Federal Audit Faults Oregon’s Oversight of Medicaid Insurers

The Oregon Health Authority failed to hold four coordinated care organizations accountable to Medicaid rules that guide quality and access to health care, a federal audit has found.

Federal auditors found shortcomings in how coordinated care organizations license and oversee providers and how the networks handle grievances from clients concerned about their care. 

The U.S. Department of Health and Human Services audit, released Wednesday, focused on four unnamed coordinated care organizations that served Oregon Medicaid clients in 2016 and 2017. The health authority contracts with 15 coordinated care organizations to serve the 1.2 million Oregonians enrolled in Medicaid.

The health authority agreed with the recommendations, which included providing more guidance to coordinated care organizations about how to credential providers and handle grievances from people denied care.

“While flexibility that allows for innovation is part of how we approach running the Oregon Health Plan, clear contracts, reporting and enforcement also allow us to make sure members receive the care they deserve," authority Director Patrick Allen said in a statement. 

Allen said the agency’s goal in its current CCO plan is intended to hold the Medicaid networks more accountable while working on better results for people. That includes clear expectations in contracts, Allen said.

The audit found that coordinated care organizations failed to ensure that providers were properly credentialed and sometimes allowed them to operate outside the scope of their license. Coordinated care organizations also failed to report providers with licensing board actions against them, the audit said. 

In one instance, a coordinated care organization failed to monitor a  pediatric dentist in its network after the Oregon Board of Dentistry placed the provider on a restricted license in 2015. The board ordered the dentist to not do advanced advanced orthodontic work. In 2019, the dental board revoked the license and found the dentist a threat to public health and safety, auditors found. The coordinated care organization failed to report the provider to the health authority as required.

Audit documents don’t name the coordinated care organizations, but auditors picked one that serves rural clients, one with urban clients and two others that serve a mix of rural and urban people. 

On another front, the audit said coordinated care organizations did not resolve grievances from people concerned about access to dentists, non-emergency medical transportation services and primary care providers. For example, one patient complained to her coordinated care organization that a doctor she saw during a hospital stay asked why her primary doctor had not prescribed certain medication for her diabetes. A health care professional never reviewed the grievance as required and the patient switched doctors.

At times, the organizations reported incomplete or inaccurate information about appeals to the health authority for oversight purposes. This included summary data sets that didn’t match more extensive records on file.

Coordinated care organizations struggled to credential non-licensed staff who worked for mental health and substance abuse treatment providers. In one instance, a coordinated care organization received pushback from a provider, saying it was unnecessary because the state agency already certified the facility to provide outpatient addiction and mental health services. State agency officials told auditors that coordinated care organizations are to credential non-licensed mental health and substance abuse providers as certified drug and alcohol counselors.

Auditors recommended that the authority provide more guidance to coordinated care organizations about provider credentialing and grievances from clients and take steps to ensure that coordinated care organizations submit accurate and complete data on grievances and appeals.

Auditors also recommended that the health authority provide more guidance to coordinated care organizations about how to monitor subcontractors. Auditors want coordinated care organizations to no longer subcontract out the task of making a determination on final appeals from people seeking care.

The authority said it has already put improvements in place to address the problems, including increased requirements for coordinated care organizations to report on subcontractor performance and file quarterly reports on grievances and appeals. The authority said it has stepped up its enforcement and monitoring of contracts and issued three notices of corrective action since 2019.

Auditors found general compliance in other areas, such as the distance between patients and providers and how coordinated care organizations assigned primary care providers. 

You can reach Ben Botkin at [email protected] or via Twitter @BenBotkin1


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