Objective

To determine if the Department of Health (DOH) has provided adequate oversight of Medicaid managed care provider networks to ensure cost efficiency and access to adequate in-network care. The audit covered the period from January 2023 through December 2023.

About the Program

DOH administers New York’s Medicaid program. Most of the State’s Medicaid members receive their services through managed care. DOH is responsible for ensuring that managed care organizations (MCOs) maintain and monitor a network of providers supported by written agreements that is sufficient to provide timely and adequate access to all services covered under the contract. If the provider network cannot provide services, the member can go out of network. MCOs are required to submit their provider network to DOH quarterly using the Provider Network Data System (PNDS) for assessment of its adequacy. This information is used to generate a deficiency report identifying areas where the MCO lacks enough providers in certain counties. MCOs are given an opportunity to dispute deficiencies and provide supporting information to have the deficiency removed. DOH reviews the MCO’s responses and updates the status of the deficiency. At the conclusion of this process, the remaining deficiencies are compiled into a quarterly Statement of Agreement (SOA) for each MCO.

Key Findings

We found that DOH lacked sufficient oversight of managed care provider networks. We determined that, in many instances, DOH did not follow its internal PNDS Review Guidance. SOAs contained inaccurate deficiencies, and deficiency statuses were not always updated so it was unclear whether DOH took the additional steps needed to complete its quarterly network adequacy review. Additionally, we found records that appear to have been incorrectly labeled as “excluded” from the network adequacy process, which could result in incomplete SOAs. We also found that DOH does not provide MCOs with adequate guidance regarding the deficiency review process or out-of-network provider payments, which may expose the Medicaid program to increased expenses. Furthermore, despite having access to the SOA data, DOH officials do not use this information to identify patterns or areas for improvement or to provide any other oversight of the network adequacy process.

Key Recommendations

• Improve monitoring and controls over the provider network adequacy process to ensure network deficiencies are reported timely and accurately, including issuing guidance detailing MCO responsibilities within the deficiency review process.
• Evaluate the provider network deficiencies identified in SOAs and take steps to improve MCO provider networks.