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Medicaid Managed Care Capitated Payment Study Appendicies

Table of Medicaid Managed Care Capitated Payment Study

Appendix C.1: Medicaid Managed Care Capitated Payment Study Participants

Organization Description of Role
Comptroller of Public Accounts Provided overall project management. Solicited bids and selected a contractor for the study. Evaluated and enhanced study design from the first study. Coordinated project meetings and interviews, and information requests from all agencies involved with the Medicaid, State Employees Workers' Compensation and Medicaid Managed Care studies. Compiled and validated all study information received. Worked with consultants on aspects of the study, including completing information sheets, assisting with medical record review and resolving issues as they arose.
Denise Lenihan, C.P.A. Professional auditor. Reviewed online Medicaid client eligibility information, HMO contract information and delivery supplemental payment information for the study and compiled the results.
Health and Human Services Commission (HHSC)
Research and Forecasting
Provided the sample selection for the study.
Office of Eligibility Services (OES) Coordinated online systems access and managed care data needs with HHSC, NHIC and DHS for the study reviews.
State Auditors Office (SAO) Provided assistance in evaluating and enhancing the Medicaid study methodology. Validated the Medicaid sample universe data. Performed the overpayment rate computation.

Appendix C.2: Medicaid Managed Care Capitated Payment Study Worksheet
 Medicaid Managed Care Capitated Payment Study Worksheet  part 1  Medicaid Managed Care Capitated Payment Study Worksheet  part 2

Appendix C.3: Medicaid Managed Care Capitated Payment Study Error Code Table

Managed Care Capitated Review Error Code Error Code
Description
Review Error Description Payment Determination
for Sample Service
Review Error Action
C Capitated
payment error
An over or under-payment on a client during a benefit month due to an incorrect address, SDA assignment, program type/risk code assignment, premature disenrollment or MCO assignment Over/under-payment to the Managed Care contractor. Refer to HHSC/OIG, Eligibility and Managed Care departments for appropriate corrective action.
E Ineligible client for Managed Care program A Capitated premium payment was made on a disenrolled or ineligible managed care client Overpayment to the Managed Care contractor. Refer to HHSC/OIG, Eligibility and Managed Care departments for appropriate corrective action. Adjustment of medical claims and/or premium payments if appropriate.
P Process A processing error related to program eligibility such as SSN validation, re-certification, multiple Medicaid numbers, etc. that may cause a gap in managed health care or identify an ineligible client No over/under-payment Refer to HHSC/OIG, Eligibility and/or Managed Care departments for education and appropriate corrective action. Adjustment of medical claims and/or premium payments if appropriate.

Appendix C.4: Medicaid Managed Care Capitated (Premium) Payment Study Sample Statistical Data Tables
Exhibit 1: Medicaid Managed Care Capitated Payment Error Calculation Table

  Total Number of Sample Clients Sample Premiums Paid Amount Total Number of Payments Errors Total Payment Error Amount Payment Error Rate Sample Premiums Universe Amount Paid Lower 95% Confidence Interval Upper 95% Confidence Interval Margin of Error on Proportion of Sample Dollars Payment Error
Managed Care
Capitated (Premium) Payment Study
1,067 $148,254.03 23 $3,234.63 2.18% $238,960,031.42 2.11% 2.26% 0.07%

Exhibit 2: Medicaid Managed Care Capitated Study Error Summary

Type of Errors Total Number of Errors Total Number of Payment Errors Total Number of Overpayment Errors Overpayment Amount Total Number of Underpayment Errors Underpayment Amount Total Dollar Amount
of Payment Errors
Capitation 21 21 9 $1,021.70 12 $1,599.05 $2,620.75
Eligibility 2 2 2 $613.88 0 $0.00 $613.88
Processing 45 0 0 $0.00 0 $0.00 $0.00
Totals 68 23 11 $1,635.58 12 $1,599.05 $3,234.63

Exhibit 3: Medicaid Managed Care Study Computation of the Overpayment Error Rate performed by the State Auditor's Office

Step Computation Description
1 Total dollars in the sample were calculated.
2 Total dollars in the universe were calculated.
3 The total dollars overpaid was calculated.
4 A point estimate of the error payment rate was calculated by dividing the total number of dollars overpaid and underpaid by the number of dollars sampled.
5 A margin of error at 95% confidence was calculated by taking the square root of [(1.96^2) x dollars sampled].
6 The above margin of error was multiplied by [1-(sample dollars /universe dollars)] to adjust for the finite universe.
7 The margin of error was added to and subtracted from the point estimate error rate to render a 95% confidence interval.
8 The dollars in the universe were multiplied by the lower confidence limit, point estimate, and upper confidence limit of the 95% confidence interval to
extrapolate the error rate to the universe of dollars.