Audit summary highlights recommendations to MCOs

The OIG completed a summary of five recent audits of State of Texas Access Reform PLUS (STAR+PLUS) nursing facility claims paid by the five Texas MCOs that participate in the STAR+PLUS program. The OIG conducted these audits as a follow-up to complaints of nursing facility payments from MCOs being delayed by more than 90 days and of unprocessed nursing facility utilization review resource utilization group (RUG) rate retroactive adjustments.

These five audits focused on (a) clean claim payments made more than 90 days after the received date, (b) retroactive adjusted claim payments made more than 30 days after receipt of the SAS notice, and (c) unprocessed nursing facility utilization review RUG rate retroactive adjustments. The scope of the audits included clean claims received during fiscal year 2018, including run-out of retroactive adjustments through April 13, 2019.

The populations for the five MCO audits were outlier claims initially paid past the 90-day requirement. For these audits, outlier claims are considered nursing facility claims for the same member and service dates with more than 90 days between (a) the date the claim was first received and (b) the date the final payment is made. Based on self-reported information, the audited MCOs paid most clean claims timely. Although the MCOs adjudicated most clean claims within required timelines, in all five audits, MCOs did not always (a) make payment adjustments timely or (b) make retroactive utilization review adjustments timely or at all.

The OIG tested a statistically valid sample of 30 adjusted claims identified as outliers for each MCO. That testing identified high error rates, indicating that the five MCOs did not process adjustments within required timeframes. Specifically, within the samples, payments associated with adjustments that were not processed timely resulted in delayed payments to nursing facilities ranging between 31 days and 671 days. Significant delays in payments to nursing facilities could impact the nursing facilities’ ability to operate and provide quality care to residents. The OIG recommended that the MCOs ensure their processes effectively identify and process all retroactive claims adjustments within 30 days of an HHSC SAS notice. All five MCOs indicated that, before the reports were issued, they had already strengthened their processes to ensure adjustments are processed within 30 days.

In addition, MCOs did not consistently process retroactive OIG nursing facility utilization review RUG rate adjustments as required. As of January 2020, the MCOs had not processed expected outstanding adjustments. Specifically, they had not processed $363,259 in adjustments expected to increase payments to nursing facilities and $2,563,294 in adjustments that were expected to reduce prior payments, and therefore, would result in overpayments that were due back to HHSC. When combined, those changes resulted in a net estimated overpayment amount of $2.2 million. The MCOs asserted that, among other things, reasons for not having processed the adjustments included experiencing difficulties with the update file format and confusion determining which update file is current. In October 2020, TMHP changed the location of some files the MCOs use to distribute and submit SAS record changes.

As of May 28, 2021, all the MCOs had made significant progress toward processing outstanding adjustments and improving their processes to ensure adjustments are processed timely. Read the full summary on the OIG website.