Inconsistent data found in MCO’s provider appeal reports

A recent inspection of a managed care organization (MCO) reviewed whether appeals for denied claims filed by providers are properly processed and resolved in a timely manner. Of the 120 Claims Summary Reports (CSRs) for FirstCare Health Plans that were inspected, 98% met specific requirements, including:

  • Tracking appeals.
  • Notifying providers of the appeal results.
  • Providing reasons when denying appeals.
  • Resolving all tested appeals within 30 days.

However, a review of archived detailed reports contained discrepancies that raised questions about the reliability of the submitted CSRs. Archived reports are used to create the CSRs submitted to Texas Health and Human Services and then stored in the MCO’s data warehouse. A comparison of the 120 CSRs and archived reports found 46 instances where the two reports did not match.

A further inspection of the discrepancies showed the CSRs submitted to HHSC were correct and the archived information was incorrect. FirstCare claimed the information in their archive had been changed after the reports were completed but had no reason for why or how they were changed.

Inspectors explained that without accurate, unaltered records, the integrity of the CSR submission process may be compromised and recommended strengthening processes and controls to prevent future unauthorized changes to archived reports.