Managed Care Oversight Improvement Initiatives


HHSC contracted with an independent consultant, Deloitte, to evaluate potential improvements to the agency’s oversight of managed care organizations in compliance with Rider 61, General Appropriations Act, 85th Legislative Session. The subsequent Rider 61(b) report completed by Deloitte outlined several opportunities for strengthening oversight of the Texas Medicaid program.

As a result of the report, HHSC undertook multiple initiatives to make improvements to managed care oversight. Goals of the initiatives and key accomplishments are below.

Clinical Oversight and Administrative Simplification

This initiative has two goals:

  • Strengthen the oversight of utilization management practices to include prior authorization policies and processes used by MCOs.
  • Ease administrative burdens currently experienced by MCOs, providers and members in Medicaid programs.

Key Accomplishments:

Streamlined processes for MCOs

  • Promoted consistency across MCOs through private duty nursing (PDN) training and developing a standardized prior authorization data collection tool.
  • Developed guidance for MCOs on claims project deliverables associated with nursing facilities.

Expanded use of data

  • Developed an enhanced process to trend utilization data for specific programs.

Complaints Process and Data Analytics

This initiative focuses on evolving the managed care member and provider complaints process to streamline intake and tracking, more effectively leverage complaints data to identify risks and improve quality of services.

Key accomplishments:

  • Improved the HHSC complaints intake and resolution process.
  • Standardized definitions and data categorizations across HHSC, MCOs, and DMOs.
  • Revised MCO and DMO self-reported data requirements.
  • Communicated process changes and timelines to members and providers.

Network Adequacy and Access to Care

This initiative’s goal is to build a comprehensive strategy to ensure members have access to providers at the right time and place. This includes:

  • Improving the accuracy of provider directories.
  • Incentivizing the use of telemedicine services.
  • Reducing administrative burdens related to network adequacy reporting and monitoring.

Key accomplishments:

  • Streamlined the contractual remedies process related to MCOs meeting network adequacy requirements (Corrective Action Plans and exception requests).
  • Contracted with Texas A&M University to develop a cost-effectiveness methodology to evaluate telemedicine and telehealth services.
  • Worked with stakeholders to develop new network adequacy measures for personal attendant services and treatment of substance use disorder.
  • Executed a Memorandum of Understanding with Texas Department of Insurance to:
    • Reduce duplication of MCO/DMO oversight activities.
    • Review and revise similar reporting requirements.
    • Share information between agencies on oversight findings.
    • Identify additional opportunities for collaboration.

Outcome-Focused Performance Management

This initiative focuses on bolstering oversight tools related to comprehensive MCO on-site reviews and reporting efficiencies. This includes:

  • Improving the MCO operational review process by expanding the scale of biennial MCO on-site reviews to include finance and reporting, quality, and pharmacy.
  • Streamlining review processes to minimize administrative burden.

COVID-19 impacted efforts to implement some modules designed to include in-person components that had to be reconsidered because of the pandemic.

Key accomplishments:

  • Transitioned multiple deliverables to HHSC’s centralized portal for MCOs, TexConnect, allowing for ongoing review to ensure reporting requirements provide meaningful information on targeted performance.
  • Monitored MCOs and addressed performance issues with the plans.
  • Completed operational reviews utilizing current monitoring information and tools, leveraging virtual engagements.

Service and Care Coordination

This initiative’s goal is to improve service and care coordination within managed care.

Key accomplishments:

  • Updated the HHS Long-term Care Provider Web-based Training webpage to include an overview of service and care coordination for members within managed care programs.
  • Reviewed all managed care contract and manuals across programs for potential revisions to be in the next contract update.

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