Audits Don’t Guarantee Care

Published November 5, 2014

Even though Medicaid has long had a reputation for making it difficult for enrollees to get medical care, states still do not have the necessary systems for ensuring Medicaid delivers adequate health care.

States have dreamed up hundreds of metrics for monitoring the quality of their Medicaid programs, but audit lists with hundreds of items generally make things worse. Trivial items get as much weight as important ones, auditors rely on unverified paperwork or managerial affirmations, and everyone loses track of what is really important.

For example, even though an unknown number of its newly enrolled Medicaid clients had no access to care, Denver Health, a major Colorado Medicaid contractor, scored a 92 percent on its 2013 audit. The auditors graded it on 114 audit elements provided by the state Medicaid department.

Appointments not available

The new Denver Health clients had no access because they could not get an appointment with a Denver Health primary care provider, and only those providers could give them access to Denver Health services. Denver Health claimed waits were no longer than two weeks, even though it had no systems for tracking waiting lists.

In 2013, Denver Health admitted its clinic system was operating at capacity and openings for new Medicaid patients were created “through an estimated 20 percent turnover in clients who move out of the area, disenroll, lose coverage, or die.”

Denver Health staff rationed appointments for new members by putting them on informal waiting lists. After interviewing the scheduling staff, the auditors concluded, “based on the process described,… the appointment standards for any type of appointment for a new, unestablished patient would not be met.”

Denver Health passed its audit by meeting all the audit requirements for paperwork on coverage, utilization management, provider certification, and denial of claims. It had “committees, workgroups, staff trainings, and evaluation metrics regarding provision of interpreters and understanding of culture with respect to health care.” Member to provider ratios met state standards, and there were 54 bus stops within a quarter of a mile of its clinics.

Coverage is not the same as care, however, and audits are no guarantee a monopoly provider will perform as advertised.

Linda Gorman ([email protected]) is director of the Health Care Policy Center at the Independence Institute.