunction with annual external quality reviews. An additional validation was performed by either the National Committee for Quality Assurance (NCQA) or the Utilization Review Accreditation Commission (URAC) as part of the contractually required health plan accreditation process. Plans are contractually required to obtain accreditation from either NCQA or URAC for their Bayou Health plan serving Louisiana members. All Bayou Health plans have obtained accreditation from these national accrediting bodies, which are rigorous processes involving comprehensive reviews of the plans’ policies, procedures and practices.

  Downloadable Assets:

  2014 Managed Care Transparency Report Appendix 14.I: Total Number of Health Care Providers (Section 4) Appendix 14.II: Primary Care Service Providers (Section 5) Appendix 14.III: Contracted Providers with Closed Panels (Section 6) Appendix 14.IV: Number of enrollees who received services from each Managed Care Organization (Section 15) Appendix 14.V: Total number of denied claims (Section 20) Appendix 14.VI: Total number of clean claims (Section 21) Appendix 14.VII: Claims paid to out-of-network providers (Section 23) Appendix 14.VIII: Pharmacy benefits by month (Section 24) Appendix 14.IX: MSLC Survey