Federal audit of Medicaid program supports need for Oregon’s CCO 2.0 accountability reforms

September 23, 2020

The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has released a report on Oregon’s oversight of its coordinated care organizations (CCOs). The report reviewed four CCOs and found they met requirements related to time and distance standards, timely access to care, and assignment of primary care physicians. However, the report faulted the Oregon Health Authority (OHA) for not holding the four CCOs better accountable to comply with requirements related to provider credentialing and grievances. The audit covers services delivered by Oregon’s Medicaid program for the years 2016-2017.

"While flexibility that allows for innovation is part of how we approach running the Oregon Health Plan, clear contracts, reporting and enforcement also allow us to make sure members receive the care they deserve," said OHA director Patrick Allen. "It was our goal in CCO 2.0 to hold CCOs and the Oregon Health Authority more accountable for working together to deliver better results for OHP members and taxpayers. We’re providing support to CCOs where needed and setting clearer expectations in our contracts. We expect Oregon’s CCOs will rise to meet these expectations."

The report offered four main findings for OHA to act on:

1. Provide additional guidance to CCOs on the processes for provider credentialing and for beneficiary grievances and appeals.
2. Provide additional guidance to CCOs on monitoring subcontractors.
3. Take actions to ensure that CCOs do not subcontract the adjudication of final appeals.
4. Take actions to ensure that the data that CCOs submit on grievances and appeals in the grievance workbooks are accurate and complete.

OHA agreed with the audit’s findings. The agency has made the following changes to program oversight and through its CCO 2.0 contracts that address the audit’s compliance concerns:

• Increased requirements for the development and monitoring of provider networks.
• Clarified that CCOs were fully responsible for oversight of behavioral health, dental, and transportation benefits.
• Required CCOs to report annually on subcontractor performance.
• Required CCOs to submit quarterly reports on grievances and appeals.
• Required CCOs to develop an annual health equity plan and provide language access and interpreter reporting.
• Improved and streamlined OHA’s oversight of CCO performance.
• Increased enforcement and monitoring of CCO contracts, including issuing three notices of corrective action since 2019.

The report, "Oregon’s Oversight Did Not Ensure That Four Coordinated-Care Organizations Complied With Selected Medicaid Requirements Related to Access to Care and Quality of Care," can be found on the OIG website.

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