Office of the Legislative Auditor - Financial Audit Division

Report Summary
Managed Care Organizations: Reporting of Dental and
Mental Health Encounter Data

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 enrollees. To manage dental and mental health benefits services under these programs, several MCOs contract with third-party administrators. For calendar year 2018, eight MCOs reported $5.2 billion in expenses for medical benefits and other professional services. Our audit scope represented a small percentage of total services for this time period. For example, on average, MCO dental expenses accounted for about 3.1 percent of total 2018 reported Medicaid expenses. The average monthly enrollment for MHCP in 2018 was approximately 961,000 individuals for all MCOs.

The Office of the Legislative Auditor (OLA) audited these eight MCOs to determine their compliance with key legal and DHS contract requirements regarding MCO oversight of third-party administrators for dental and mental health services and reporting of dental and mental health encounter claims data to DHS. Our audit scope focused on DHS contracts and samples of payments to providers reported to DHS by the MCOs during calendar years 2017 and 2018.

Conclusions

Blue Plus, Hennepin Health, Medica Health Plans, South Country Health Alliance, and UCare Minnesota complied with the legal and DHS contract requirements we tested for oversight of their respective third-party administrators for dental or mental health benefits. HealthPartners, Itasca Medical Care, and PrimeWest Health did not subcontract for these administrative services.

For the sample of mental health encounter records we tested, Blue Plus, HealthPartners, Hennepin Health, Itasca Medical Care, Medica Health Plans, PrimeWest Health, South Country Health Alliance, and UCare Minnesota complied with selected legal and DHS reporting requirements, and the payment information was accurate, complete, and timely.

For the sample of dental encounter records we tested, HealthPartners, Itasca Medical Care, Medica Health Plans, and PrimeWest Health complied with selected legal and DHS reporting requirements, and the payment information was accurate, complete, and timely.

Blue Plus, Hennepin Health, South Country Health Alliance, and UCare Minnesota also generally complied with these requirements; we found a small number of exceptions in their reporting of dental encounter claim data, discussed more thoroughly in the findings and recommendations in this report.

• Finding 1. For 2 of 84 dental claims that we audited, Blue Plus did not comply with a Department of Human Services contract requirement for submitting corrected encounter claims. (p. 10)
• Finding 2. For 1 of 84 dental claims that we audited, UCare Minnesota did not comply with a Department of Human Services contract requirement for submitting corrected encounter claims. (p. 11)
• Finding 3. For 1 of 84 dental claims that we audited, Hennepin Health did not comply with a Department of Human Services contract requirement for submitting corrected encounter claims. (p. 12)
• Finding 4. For 2 of 84 dental claims that we audited, South Country Health Alliance did not comply with a Department of Human Services contract requirement for submitting corrected encounter claims. (p. 13)
• Finding 5. For 3 of 84 dental claims that we audited, South Country Health Alliance did not comply with a Department of Human Services contract requirement to report denied claims for payment. (p. 13)

We also concluded that, for the samples we tested, the MCOs serving MinnesotaCare enrollees in 2018—Blue Plus, HealthPartners, Hennepin Health, Itasca Medical Care, PrimeWest Health, South Country Health Alliance, and UCare Minnesota—complied with legal requirements related to dental payment rate increases for this program.