OIG audit examines payments to nursing facilities

OIG conducted an audit of State of Texas Access Reform PLUS (STAR+PLUS) nursing facility claims paid by Cigna-HealthSpring, a managed care organization (MCO). The audit was a follow-up to complaints of nursing facilities payments being delayed by more than 90 days and unprocessed retroactive adjustments.

Cigna-HealthSpring was one of five MCOs audited to address this concern. The audit objective was to determine whether the MCO accurately and timely adjudicated qualified nursing facility provider clean claims in compliance with selected criteria.

Cigna-HealthSpring adjudicated an average of over 99.8 percent 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, Cigna-HealthSpring did not always (a) process resource utilization group rate adjustments as required or (b) process other types of adjustments timely.

OIG offered recommendations to Cigna-HealthSpring, which, if implemented, will result in the MCO complying with its contractual requirements to automatically identify and process all retroactive adjustments within 30 days. Read the full audit here. https://oig.hhsc.texas.gov/sites/default/files/documents/cigna-healthspring-nf-claims-final-8-26-20.pdf