Audit recommends MCO payment improvements
The OIG conducted an audit of State of Texas Access Reform PLUS (STAR+PLUS) nursing facility claims paid by Superior HealthPlan, Inc. (Superior), a managed care organization (MCO).
The audit was a follow-up to complaints of MCO payments to nursing facilities being delayed by more than 90 days and unprocessed retroactive adjustments related to nursing facility utilization review resource utilization group (RUG) rates.
Superior was one of five MCOs audited to address this concern. The audit objective was to determine whether Superior accurately and timely adjudicated qualified nursing facility provider clean claims in compliance with selected criteria.
Superior adjudicated an average of over 99.99% of clean claims within 10 days in calendar year 2018 and met the clean claim adjudicated timeframe as required by its Uniform Managed Care Contract. However, Superior did not always (a) process RUG rate adjustments as required or (b) process other types of adjustments timely. Specifically, Superior did not process $207,941 in net RUG rate adjustments, and for 22 (73%) of 30 other types of adjustments tested, Superior did not process the adjustments totaling $1,266 timely, which caused delays in payments to nursing facilities that ranged from 31 to 661 days.
The OIG offered recommendations to Superior, which, if implemented, will result in Superior complying with its contractual requirements to automatically identify and process all retroactive adjustments within 30 days. Read the full report.