Mitigate Compliance Risks by Addressing These Key Documentation and Billing Challenges for Medicaid Managed Care Plans

More state Medicaid programs are now addressing SDOH through managed care plans and Section 1115 demonstration waivers. However, while these Medicaid programs offer states the ability to experiment and innovate through various approaches, several compliance and regulation challenges must be reconciled.

Traditionally, concentrated efforts to improve health looked to the healthcare system to drive improvements. However, that outlook is changing with an increased recognition from healthcare leaders that these improvements cannot happen without addressing larger non-medical social determinants of health (SDOH).

The Centers for Disease Control and Prevention (CDC) broadly defines SDOH as the conditions in the places where people live, learn, work and play. This includes factors such as employment, socioeconomic status, education, social support networks, and an individual’s neighborhood or physical environment—not to mention access to healthcare. Although Medicaid funds could not traditionally be used to pay for non-medical benefits to target SDOH, more state Medicaid programs are now addressing SDOH through managed care plans and Section 1115 demonstration waivers.

In fact, according to a recent article in Health Affairs, approximately 40 states currently incorporate SDOH-related activities ranging from food, housing, transportation insecurity or other related concepts that affect wellness and community health. While these Medicaid programs offer states the ability to experiment and innovate through various approaches, several compliance and regulation challenges must be reconciled.

At Medecision’s 2019 Liberation event—an exclusive three-day gathering of healthcare leaders designed to explore how innovation and disruption come together to solve the biggest challenges in healthcare—this topic was discussed in detail by Frank Micciche, vice president of Public Policy and Communications for the National Committee for Quality Assurance (NCQA).

Overarching Challenges 

Micciche says that there are no shortage of benefits to state Medicaid programs and Medicaid managed-care plans that address SDOH. He says that these benefits could be social services, employment services or any number of programs that would allow a person to follow through on the care they’re being offered while managing their day-to-day living activities.

However, Micciche says that challenges around documentation, coding and billing for nonmedical benefits to state Medicaid programs and managed care plans can be significant. One key challenge lies in coding.

“Everything is coded to the nth degree on the medical side to the frustration of pretty much everyone involved,” he says. “But we don’t have these kinds of codes in place for some of these SDOH services.” Though he notes that United Healthcare and the American Medical Association, among others, are working on developing codes that would apply to these services, this remains a work in process.

“The challenge is that providing the services does have a cost,” Micciche explains. “So, as a plan, a provider or a social services organization, you want to make sure you’re getting reimbursed for that cost or at least able to demonstrate that you’ve provided that cost.”

Similarly, another problem revolves around effectively tracking the management of an individual’s care. “Whether it’s medical or nonmedical, if you can’t track it, you can’t relay that information to everyone involved in the management of an individual’s care,” Micciche says. “If you’re not tracking it and can’t identify the holes in their treatment, then the whole concept of a wraparound level of services loses a lot of its value.”

Micciche says that there is also a need to elevate the business acumen of some social service providers. This is both a challenge and a strategy that Medicaid managed care plans can use to mitigate compliance risks.

“Individuals in community-based organizations are often not skilled in ICD-10 codes and all the other arcana of Medicaid and healthcare in general,” he explains. “So to the degree that technology or organizations like NCQA can help, we’re developing programs that will allow us to accredit these community-based organizations. If we can increase their sophistication without distracting them too much from their role in providing these services, that can be a benefit to everyone involved—the plans, the individuals receiving the services and to the Medicaid programs themselves.”

Strategic Leaps Forward

However, to address some of these complex compliance and regulation challenges, broad cooperation is required. With the growth of Medicaid managed care, CMS, states and providers must work together to develop a standardized set of best practices to prevent fraud, waste and abuse. Of course, with the 2016 Medicaid Managed Care final rule, CMS increased and standardized program integrity and other program oversight requirements.

However, states must create a monitoring system that scrutinizes the integrity of their programs, including the criteria for identifying fraud and the methods for verifying that billed services were provided. Additionally, according to a report from Bloomberg Law, each state is required to establish a single identifiable entity, separate from the Medicaid program, to investigate and prosecute Medicaid fraud.

Micciche says that the NCQA also has a program that certifies that community-based organizations are providing coordinated care. “This gets back to the idea that business acumen and setting up standards of what good care looks like is —particularly in the long-term services and supports area.”

Although there is more work to do in mitigating compliance risks, Micciche says that plans are very motivated to improve their quality, adding that financial incentives can be very legitimate tools.

“The fact that there is reimbursement involved makes me very optimistic that programs will figure it out,” Micciche adds.