Audit recommends improvements to speed payments to nursing facilities

The OIG conducted an audit of State of Texas Access Reform PLUS (STAR+PLUS) nursing facility claims paid by UnitedHealthcare Community Plan (UnitedHealthcare), a managed care organization (MCO).

The audit was a follow-up to complaints of MCO payments to nursing facilities being delayed by more than 90 days and unprocessed retroactive adjustments related to nursing facility utilization review resource utilization group (RUG) rates.

UnitedHealthCare was one of five MCOs audited to address this concern. The audit objective was to determine whether UnitedHealthCare accurately and timely adjudicated qualified nursing facility provider clean claims in compliance with selected criteria.

UnitedHealthCare adjudicated almost 97% of clean claims within 10 days in calendar year 2018. However, UnitedHealthCare did not always (a) process RUG rate adjustments as required or (b) process other types of adjustments timely. Specifically, UnitedHealthCare processed only 21% of the identified RUG adjustments and as of January 16, 2020 had not processed the remaining 79% retroactive RUG adjustments. STAR+PLUS managed care organizations (MCOs) are required by contract to retroactively process RUG rate adjustments automatically no later than 30 days after receipt of a Texas Health and Human Services Commission (HHSC) notification. UnitedHealthcare implemented an automatic process to identify and process all retroactive RUG rate adjustments.

The OIG offered recommendations to UnitedHealthCare, which, if implemented, will result in UnitedHealthCare complying with its contractual requirements to automatically identify and process all retroactive adjustments within 30 days. Read the full report.