The state agency responsible for overseeing Medicaid in Illinois failed to properly monitor $7.11 billion in payments made to and by managed care organizations, according to a report issued Tuesday by the Illinois auditor general.
The report, requested by the state legislature last May, comes as Illinois shifts hundreds of thousands more people into the Medicaid managed care program and raises questions about its ability to oversee the expanded program.
Medicaid managed care organizations, or MCOs, are private insurers that administer benefits for Medicaid, a state and federally funded insurance program for the poor. The state pays the organizations a set amount per person per month, rather than paying per service, allowing them to derive profits from the savings they might create.
According to the report, the Department of Healthcare and Family Services could not provide auditors with complete or reliable data that the agency was required to collect under its agreements with the 12 MCOs it contracted with in 2016. The agency wasn’t able to provide data on paid claims MCOs made to providers; the claims denied by MCOs; administrative costs and coordinated care costs incurred by MCOs; and what percentage of each MCO’s premium income goes to health care and quality improvement as opposed to marketing and other costs, which is information required by federal law.
– Chicago Tribune