2022-067a ? In amendment 5 with the health plans, signed in the fall of 2021, EOHHS strengthened its contractual requirements with the health plans by requiring the plans to reconcile differences between claims submitted and accepted via the encounter submission process to encounterable claims as re...
2022-067a ? In amendment 5 with the health plans, signed in the fall of 2021, EOHHS strengthened its contractual requirements with the health plans by requiring the plans to reconcile differences between claims submitted and accepted via the encounter submission process to encounterable claims as reported in the quarterly financial data cost reports within 0.1%. The contract at section 2.13.02.04 includes the following language: ?Contractor is responsible to reconcile Financial Data Cost Report (FDCR) cost allocations and the File Submission Report (FSR), which contains the encounter data reporting outlined above. The reported Incurred Expenditures submitted in the File Submission Report must align with the sum of the Direct Paid, Non-State Plan Paid, and Subcapitated Proxy Paid expenditures submitted in the Financial Data Cost Report for each state fiscal year within the point one percent (.1%) threshold. The FSR and FDCR used for this comparison will include the same paid run-out period. Failure to meet threshold will result in financial penalty and/or corrective action by EOHHS as outlined in ?Rhode Island Medicaid Managed Care Encounter Data Methodology, Thresholds and Penalties for Non-Compliance.?? Achieving this level of compliance has proven more difficult than anticipated. To date, EOHHS has not imposed any financial penalties as a result of this new requirement. We have, however, worked proactively with the health plans to resolve outstanding issues and reconcile differences. EOHHS staff meet with managed care staff regularly throughout the month to resolve issues that arise during the claims submission process and to determine the root cause for claim rejections. This work is ongoing. EOHHS plans to further strengthen its oversight and improve plan compliance with the procurement of the managed care contracts. That revised encounter data quality plan, which is subject to further modification into the fall as we prepare the revised procurement documentation, is available on EOHHS?s website, here: https://eohhs.ri.gov/sites/g/files/xkgbur226/files/2021-10/4.1-rhode-island-medicaid-managed-care-encounter-data-quality-measurement-20210826.pdf Anticipated Completion Date: Ongoing Contact Person: Bill McQuade, Chief of Program Analytics Executive Office of Health and Human Services bill.mcquade@ohhs.ri.gov 2022-067b ? Over the course of the last two FY audits, EOHHS continued to make improvements to automatically identify and terminate Medicaid eligibility for deceased individuals. EOHHS has completed root cause analysis and has submitted business requirements for SFY24 Annual Planning to resolve downstream issues in the MMIS when Date of Death (DoD) is not received from RI Bridges or associated interface. EOHHS has submitted both an interim business plan (IBP) and permanent system interface modification to align date of death data between RI Bridges and MMIS. Anticipated Completion Date: Ongoing. IBP is scheduled for implementation in June 2023, while the permanent system modification will be scheduled later in CY2024 post SFY24 annual planning decisions. Contact Person: Brian Tichenor, RIBridges Medicaid Administrator Executive Office of Health and Human Services brian.tichenor@ohhs.ri.gov