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MO HealthNet Program Integrity : Findings and Recommendations

June 2010

Missouri Department of Social Services

This report, prepared under contract to the Missoui Department of Social Services, MO HealthNet Division, focuses on organizational recommendations, as well as recommendations to improve MO HealthNet Program Integrity operations related to cost avoidance and recoveries. The report also provides recommendations to continue developing a collaborative relationship with Medicaid Fraud Control Unit (MFCU), best practices from other states, and Lewin's perspective on creating a new Office of Medicaid Program Integrity.

Client Area: State and Local Governments
Expertise Area: Medicaid and CHIP, Program Integrity


Missouri Medicaid Report on High-Cost Beneficiaries

April 2010

Missouri Department of Social Services

For the Missouri Department of Social Services, The Lewin Group examined high-cost individuals in the MO HealthNet program. For the analysis, Lewin evaluated high-cost individuals from two different perspectives: individuals whose claims history demonstrated unusually high use of certain services, specifically pharmacy, inpatient hospital and emergency room (ER) and individuals whose overall claims history demonstrated unusually high overall spending levels.

Client Area: State and Local Governments
Expertise Area: Medicaid and CHIP


MO HealthNet Comprehensive Review Final Report

April 2010

Missouri Department of Social Services

MO HealthNet retained The Lewin Group to conduct a comprehensive review of Missouri’s Medicaid program. The review included numerous interviews with Missouri officials, documentation review, and intensive data analysis. Specific areas of analysis included the pharmacy program, clinical services, long-term care, high volume providers, high cost participants, and non-emergency medical transport. The report includes a “big-picture” assessment of the Missouri Medicaid program and potential opportunities for organizational improvement.

Client Area: State and Local Governments
Expertise Area: Medicaid and CHIP


MO HealthNet NEMT Review: Final Report

February 2010

Missouri Department of Social Services

For the Missouri Department of Social Services, The Lewin Group conducted a high-level review of MO HealthNet’s Non-Emergency Medical Transportion (NEMT) program. The review focused on the following questions: Should MO HealthNet continue to use actuarially-sound rates? What alternative reimbursement approaches might Missouri consider? What best practices have states implemented to oversee brokers and assure quality in their NEMT programs? What service or contract modifications Missouri might consider incorporating into its NEMT broker program?

Client Area: State and Local Governments
Expertise Area: Medicaid and CHIP


MO HealthNet Clinical Services Report

January 2010

Missouri Department of Social Services

Under contract to the Missouri Department of Social Services, The Lewin Group conducted a review of selected areas of the MO HealthNet Clinical Services Program for potential short and longer-term cost-savings and areas in which operational effectiveness and efficiency could potentially be improved. The report focuses on the following areas: Inpatient Hospital, Outpatient Hospital, Chronic Care Improvement Program, Durable Medical Equipment, and Hospice.

Client Area: State and Local Governments
Expertise Area: Medicaid and CHIP


MO HealthNet Comprehensive Review: Short-term Cost Containment Opportunities

January 2010

Missouri Department of Social Services

The purpose of this report, prepared under contract to the Missouri Department of Social Services, is to present strategies for containing costs for Medicaid services in Missouri's Medicaid program, MO HealthNet. It includes short-term cost containment opportunities, as well as opportunities for operational improvement.

Client Area: State and Local Governments
Expertise Area: Medicaid and CHIP


MO HealthNet Long Term Care Review Cost Containment Opportunities

January 2010

Missouri Department of Social Services

The purpose of this report, prepared under contract to the Missouri Department of Social Services, is to present strategies for containing costs for long-term care services in Missouri's Medicaid program, MO HealthNet. This report focuses on short-term cost containment opportunities, but it also previews longer-term opportunities for improving the long term care system.

Client Area: State and Local Governments
Expertise Area: Center on Aging and Disability, Medicaid and CHIP


MO HealthNet Medicaid Pharmacy Report

November 2009

Missouri Department of Social Services

Under contract to the Missouri Department of Social Services, The Lewin Group identified pharmacy savings opportunities in the MO HealthNet Program that can help the State address its near-term fiscal crisis and to favorably impact longer-range prescription drug costs.

Client Area: State and Local Governments
Expertise Area: Medicaid and CHIP


Evaluation of New York’s HIV Special Needs Plan Program: Cost and Usage Impacts

November 2009

New York State Department of Health AIDS Institute

The Lewin Group, in collaboration with the New York State Department of Health AIDS Institute, conducted an evaluation of New York State’s Medicaid HIV Special Needs Plan program. The study focused on the following impact areas:  inpatient hospital costs and utilization, prescription drug costs and utilization, trends in overall medical costs, and the program’s effect on cost and HIV SNP enrollees’ service utilization compared to Medicaid spending had the HIV SNP initiative not been implemented.

Client Area: State and Local Governments
Expertise Area: Medicaid and CHIP


Mandated Report to Congress: Analysis of Impacts and Issues Relating to Four Medicaid Regulations

September 2009

Prepared for: The United States Congress Under contract to: U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services

Congress directed Secretary of Health and Human Services to describe the problems that four Medicaid regulations were intended to address and their impact, and to commission an independent study on the prevalence of these problems and the potential impacts of four of the regulations:

  • Cost Limit for Providers Operated by Units of Government and Provisions to Ensure the Integrity of Federal-State Partnership (CMS-2258-P) – proposed rule published January 18, 2007
  • Graduate Medical Education (CMS-2279-P) – proposed rule published May 23, 2007
  • Coverage for Rehabilitative Services (CMS-2261-P) – proposed rule published August 13, 2007
  • Elimination of Reimbursement Under Medicaid for School Administration Expenditures and Costs Related to Transportation of School-Age Children Between Home and School (CMS-2287-F) – final rule published December 28, 2007, final rule rescinded on June 30, 2009

Overall, we found that states do in fact have difficulty, in some instances, tracking where their Medicaid dollars go and the precise purposes to which these dollars are applied, which, in turn, creates oversight problems with CMS. There is no doubt that many of the issues raised by the Secretary and addressed in the regulations are ones that require continued focus from CMS and the states. On the other hand, we found little evidence within the states to substantiate some of the specific problems expressed by the Secretary in his 2008 report. In addition, many of the more significant concerns identified in the Secretary’s report arise from fundamental disagreements about the appropriate scope of Title XIX. In many cases, while we find that a problem raised by CMS exists in a state, we do not find any indication that the state has acted inappropriately.

The letter approving the report is available by clicking here.

Expertise Area: Medicaid and CHIP

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