The Medicare & Medicaid Managed Care Lifecycle

With the ever-increasing growth of Medicaid and Medicare managed care, Direct Care Innovations is at the forefront of providing solutions that help agencies navigate these complex systems. On average, 100 million enrollees receive federal health benefits, representing a significant portion of the CMS budget. The Office of Inspector General (OIG) has released a strategic plan prioritizing managed care oversight. This plan addresses the risks and vulnerabilities of Medicaid/Medicare managed care, including fraud, waste, and limited access to quality care.

Plan Establishment & Contracting

Effective fiscal oversight of Medicare and Medicaid begins with new managed care plans or the renewal of continual contracts. When information in MCO/CMS contracts is inaccurate or managed care plans are not following established contracts, there is an increased risk that enrollees will not receive quality or sufficient services. Other plan and contract areas to be reviewed may include the enrollee process, various contracts between states and CMS, and the fidelity of plan bids.

Enrollment

There are times when Medicare Advantage organizations use problematic marketing methods to attract new Medicare enrollees. They may advertise incorrect information that can lead enrollees not to receive the services for which they are qualified. The enrollment process may also lead to misinformation reported by enrollees, whether accidentally or purposefully, resulting in missed payments, limited access to services, and other enrollment issues. 

Payment

In traditional managed care plans, CMS pays fixed monthly payments to private insurance plans and/or health care providers, which are required via contracts. Organizations and providers may deliberately make false diagnoses or abuse enrollees’ rights to plan-covered care to maintain higher profits. The OIG continues to investigate these fraudulent types of health care practices and others, such as deceptive billing methods and neglect of patient care. 

Services to People

The fourth part of the Managed Care Life Cycle prioritizes high-quality care and access to services for enrollees. Some managed care plans contain restrictive regulations that intentionally limit patients’ rights to medical care while increasing their profits and reducing medical costs. To ensure enrollees are provided services covered by their plans, the OIG will review ineligible or excluded providers, specific coverage determinations, and nontraditional or flexible benefit options such as fitness memberships.

Prioritize the Efficiency of Your Managed Care Organization

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“Managed Care,” Office of Inspector General, U.S. Department of Health and Human Services, last modified August 27, 2024
https://oig.hhs.gov/reports-and-publications/featured-topics/managed-care/.