One of the main components of the Technical Manual is detailed technical documentation for the MCO submission of encounter data (member level service utilization). The enhanced documentation and formalized processing promotes consistency and accuracy in the encounter data. Encounter data is vital to Agency operations and is used for provider program integrity investigations, pharmacy rebate collection, focused quality studies, and reporting to CMS.
In addition, the Technical Manual also contains extensive documentation for every deliverable in the current Medallion II contract. Specifications are provided for each deliverable, including format, naming conventions, content, valid values, ...view middle of the document...
MCO Program Integrity Referral Process
• Collaborative approach, program integrity reports and reporting processes standardized for efficiency and accuracy
• New reporting matrix developed – used to notifying DMAS of Program Integrity referrals – since developing the new reporting matrix in March, the Department has received a total of 7 credible cases; 6 Provider Investigations and 1 Recipient Fraud.
• Enhanced oversight, and teamwork with MCOs and b/t divisions (and MCFU) to achieve comprehensive PI reporting & concrete referrals
Improper Payments to Providers
While prevention of improper payments has been a common practice among the MCOs for a number of years, the structured approach set forth by DMAS has enabled more standardized processes and measurable results across the Medicaid program. For calendar year 2013, MCOs avoided or recovered over $4 billion dollars. This is up from calendar year 2012, where only $1.5 billion was reported. Notably, the vast majority of these dollars were savings that resulted from preventative controls, which stop improper payments before they are paid.
The on-going work by the Virginia Managed Care Program Integrity Collaborative continues to monitor the propensity of higher costs of care, program spending levels, imposed beneficiary cost sharing and taxes triggered by fraud losses.
IX. Quality Focus
Ensuring that VA Medicaid members in the Managed Care program receive the highest level of quality of care is at the center of the MCO’s quality care management efforts. Three major elements of the Medicaid Managed...