Be audit-ready:
Are your oversight practices strong enough?

Answer 10 questions about your managed care organization oversight practices to get an expert recommendation.

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A better relationship between PI units and the contracting agency is key for good contract oversight and could lead to PI units providing input on future contracts.

Ongoing review of data from other agencies, like income or licensing information, is key for discovering who should be ineligible to receive benefits or payments.

It's important to validate encounter data to allow your PI unit to perform analytics with confidence.

Penalties can be an effective tool for encouraging compliance — but only if PI units are willing to use and enforce them.

It's important to review all overpayments to ensure they are categorized correctly as administrative or non-administrative.

You don't want to be on the hook for paying suspended providers. If you pay a suspended provider, the federal government is entitled to collect their share of the payment from your agency.

Many MCOs don't share the cases they are pursuing, but you should encourage open communication. The PI unit is often in a better position to help coordinate investigations.

Coordinating investigations is key for agencies and governments to use their limited resources effectively. Effective coordination provides opportunities to collaborate and develop strategies for routing out bad actors.

Federal requirements mandate that MCOs impose payment suspensions immediately, but it's critical to verify network adequacy (the availability of providers) first. Suspending rare types of providers can cause care interruptions and create issues for MCOs.

Deep audits of MCO activities may seem impractical if you have limited resources, but compliance plans should be a top priority.

Question 1 of 10

Does your program integrity (PI) unit or Inspector General's office meet regularly with the state agency unit that oversees your managed care contract?

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Question 2 of 10

Do you regularly check databases at your fellow state agencies to ensure member eligibility status and provider enrollment is proper?

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Question 3 of 10

Does your PI unit regularly validate encounter data from managed care organizations (MCOs)?

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Question 4 of 10

Does your PI unit penalize MCOs if they don't comply with PI reporting requirements?

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Question 5 of 10

Does your PI unit regularly analyze overpayments that MCOs recover from providers?

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Question 6 of 10

Does the PI unit regularly conduct data analysis to ensure MCOs are not paying providers who were suspended due to a credible allegation of fraud?

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Question 7 of 10

Do the MCOs you work with keep you informed about their fraud, waste and abuse investigations?

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Question 8 of 10

Do you notify all the MCOs and the Medicaid Fraud and Control Unit about all known investigations conducted by MCOs or the state?

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Question 9 of 10

Do you ask MCOs about network adequacy before payment suspension and then audit the MCOs to ensure that they immediately suspended the provider?

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Question 10 of 10

Do you audit the compliance plans for MCOs or other federal requirements annually?

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Your MCO oversight practices leave you vulnerable

Your MCO oversight practices have room to grow

Your MCO oversight practices are strong


Let's help you improve

Your program integrity may have some gaps that need to be addressed. Watch the video to hear from expert consultant Dennis Garvey about why it's important to consider seeking an outside perspective.

Program integrity consulting with experts like Dennis can help you quickly identify the best ways to improve your program integrity.

Let's get started

You're making an effort to be good stewards of public resources, but there's room for improvement. Watch the video to hear from expert consultant Dennis Garvey about why it's important to continue striving for improvement.

Program integrity consulting with experts like Dennis can help you quickly identify the best ways to take your program integrity to the next level.

Let's help keep it that way

Your program integrity is well-rounded, and you're taking good care of the resources you're providing oversight for. Are you covering everything, though? Hear from expert consultant Dennis Garvey about why it's important not to get complacent.

Program integrity consulting with experts like Dennis can help you sustain and strengthen your program integrity even further.

Let's help you improve

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Let's help keep it that way