Report: OHA falls short on fixing Medicaid payment problems

SALEM, Ore. (AP) – The secretary of state’s office says the Oregon Health Authority still needs to strengthen its efforts to detect and avoid improper Medicaid payments.

The office’s audit division on Wednesday released a follow-up report to a 2017 audit that found widespread problems in the Health Authority’s payment system for Medicaid.

The Statesman Journal reports that auditors found that two of the eight recommendations in the audit have been put in place and six recommendations have been partially implemented.

OHA officials agreed with all the recommendations.

The original 44-page audit, released in November 2017, found problems such as poor management of payment and eligibility issues and a lack of an agency-wide process to detect improper payments.

At the time, auditors also found the agency had about $88 million in avoidable expenses because of its backlog in determining eligibility for Medicaid recipients. Medicaid provided health insurance benefits to about one million low-income Oregonians in 2017.
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News release from the Oregon Secretary of State’s Office:

Follow-up Report on Oregon Health Authority Medicaid Program SALEM, OR — Today, Acting Secretary of State Leslie Cummings released a report showing the Oregon Health Authority (OHA) Medicaid program has made progress implementing some of the eight recommendations made in Audit Report 2017-25, “Oregon Health Authority Should Improve Efforts to Detect and Prevent Improper Medicaid Payments.”

In November of 2017, the Secretary of State released an audit of OHA that focused on Medicaid spending. The audit identified eight specific areas where the agency should make corrections. OHA agreed with all eight recommendations and began to implementation. All of the recommendations will help ensure taxpayer dollars are spent wisely within the Medicaid program, which represents approximately one out of every three dollars in state spending and provides vital medical coverage to the neediest Oregonians. About 25% of Oregonians participate in Medicaid.

The follow-up report found that the agency has fully implemented two of the eight recommendations and has made some progress toward implementing the remaining six. To date, OHA has:

Implemented a monthly reconciliation process to identify individuals who need their eligibility re-determined; Developed new Coordinated Care Organization contracts with improved OHA oversight and automatic penalties for non-compliance; and Contracted with vendors to provide improved testing of information technology system controls and validation of encounter data used in the rate setting process.

During the follow-up report investigation, OHA reported to auditors that they needed more time to finalize the implementation of five of the recommendations and had decided to only partially implement one of the recommendations.

Even though OHA has implemented a reconciliation process to identify individuals whose eligibility needs to be re-determined, the agency still faces a backlog in processing Medicaid applications. To address this, additional staff are being hired. This will also help ensure more timely eligibility reviews.

After the recommendations are implemented, program integrity efforts will require continuous improvement as the Medicaid program evolves. For example, OHA must gain a better understanding of the accuracy and completeness of the data used in the rate setting process beyond the planned improvements. Additionally, the agency needs to institute planned and adequate strategies for testing systems to ensure strong preventative controls exist. Other areas where ongoing work is needed include oversight of CCOs, review of Oregon Administrative Rules, application of data matching techniques, and reconciliation of eligibility systems.

“We are encouraged by the progress OHA has made to implement the audit’s recommendations,” said Acting Secretary of State Leslie Cummings. “But there is still more work to be done to ensure Oregon improves its efforts to prevent and detect improper payments within the Medicaid program.”

Read the full November 2017 audit and the full follow-up report on the Secretary of State website.