monitoring network adequacy and most common issues …...toby strong mcqa office auditor financial...

Monitoring Network Adequacy and Most Common Issues Found during Examination

Managed Care Quality Assurance Office and Quality of Care Examinations

Texas Department of Insurance

Monitoring Network Adequacy

2

Debra Diaz-Lara and Rita Martinez

TEXAS DEPARTMENT OF INSURANCE • 2018

Managed Care Quality Assurance- MCQA

TEXAS DEPARTMENT OF INSURANCE • 2018 3

Debra Diaz-LaraDirector - Managed Care Quality Assurance Office

TBDTeam Lead - Independent Review Organizations (IRO) and Utilization review Agents (URA)

Carolyn PowersTeam Lead - Network Adequacy, Form Review and Workers’ Compensation Health Care Networks (WCNet)

Nikki HoskinsTeam Lead - MCQA Technology and Administrative Support, Prompt Pay Reporting

Toby StrongMCQA Office Auditor

Financial Regulation Division

TDI Mission and Goals


TDI is a dynamic leader in state, national and global regulation, consumer protection and promotion of market viability through:

Regulating the insurance industry fairly and diligently

Promoting a stable and competitive market

Providing information that makes a difference

Effective communication with stakeholders to ensure a strong, positive, and legitimate insurance market

Developing regulatory tools/ processes that are adaptable, but permitted within our statutory framework

Network Adequacy Reviews


Certificate of Authority- Quality of Care Examinations

Service Area Expansion or Reduction- MCQA Office

Material Change or Network Configuration Change- MCQA Office

Examinations- Quality of Care Examinations, Market Conduct Examinations

Annual Network Adequacy Report- MCQA Office

• Audits

Complaints Received- MCQA Office

Network Adequacy Review


Health Maintenance Organizations (HMO)

Applicable Law &Rules

• TIC Chapter 843

• 28 TAC Chapter 11

• 28 TAC 11.1610 Annual Reports due August 15

• 28 TAC §11.1607 Accessibility and Availability Requirements

http://www.statutes.legis.state.tx.us/Docs/IN/htm/IN.843.htm

http://texreg.sos.state.tx.us/public/readtac$ext.ViewTAC?tac_view=5&ti=28&pt=1&ch=11&sch=Q&rl=Y

http://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=28&pt=1&ch=11&rl=1610

http://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=28&pt=1&ch=11&rl=1607



Network Adequacy for Preferred Provider Benefit Plans (PPBP) and Exclusive Provider Benefit Plans (EPBP)

Applicable Law & Rules

• TIC Chapter 1301

• 28 TAC Subchapter X

• 28 TAC §3.3704 Freedom of Choice Availability of Preferred Providers

• 28 TAC §3.3709 Annual Reports due April 1

• 28 TAC §3.3710 Failure to Provide an Adequate Network

Requests for Access Plans- required by rule, ensures enrollees get care

Narrow Networks- trending up over the last 3 years resulting in cost containment for carriers, however the network MUST be adequate

Network Configurations- material changes to a network


http://texreg.sos.state.tx.us/public/readtac$ext.ViewTAC?tac_view=5&ti=28&pt=1&ch=3&sch=X

http://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=T&app=9&p_dir=N&p_rloc=160665&p_tloc=14719&p_ploc=1&pg=5&p_tac=&ti=28&pt=1&ch=3&rl=3704

http://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=T&app=9&p_dir=N&p_rloc=160670&p_tloc=&p_ploc=1&pg=12&p_tac=&ti=28&pt=1&ch=3&rl=3704




Network Adequacy for Workers’ Compensation Health Care Networks (WCNet)

Applicable Law & Rules

• TIC 1305 Workers’ Compensation Health Care Networks

• 28 TAC §10.26 Modifications to Service Area

• 28 TAC §10.27 Modifications to Network Configuration

• 28 TAC §10.80 Accessibility and Availability Requirements





Quality of Care Examinations

Financial Regulation Division

Rita Martinez – [email protected]

512-676-6869




Types of Entities Examined

• Health Maintenance Organizations (HMOs)

• Exclusive Provide Benefit Plans

• Independent Review Organizations

• Worker’s Compensation Networks



Frequency of Examinations

• Statutorily Required

oQualifying – certificate of authority (COA) application

o Initial – one year after issuance of COA

o Triennial- every three years for HMOs

oQuinquennial – every five years for EPBPs

oReferrals from Other Divisions



HMO Common Compliance Issues



Complaint System



For an oral complaint, acknowledgement letter did not include a one-page complaint form that prominently and clearly states the form must be returned to the HMO for prompt resolution.

Complaint resolution letter does not contain a complete description of the HMO’s process for appeal as required in TIC Sections 843.254-843.258.



Clean Claims – Prompt Pay



Incorrect received date. Claims submitted electronically, the claim is presumed received on the date of the electronic verification of receipt by the HMO or the HMO's clearinghouse.

HMO used the processed date and not the “actual” paid date to determine if the claim was paid within the applicable statutory timeframe.



HMO did not pay prompt payment penalties to providers or to the Department.

HMO did not submit to the Department quarterly claims payment reports or for the HMO’s delegates.

HMO did not pay a non-contracted provider prompt pay penalties when provider provided emergency care or services that were not reasonably available from a network provider.



Provider Credentialing / Recredentialing



Current list of network providers show recredentialing was not completed within 36 months of the previous credentialing decision.

HMO did not provide a credentialing file for a provider listed on its current list of credentialed an contracted network providers.



For a group contract, a list of the providers contracted with the group and the date the provider joined the group was not provided with the credentialing file.

Recredentialing file did not include documentation of the previous credentialing date.



Network Accessibility and Availability



HMO does not have an adequate network for its approved service area, 30 miles for PCP and general hospital and 75 miles for specialty care and specialty hospitals.

HMO does not contract with hospital-based providers in the HMO’s contracted hospitals within the HMO’s approved service area.



Utilization Review Agent

Adverse Determination (AD)

Initial and Appeal



HMO/URA did not use the adverse determination template letters and forms approved by the Department.

The HMO or URA who issued the AD letters is not a licensed URA.



The URA did not afford the provider of record a reasonable opportunity to discuss the services under review prior to issuing the AD or appeal of an AD.

AD appeal acknowledgment letter did not include a list of relevant documents the appealing party must submit for review.



The AD notice did not include the most current IRO form, LHL009 / 1217.

IRO request for a life-threatening condition was not forwarded to the Department.



QI, Delegated Entities, Form Filings, and CAP



The Quality Improvement Program, did not include the active involvement of one or more enrollees who are not employees of the HMO.

The HMO’s Quality Improvement Committee did not include practicing physicians and individual providers.



The HMO did not file the executed delegation agreement with the Department 30 days after the agreement or amendment was executed.

The HMO did not monitor its delegated entity for compliance with all applicable statute and rules.



The HMO did not implement its corrective action plan (CAP) within 90 days from receipt of its final examination report.



Examination Tips

Examination Tips


Adhere to the due dates and if absolutely necessary request an extension prior to the due date.

Make sure to perform a quality check of the information you are submitting and also the information provided by your delegates.

Examination Tips


Begin preparing the CAP as soon as you accept a deficiency. You may implement the CAP prior to the examination closing.

Changes to adverse determination template letters and utilization review policies and procedures must be submitted for approval by using the URA Application Form, LHL005.


Questions?

monitoring network adequacy and most common issues …...toby strong mcqa office auditor financial...

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