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1. What is MCPIR, and who is a review conducted on?
Managed Care Program Integrity Reviews (MCPIR) evaluate the contractual performance of a managed care organization (MCO) as it relates to the MCO’s program integrity obligations under its contract with the department. These reviews are conducted in accordance with NYS SSL 364-j(36)(b).
2. What is a MCPIR Matrix and how is it useful?
A MCPIR Matrix provides a list of the program integrity contractual obligations under review for a given period, including benchmarks and measurement assessments. The Matrix also outlines how OMIG will measure the performance standards for compliance, and what the MCO needs to produce/show to demonstrate that they complied.
3. Where can I find the MCPIR Matrix?
The Medicaid Inspector General, in consultation with the commissioner, publishes MCPIR Matrices on its website.
4. What type of contractual provisions will be included in a MCPIR review?
In a MCPIR review, OMIG will assess the MCO’s compliance with program integrity related contractual obligations. For each contractual obligation, OMIG may assess more than one aspect of the obligation. These obligations include provisions related to the prevention of fraud, waste and abuse in the Medicaid program.
5. What is the MCPIR Module?
The MCPIR module outlines each contractual obligation under review with questions, information and documentation requests related to those obligations. The MCO’s responses in the module and document submissions will be used to determine their compliance with contractual obligations.
6. What is the MCO’s role in these reviews?
If identified for review, the MCO will receive a MCPIR review module to complete. The MCO is expected to complete the module and compile the requested information/ documentation for submission by the due date indicated in the Audit Notification Letter.
MCPIR reviews are conducted in a manner which fosters communication between OMIG and the MCOs throughout the engagement. Active participation and sharing of documentation facilitate the review process and may help to resolve findings and issues early in the process. MCOs are encouraged to remain engaged throughout the process.
7. If I am notified that a MCPIR review is being conducted, how long do I have to send in my documents?
MCOs identified for review will receive an Audit Notification Letter (ANL) from OMIG which notifies the MCO of OMIG’s intent to conduct the review, instructs the MCO to complete the MCPIR review module and provides the due date for the completed module. The MCO is given 35 days from the date of the ANL to complete and submit the module with the supporting documentation. If for any reason the MCO believes they need additional time, we encourage the MCO to request an extension from the OMIG contact provided in the ANL.
8. How does OMIG determine the amount of recovery?
Pursuant to SSL 364-j(36)(c), where OMIG determines that a Managed Care Organization (“MCO”) is not meeting its program integrity obligations under the Contract, OMIG may recover up to 2% of the administrative component of the Medicaid premium paid to the MCO for the period under review.
For each Matrix Line (ML), the number of contractual obligations related to each provision met vs. total obligations assessed will provide a score out of 100. The scores for the MLs will be averaged so that the MCO will receive one average score. The average score will be used to determine the percentage of recovery. The front page of the Matrix contains a chart that converts the MCO’s score into a recovery percentage (max 2%).
9. Will MCOs have the ability to respond to any Findings made during the review?
MCOs will have the opportunity to respond to and challenge the findings of the Draft Audit Report within 30 days of receipt of the Draft Audit Report. The MCO’s response will be reviewed and considered by the OMIG prior to issuing a Final Audit Report.
10. Will MCOs be provided a breakdown of how the administrative component of the Medicaid premium paid is calculated?
The calculation of the administrative component paid will be provided as an attachment in the Draft Audit Report and Final Audit Report. It includes a full breakdown of how the total administrative component of the MCO’s rate is calculated for the applicable review period.
11. What happens if a MCO disagrees with the Final Audit Report determination?
The MCO has the right to challenge the Final Audit Report determination by requesting an administrative hearing within sixty (60) days of the date the Final Audit Report was issued. If the MCO wishes to request a hearing, the request must be submitted in writing to the OMIG Office of Counsel. Additional information on how to request a hearing is included in the Final Audit Report.
12. How do I stay informed of changes or updates to MCPIR reviews?
We encourage MCOs to visit the Managed Care Program Integrity Review page on the OMIG website, and these FAQs as they will be updated when there are changes or new questions raised.
MCOs’ questions and concerns are important to OMIG and help inform updates to these FAQs. MCOs are encouraged to access the FAQs regularly, as OMIG will revise and update the information as necessary
For more Information If you have additional questions, please reach out to OMIG MCPIR by email at: [email protected].