Frequently asked questions: interim report on CMO audit [Jan. 2008]

Interim Report on the CMO Audit
FREQUENTLY ASKED QUESTIONS
Interim Report on CMO Audit
Why did Georgia implement Georgia Families?
In 2006, the state of Georgia implemented Georgia Families, a managed care program through which health care services are delivered to members of Medicaid and PeachCare for KidsTM. The intent of this program is to:
1. Offer care coordination to members 2. Enhance access to health care services 3. Achieve budget predictability as well as cost containment 4. Create system-wide performance improvements 5. Continuously and incrementally improve the quality of health care and services provided to
members 6. Improve efficiency at all levels
What issues will be addressed in the report conducted by Myers and Stauffer LC?
The final report will include analysis of provider related issues, claims payment, and denial issues, and a review of certain Georgia Families and Care Management Organizations (CMO) policies and procedures. Myers and Stauffer prepared an interim report that addresses hospital specific issues. The follow-up reports will include physician and ancillary service provider issues and concerns.
Why does the Interim Report on CMO Audits only address hospital concerns?
The scope of the entire project was to analyze and summarize a sample of the concerns reported to Myers and Stauffer LC by all provider types. It was determined that this needed to be done in waves; therefore, Myers and Stauffer started with hospitals and are in the process of assessing the physician related issues. This will be followed by an assessment of issues presented by the ancillary service providers.
Are the issues that the Georgia Families program faced unique to Georgia?
No. When state Medicaid programs substantially alter their care delivery model, it is not unusual to experience certain challenges and issues during the transitional phase, including: high volume of claims denials, claims mispayments, occasional duplicate payments, payment delays, communication issues, provider setup delays and contracting issues

2 Peachtree Street, Atlanta, Ga 30303 www.dch.georgia.gov

January 2008

Interim Report on the CMO Audit
How did Myers and Stauffer LC substantiate the information in the report?
Myers and Stauffer LC required hospitals to submit data and other documentary evidence to support their positions/claims
Myers and Stauffer LC required both hospitals and the CMOs to sign letters attesting to the accuracy and completeness of the information and documentation submitted
Myers and Stauffer LC confirmed issues through a series of meetings conducted in November 2007. These meetings included hospital representatives, CMO management, and Myers and Stauffer
Is this the only monitoring and oversight activity of the CMOs that DCH requires?
No. DCH contractually requires each CMO to provide a number of weekly, monthly and quarterly reports which include, but are not limited to, the number of well child visits, network adequecy, immunizations, claims payment outcomes, quality of care and customer service
When will a final report be issued?
A final report will be completed in June 2008 after all provider types have been interviewed and the data has been analyzed
The final report will include a summary of all of the issues with trends, recommendations for improving the Georgia Families program, best practices related to establishing and maintaining positive provider relations and managed care practices, and other observations, as applicable, resulting from these analyses and activities