In the spring of 2021, the Oregon Health Authority which is largely responsible for Oregon Medicaid programs added two provider names to the state list of sanctioned providers for the first time. While plans for a populated state sanction list have been underway for a while, and there have been 134 Medicaid fraud convictions since 2016 in the state of Oregon, the state has not previously published a list of providers ineligible to participate in the Oregon Health Plan (OHP) Medicaid programs. It remains unclear when the balance of provider names, which need to be captured on the state list of sanctioned individuals and entities, will be added to the list. As soon as it was available, Streamline Verify added this new Oregon resource to our portfolio of databases which will now be screened for our clients, in addition to the 42 other state lists used. 

History of the Oregon Health Plan

Oregon has been on the forefront of states developing innovative Medicaid programs. In 1994 the state received an 1115 demonstration waiver from CMS to implement the Oregon Health Plan which was starkly different from any other Medicaid plan in the nation. Instead of offering the standard suite of benefits available from a traditional managed care or fee-for-service program the Oregon Health Plan provided medically necessary services in accordance with a Prioritized List of Health Services which ranked health care conditions and associated treatments in order of clinical effectiveness and cost-effectiveness.

Oregon’s current List of Prioritized List of Health Services is comprised of 662 condition-treatment pairings.  Effective January 1, 2020 – December 31, 2021, lines 1-471 of the Prioritized List of Services are funded for Medicaid recipients in Oregon. If a patient presents with a condition and the proposed treatment falls “above the line”, it would be covered. If it falls “below the line”, then the service is not covered. When the Oregon Health Plan was initially implemented in 1994, there were no internet resources or digital tools to assist with this new model and management of “the line” by OHP-contracted managed care plans was often inconsistent and time-intensive. Fortunately, there are many resources to assist the current CCOs and providers with determination of coverage decisions.

In 2012, in another innovative move, Oregon launched a new managed care model that replaced existing OHP contractors with risk-bearing, locally-governed provider networks called Coordinated Care Organizations (CCOs). In addition to providing acute, primary and specialty physical health services, this new model also included behavioral health and dental care which had previously been managed under separate contracts.  The current fifteen (15) CCOs are paid a single global Medicaid amount per member per month that grows at a fixed rate. The CCOs will be held accountable against performance-based metrics and quality standards that align with industry standards, new systems of governance, and payment incentives that reward improved health outcomes. Effective January 1, 2020, a new CCO contract, known as CCO 2.0 went into effect which significantly increased accountability of the CCOs to increase oversight of delegated entities and to increase reporting and disclosure duties to the Oregon Health Authority.

Troubling Audit Findings

Notwithstanding to work of the state to continually innovate to improve the reach, affordability and quality of the services available to Oregon Medicaid recipients, a November 2017 audit report by the Oregon Secretary of State cast a shadow over the program management. In this report which assessed certain aspects of the Oregon Health Authority’s financial stewardship of the state Medicaid program, the Secretary of State found that Oregon Health Authority should strengthen efforts to detect and prevent improper payments in Oregon’s $9.3 billion per year Medicaid program. The audit report also noted delays in processing eligibility for thousands of Oregon’s Medicaid recipients resulted in millions of dollars of avoidable Medicaid expenditures, a critical issue the OHA failed to disclose until raised in a May 2017 auditor alert. Furthermore, OHA did not timely disclose relevant information, which impeded the audit. The state audit team made eight (8) recommendations to improve performance. In the report, auditors specifically found that OHA management had not prioritized program integrity functions and recommended that the agency increase oversight of CCO program integrity efforts, such as approving CCO’s fraud, waste, and abuse policies and reviewing how CCO’s prevent, detect, and recover improper payments. In a follow up review  in 2019, the Oregon Secretary of State found that only 2 of the 8 recommendations made in 2017 had been implemented.

CMS similarly cast doubt on Oregon’s program integrity efforts for its Medicaid program in both a final December 2014  final audit report and a 2018 follow-up focused audit on the subject.  The final 2014 report set thirteen (13) major risk areas, with recommendations for corrective action. Included in one of those four overarching risk areas was the failure of the state to perform the necessary exclusion screening searches against the two federal exclusion databases as required by CMS and also was not contractually requiring CCO’s to perform required screening either.  The report also referenced the repeat risks remaining from the time of the agency’s last comprehensive program integrity review in 2010 and the priority to address these immediately. The 2018 focused audit found that only two of the thirteen risk areas had been adequately addressed.

Conclusion

There is new management at the Oregon Health Authority and work appears underway to resolve the remaining issues raised by the state auditors. The OHA is beginning to actively populate the state’s Sanctioned Medicaid Provider List. Also, the OHA issued a new CCO contract that has substantially increased expectation of its contract partners to implement more robust fraud detection and mitigation processes and to increase reporting on program integrity issues to the state. Whether or not these types of efforts will result in different outcomes in future CMS and state audits related to program integrity remains to be seen. However, with its history of pioneering new and complex models of coverage for its Medicaid population, there is hope that Oregon can meet these new challenges.