As MCOs contend with more federal and state-level regulations, below are a few adjustments leaders can make to ensure compliance while Medicaid enrollees increase.
As COVID-19 continues to disrupt the economy and keep many out of work, and Medicaid expansion continues across the country, states must prepare for new strains on the Medicaid system.
According to a recent report from the Urban Institute, states that are expanding Medicaid can expect more than half of the people who are newly unemployed to join plans. In non-expansion states, one-third of those who lost employer-sponsored health insurance are likely to become eligible for Medicaid. As enrollees increase, Managed Care Organizations (MCOs) will be put to the test, especially when it comes to ensuring submitted encounter data are compliant, timely and accurate.
The healthcare industry often discusses encounter management in terms of risk adjustment and Medicare Advantage, but the reality is MCOs are under more intense encounter scrutiny than ever before, from the Office of the Inspector General (OIG) and even more so from state-level regulators’ compliance standards.
The OIG announced a planned study by 2021 of three to five states to determine if states had the required elements and steps to ensure that managed care encounter data is accurate and complete. The risk of noncompliance can be costly to the state (which could lead to reductions in Medicaid funding) as well as the MCOs themselves in the form of state-levied financial penalties.
As MCOs contend with more federal and state-level regulations, below are a few adjustments leaders can make to ensure compliance:
In the midst of widespread unemployment and continuous expansion to state Medicaid systems, MCOs are falling under increased scrutiny by both state and federal offices. Keeping these three elements in mind can mean the difference between struggling to update sub-optimal systems and being subjected to non-compliance penalties, and enjoying business continuity and continuous compliance.
Aaron Fulner is senior director at Edifecs focused on insurers involved in commercial, managed Medicaid, Medicare Advantage, and dual eligible programs.