LDH Unable to Ensure Reliability of Medicaid Provider Data Received from Managed Care Organizations

The Louisiana Department of Health (LDH) needs to strengthen the processes it uses to ensure the reliability of the provider data submitted by the managed care organizations (MCOs) in their encounter claims.

The MCOs provide medical services for the State’s Medicaid program. Without reliable data, auditors said, LDH cannot effectively monitor the MCOs or reduce the risk of improper Medicaid payments.

As part of their work, auditors in the Medicaid Audit Unit examined encounter claims at LDH covering the period from February 2012 to December 2017.

Auditors found that LDH did not ensure the MCOs used valid provider type and specialty combination codes as required and identified 194,376 claims totaling $13,091,888 with an invalid combination of provider type and specialty code. As a result, LDH cannot determine if appropriate providers actually provided the services.

In addition, LDH accepted encounter claims from the MCOs when the Provider Registry file indicated the contracted provider was not enrolled with the MCO on the date of service. Auditors found $136 million in such encounters between February 2012 and December 2017. LDH also could not ensure the encounter data captured the correct provider location because the Provider Registry file allows only one location per provider. According to the registry site file, 28,295 providers had multiple sites. That means LDH cannot determine where services were actually provided.

While LDH developed a process to ensure providers who were paid for services were properly identified, auditors said, the Department did not use the process to deny encounters with insufficient provider information. Auditors identified 9 million encounters totaling approximately $587 million from September 2015 through December 2017 in which the provider could not be linked with an MCO health plan but was accepted into LDH’s data system. If a provider’s information about the encounter is not linked to a health plan, LDH cannot determine if the provider was allowed to perform the services.

Auditors found as well that LDH did not ensure the MCO encounter data had valid provider identification numbers. Approximately 366,000 encounters totaling $43.5 million from February 2012 through September 2015 had a provider identification number of “9999999,” while about 41 million encounters totaling $2.41 billion from October 2015 through December 2017 had a provider identification number of “0.” As a result, LDH cannot fully identify the provider to determine if the medical service was allowed to be performed by that provider.

LDH also has not implemented a single provider registry for all providers enrolled in the state Medicaid program as required by federal guidelines. The Department did not meet the January 2018 deadline from the federal Centers for Medicare and Medicaid Services but is working toward establishing the registry.