Office of the Legislative Auditor - Financial Audit Division

Report Summary
Managed Care Organizations: Encounter and Claims Data Reporting

The Department of Human Services (DHS) is responsible for overseeing Minnesota’s public health care programs, and the department contracts with managed care organizations (MCOs) to provide certain administrative functions and services to program enrollees. For calendar year 2017, eight MCOs reported about $4.8 billion in medical expenses for MinnesotaCare, the Prepaid Medical Assistance Program, and the Special Needs Basic Care program.

The Office of the Legislative Auditor conducted this audit to determine each MCO’s compliance with selected legal and contract requirements to report patient encounter and medical claims data to DHS. Our audit scope focused on a sample of encounter data and payments to medical providers reported by the MCOs for these Minnesota health care programs for calendar year 2017.

Conclusions

For the sample encounter records that we tested, HealthPartners, Hennepin Health, Itasca Medical Care, PrimeWest Health, South Country Health Alliance, and UCare Complied with selected DHS reporting requirements, and the payment information was accurate and complete. Blue Plus and Medica also Generally Complied with these requirements, although we found a small number of exceptions.

Findings

• For 1 of 60 claims that we audited (2 percent), Blue Plus did not comply with a Department of Human Services contract requirement to report denied claims for payment.
• For 5 of 60 claims that we audited (8 percent), Medica did not comply with Department of Human Services contract requirements to report paid and denied claims for payments or to submit encounter data timely.