United Healthcare
United Healthcare2020 Compliance AuditReview Period: April 01, 2019 – March 31, 2020Final Report Issued February 2021Prepared on Behalf ofThe State of LouisianaLouisiana Department of Health
Table of ContentsIntroduction and Audit Overview . 3MCO Summary of Findings. 6MCO Final Audit Tools. 30Eligibility, Enrollment and Disenrollment . 30Marketing and Member Education . 35Provider Network Requirements . 54Utilization Management . 108Fraud, Waste and Abuse . 125Core Benefits and Services . 161Reporting. 197List of TablesTable 1: File Review Sample Sizes . 3Table 2: Review Determination Definitions . 4Table 3: Audit Results by Audit Domain . 6Table 4: Deficient 2019 Audit Elements. 72020 Compliance Report – United HealthcarePage 2 of 198
Introduction and Audit OverviewIntroductionThe Balanced Budget Act of 1997 established that state agencies contracting with Medicaid managed care organizations(MCOs) provide for an annual external, independent review of the quality outcomes, timeliness of, and access to theservices included in the contract between the state agency and the MCO. Subpart E – External Quality Review of 42 Codeof Federal Regulations (CFR) sets forth the requirements for annual external quality review (EQR) of contracted MCOs.Further, 42 CFR 438.350 requires states to contract with an external quality review organization (EQRO) to perform anannual EQR for each contracted MCO. States must further ensure that the EQRO has sufficient information to carry outthe EQR, that the information be obtained from EQR-related activities, and that the information provided to the EQRObe obtained through methods consistent with the protocols established by the Centers for Medicaid and MedicareServices (CMS).To meet these federal requirements, the Louisiana Department of Health (LDH) has contracted with IPRO, an EQRO, toconduct annual compliance audits every three years. The 2020 annual compliance audit was a partial audit of the MCO’scompliance with contractual requirements during the period of April 1, 2019, through March 31, 2020. Requirementsthat were not in full compliance in the full 2019 annual compliance audit were reviewed.This report presents IPRO’s findings of the 2020 annual compliance audit for United Healthcare (UHC).Audit OverviewThe purpose of the audit was to assess UHC’s compliance with federal and state regulations regarding: access to care;structure and operations; grievance policies; provider network relations and network adequacy; quality measurement;fraud, waste and abuse; and utilization management.The partial audit included an evaluation of United Healthcare’s policies, procedures, files, and other materialscorresponding to the following seven contractual domains:1. Eligibility and Enrollment2. Marketing and Member Education3. Provider Network Requirements4. Utilization Management5. Fraud, Waste and Abuse6. Core Benefits and Services7. ReportingThe file review component assessed the MCO’s implementation of policies and its operational compliance withregulations related to complaints and grievances, member appeals, informal reconsiderations, care management(physical and behavioral health), utilization management, and provider credentialing and recredentialing.Specifically, file review consisted of the following area:1. Case Management (behavioral and physical health)Sample sizes for each file review type are presented in Table 1.Table 1: File Review Sample SizesFile TypeCase Management (physical health)Case Management( behavioral health)Sample Size1010The period of review was April 1, 2019, through March 31, 2020. All documents and case files reviewed were activeduring this time period.2020 Compliance Report – United HealthcarePage 3 of 198
For this audit, determinations of “full compliance,” “substantial compliance,” “minimal compliance,” “non-compliance,”and “not applicable” were used for each element under review. The definition of each of the review determinations ispresented in Table 2.Table 2: Review Determination DefinitionsReviewDeterminationDefinitionFullThe MCO is compliant with the standard.SubstantialThe MCO is compliant with most of the requirements of the standard, but has minor deficiencies.The MCO is compliant with some of the requirements of the standard, but has significantMinimaldeficiencies that require corrective action.Non-complianceNot applicableThe MCO is not in compliance with the standard.The requirement was not applicable to the MCO.The 2020 annual compliance audit consisted of three phases: 1) pre-onsite documentation review, 2) video interviews,and 3) post-onsite report preparation.Pre-onsite Documentation ReviewTo ensure a complete and meaningful assessment of the MCO’s policies and procedures, IPRO prepared seven reviewtools to reflect the areas for audit. These seven tools were submitted to the LDH for approval at the outset of the auditprocess on April 8, 2020. The tools included the review elements drawn from the state and federal regulations. Basedupon the LDH’s suggestions, some tools were revised and issued as final. These final tools were submitted to the MCOon July 1, 2020, in advance of the onsite audit.Once LDH approved the methodology, IPRO sent UHC a packet that included the review tools, along with a request fordocumentation and a guide to help MCO staff understand the documentation that was required. The guide also includedinstructions for submitting the requested information using IPRO’s secure File Transfer Protocol (FTP) site.To facilitate the audit process, IPRO provided the MCO with examples of documents that the MCO could furnish tovalidate its compliance with the regulations. Instructions regarding the file review component of the audit were alsoprovided, along with a request for the universe of cases for each file review area under review. From the universe ofcases, IPRO selected a sample for each area, which was reviewed onsite.Prior to the onsite visit, the MCO submitted written policies, procedures and other relevant documentation to supportits adherence to state and federal requirements. The MCO was given a period of approximately four weeks to submitdocumentation to IPRO. To further assist MCO staff in understanding the requirements of the audit process, IPROconvened a conference call for all MCOs undergoing the audit, with LDH staff in attendance, approximately two weeksafter the request packet was sent to the MCOs. During the conference call, IPRO detailed the steps in the audit process,the audit timeline, and answered any questions posed by MCO staff.After the MCO submitted the required documentation, a team of seven IPRO auditors was convened to review theMCO’s policies, procedures, and materials, and to assess the MCO’s concordance with the state’s contract requirements.This review was documented using audit tools IPRO developed to capture the review elements and record the findings.These review tools with IPRO’s initial findings were used to guide the video interviews.Video InterviewsThe video interview component of the audit was composed of two video interview sessions. In the first sessionconducted on August 14, 2020, file reviews that were considered less than fully compliant based upon review werediscussed. In the second session on August 28, 2020, review of elements in each of the seven review tools that wereconsidered less than fully compliant based upon review.2020 Compliance Report – United HealthcarePage 4 of 198
Interviews were used to further explore the written documentation and to allow the MCO to provide additionaldocumentation, if available. File review, as indicated, was conducted to assess the MCO’s implementation of policy inaccordance to state standards. MCO staff was given two days from the close of the onsite review to provide any furtherdocumentation.Post-onsite Report PreparationFollowing the video interviews, draft reports were prepared. These draft reports included an initial reviewdetermination for each element reviewed, and either evidence that the MCO is compliant with the standard or arationale for why the MCO was not compliant and what evidence was lacking. For each element that was deemed notfully compliant, IPRO provided a recommendation for the MCO to consider in order for them to attain full compliance.Each draft report underwent a second level of review by IPRO staff members who were not involved in the first level ofreview. Once completed, the draft reports were shared with LDH staff for review. Upon LDH approval, the draft reportswere sent to the MCO with a request to provide responses for all elements that were determined to be less than fullycompliant. The MCO was given two weeks to respond to the issues noted on the draft reports.After receiving the MCO’s response, IPRO re-reviewed each element for which the MCO provided a response. Asnecessary, review scores were updated based on the response of the MCO.2020 Compliance Report – United HealthcarePage 5 of 198
MCO Summary of FindingsSummary of FindingsTable 3 provides a summary of the audit results by audit domain. Detailed findings for each of the elements that wereless than “fully compliant” follow within this section of the report.Please note this is a partial review. This table excludes full items from the prior review. Total compliance for each tool(including full items from prior year) will be higher for domains scoring less than 100%. Additionally, some items werenew requirements for this review which may have impacted overall percentagesTable 3: Audit Results by Audit DomainAudit DomainEligibility and EnrollmentMarketing and Member EducationProvider Network RequirementsUtilization ManagementFraud, Waste and AbuseCore Benefits and l mpliance00000000N/As are not included in the calculation.N/A00000000% Full1100%100%44%100%100%54%100%61%As presented in Table 3, 41 elements were reviewed for compliance. Of the 41 elements, 25 were determined to fullymeet the regulations, while 16 substantially met the regulations, 0 minimally met the regulations, and 0 weredetermined to be non-compliant. Zero elements were “not applicable.” The overall compliance score indicates that 61%of regulations not fully compliant in the prior review have been addressed by the MCO and are now fully compliant.IPRO extracted from each of the seven detailed reports those elements for which the MCO was found to be less thanfully compliant. This information was compiled into a summary report to facilitate corrective action. Table 4 presentsthis summary report and includes details about each element reviewed, the final review determination, the MCO’s initialresponse, and, when possible, suggestions to achieve full compliance.It is the expectation of LDH that UHC submits a corrective action plan for new elements determined to be less than fullycompliant.Each of the seven review tools and review determinations for each of the elements follow Table 4.2020 Compliance Report – United HealthcarePage 6 of 198
Table 4: Deficient 2020 Audit act RequirementLanguage(Federal Regulation:438.114, 438.208)SterilizationSterilization must beconducted inaccordance withLouisiana R.S.40:1159.2, stateMedicaid policy,federal regulationscontained in 42 CFR§441.250 - 441.259.All procedures mustbe documented with acompletedSterilization ConsentForm OMB 0937-0166.SuggestedDocumentationand reviewerinstructionsP/P rManual/portalServices for Special PopulationsIndividualizedP/P IndividualTreatment Plans andTreatment PlansCM recordsCare PlansAll SHCN membersTreatment &/orshall be referred for,care plansand if found eligible,Includes Caseoffered caseManagement Filemanagement,including anReview2020 Compliance Report – United HealthcarePrior Review ResultsNew requirementReviewDeterminationSubstantialComments (Note: Forany element that is lessthan fully compliant, anexplanation of thefinding and arecommendation mustbe documented below)This requirement isaddressed in theUnitedHealthcareCommunity Plan ProviderManual on pages 49, 59and 60; however, therewas no policy documentto support thisrequirement and theMember Handbook didnot inform the memberof this specific benefit.MCO Response and Plan ofActionUHC is drafting a policyaddressing sterilization whichwill be submitted to LDH viathe Act 319 process onceinternal approvals arecompleted.RecommendationThe MCO is advised todevelop a sterilizationpolicy that translatesregulations 42 CFR§441.250 - 441.259 intopolicy and procedurelanguage, and to clarifysterilization benefitcoverage language in theMember Handbook.SubstantialThis requirement is addressed in theCS WPC LA Care ManagementProcess Policy and Procedure.File Review ResultsOf the 10 case management files, 9had an individual care plan based onthe needs assessment, and 9 of 10SubstantialThis requirement isaddressed in the ChronicIllness Program ProcessPolicy and Procedure,the IntensiveOpportunity ProgramManagement Policy andProcedure, and the CaseManagement ProcessEach staff will undergo reeducation through thefollowing venues:*Each staff member willundergo an evaluation oftheir knowledge of careplanning and the contractualcomponents in their 1:1Page 7 of 198
ContractReferenceContract RequirementLanguage(Federal Regulation:438.114, 438.208)individualizedtreatment plandeveloped by thetreatingprovider(s)and aperson-centered planof care developed bythe MCO caremanager. Theindividualizedtreatment plans mustbe:SuggestedDocumentationand reviewerinstructionsPrior Review Resultscare plans included short- and longterm care goals. Of the 8 applicablefiles (excluding 2 with multipleunsuccessful outreach attempts), 8plans of care were developed withmember and/or family involvement.Of the 10 behavioral health casemanagement files, the requirementfor a care plan was applicable to 9cases (excluding 1 PASRR case). Ofthe 9 applicable cases, 8 had a careplan based upon the member’sindividual needs assessment that wasdeveloped with the involvement ofthe member/family, and thatincluded short- and long-termmember goals. Nine (9) of 9applicable files (excluding 1 PASRRcase) included a care plan thatdocumented member demographicsand supports and services. Of the 8files with documented indication forcrisis planning, 8 met thisrequirement.RecommendationThe MCO should encourage clinicalcase managers to tailor the plan ofcare to the member’s individualneeds beyond those identified by themember in the initial needsassessment.MCO Response:1. The Plan will educate our staff onEQRO audit recommendations.2020 Compliance Report – United HealthcareReviewDeterminationComments (Note: Forany element that is lessthan fully compliant, anexplanation of thefinding and arecommendation mustbe documented below)Policy and Procedure.File Review ResultsOf the 10 casemanagement filesreviewed, 10 met therequirement forinvolvement ofmember/family intreatment care planning.Seven (7) of 10 files hadan individual care planbased on the needsassessment, and 6 ofthese 7 files had careplans that also includedshort and long termgoals.Of the 10 behavioralhealth case managementfiles, 7 met therequirement for anindividual care planbased on the needsassessment and 7 ofthese 7 files met therequirement formember/familyinvolvement. Of thesesame 7 files, 6 met therequirement to includemember goals. Five (5) ofthe 10 files reviewed hada plan for addressingcrisis to preventunnecessaryMCO Response and Plan ofActionmeeting with their Managerin the next 30 days.*Each staff will participate ina Plan of Care trainingthsession to be scheduled in 4Quarter 2020 and annuallythereafter.Scheduled team meetingswill be used to deep dive intothe Plan of Care to allow staffthe opportunity to fullyunderstand the purpose andhow to utilize this tool todrive practice.A comprehensive audit toolthat incorporates all thecompliance priorities is indevelopmentIncreased auditing will occuras follows:*Increase peer auditing*Increase self-audits*Each Manager will reviewstaff audits for accuracy andcompliancePeer Audit results will beshared with staffconfidentially in their 1:1meeting with their Manager.Development of Process Flowdiagrams to identify and planPage 8 of 198
ContractReferenceContract RequirementLanguage(Federal Regulation:438.114, 438.208)SuggestedDocumentationand reviewerinstructionsPrior Review Results2. The case management team willtake the approach of being morespecific in the care plan, includingnotations within the care plan undereach O.G.I. (Opportunity, Goals, andInterventions) specific to themember's needs regardless ofwhether it applies to resources ordisease specific processes.3. The case management team willdocument updated findings withinthe member's plan of care. All noteswill reflect information and updatesthrough the period of member'senrollment.Final Review Determination:No change in determination. The planagreed to the recommendationmoving forward.2020 Compliance Report – United HealthcareReviewDeterminationComments (Note: Forany element that is lessthan fully compliant, anexplanation of thefinding and arecommendation mustbe documented below)hospitalization.RecommendationThe MCO should deployquality improvementtools such as processflow diagrams to identifybarriers to care plandevelopment andimplementationconsistent with thepolicies for the ChronicIllness Program Process,the WPC Model, theIntensive OpportunityProgram Managementpolicy, and the CaseManagement Processpolicy and procedures.Examples of barriers toconsider include whetherstaff assignments areappropriate in terms ofclinical knowledgerequired and whethercurrent systems ofcommunication anddocumentation aresufficient to ensurecontinuity andcomprehensiveness ofcare. Based upon thediscussion at theinterview, the MCOshould also exploreopportunities tointegrate the BHMCO Response and Plan ofActionfor addressing barriers is inprogress.Page 9 of 198
ContractReference6.19.4.3Contract RequirementLanguage(Federal Regulation:438.114, 438.208)Reviewed and revisedupon reassessment offunctional need, atleast every 12 months,when the member’scircumstances orneeds changesignificantly, or at therequest of themember; andSuggestedDocumentationand reviewerinstructionsP/P IndividualTreatment PlansPlan of CareIncludes CaseManagement FileReviewPrior Review ResultsSubstantialThis is addressed for Medicaid, CHIP,dual Special Needs Plans (DSNP), andMedicare/Medicaid Program (MMP)plans in the NCM 002 High-Risk CaseManagement Process Policy andProcedure.File Review ResultsThe requirement for ongoing careplan review was applicable to 6 casemanagement files (4 were excludeddue to lack of sufficient timeframefor care plan follow-up or multipleunsuccessful outreach attempts. Six(6) of 6 files met the requirement forongoing care plan review. Monitoringof outcomes and revision of thetreatment plan as necessary wasdocumented in either the care planor care coordination notes for 7 ofthe 7 applicable cases (excluding 3without sufficient timeframes).Of the 8 applicable behavioral healthcase management files7 documentedmonitoring of outcomes. Of the 7applicable behavioral health casemanagement files, 6 documented2020 Compliance Report – United HealthcareReviewDeterminationSubstantialComments (Note: Forany element that is lessthan fully compliant, anexplanation of thefinding and arecommendation mustbe documented below)Advocate/MedicalDirector treatmentplanning process withthe Case ManagementComprehensive NeedsAssessment process inorder to generate a careplan.This requirement isaddressed in the CaseManagement Policy andProcedure.File Review ResultsTen (10) of 10 files casemanagement filesreviewed met therequirement formonitoring of outcomes,and 8 of 10 met therequirement for revisionof the treatment plan asnecessary.Of the 10 behavioralhealth case managementfiles reviewed, 5 met therequirements formonitoring of outcomesand revision of treatmentplan as necessary.RecommendationThe MCO should ensurethat care plans are usedto monitor andcommunicate memberMCO Response and Plan ofActionEach staff will undergo reeducation through thefollowing venues:*Each staff member willundergo an evaluation oftheir knowledge of careplanning and the contractualcomponents in their 1:1meeting with their Managerin the next 30 days.*Each staff will participate ina Plan of Care trainingsession to be scheduled in4th Quarter 2020 andannually thereafter.Scheduled team meetingswill be used to deep dive intothe Plan of Care to allow staffthe opportunity to fullyunderstand the purpose andhow to utilize this tool todrive practice.A comprehensive audit toolthat incorporates all thecompliance priorities is inPage 10 of 198
ContractReferenceContract RequirementLanguage(Federal Regulation:438.114, 438.208)SuggestedDocumentationand reviewerinstructionsPrior Review Resultsrevision of the care plan as necessary.ReviewDeterminationRecommendationsThe MCO should ensure that careplans are used to monitor andcommunicate member outcomes,with revisions made as indicated andcommunicated to behavioral healthand physical health care managersand providers. The MCO shouldenhance case managementinterventions for the IET PIP.6.286.28.26.28.2.1Care ManagementThe MCO shall beresponsible forensuring:Member’s health careneeds andservices/care areplanned andcoordinated throughthe MCO PCP and/orbehavioral healthprovider;Comments (Note: Forany element that is lessthan fully compliant, anexplanation of thefinding and arecommendation mustbe documented below)outcomes, with revisionsmade as indicated andcommunicated tobehavioral health andphysical health caremanagers and providers.Includes CareManagement FileReview2020 Compliance Report – United HealthcareSubstantialThis requirement is addressed in theNCM 006 Integration of Physical andBH Care Policy and Procedure, in theCS WPC Chronic Illness PrgrmManagement Procedure document, ,in the WPC PD 2019 Whole PersonCentered Care Model (WPC) ProgramDescription, and the MemberHandbook for Integrated HealthServices; however, it is not clear howthis requirement is met for memberswith physical health or behavioralhealth benefits, only, perdocumentation in the MemberHandbook for Physical HealthIncreased auditing will occuras follows:*Increase peer auditing*Increase self-audits*Each Manager will reviewstaff audits for accuracy andcompliancePeer Audit results will beshared with staffconfidentially in their 1:1meeting with their Manager.MCO Response:The plan will educate our staff on theEQRO audit recommendations.Final Review Determination:No change in determination. The planagreed to the recommendationmoving forward.P/P memberServicesProvider handbookMCO Response and Plan ofActiondevelopmentDevelopment of Process Flowdiagrams to identify and planfor addressing barriers is inprogress.SubstantialThis requirement isaddressed in theMember Handbook forIntegrated HealthServices on page 44, aswell as in the MemberHandbook For PhysicalHealth Services on page46. The MemberHandbook For MentalHealth and SubstanceUse Treatment Servicesdoes not address thisrequirement; however,the MCO explained atthe interview that thisEach staff will undergo reeducation through thefollowing venues:*Each staff member willundergo an evaluation oftheir knowledge of careplanning and the contractualcomponents in their 1:1meeting with their Managerin the next 30 days.*Each staff will participate ina Plan of Care trainingsession to be scheduled in4th Quarter 2020 andPage 11 of 198
ContractReferenceContract RequirementLanguage(Federal Regulation:438.114, 438.208)SuggestedDocumentationand reviewerinstructionsPrior Review ResultsServices and in the MemberHandbook for Mental Health andSubstance Use Treatment.File Review ResultsOf the 9 applicable case managementfiles (excluding 1 with multipleunsuccessful contacts), 9 containeddocumentation that prevention andtreatment services are accessible andcomprehensive. Of the 8 applicablecase management files (excluding anadditional member withoutindications for referral), 8 met therequirement for referrals asindicated.Of the 8 applicable behavioral healthcase management files, 8 met therequirement for recording themember’s PCP in the caremanagement record or otherwisefollow-up.RecommendationThe MCO should revise the memberhandbooks for members with eitherone physical or behavioral healthbenefits only to explain to membersthat they are entitled to carecoordination and how to access thatcare coordination. The MCO shouldimprove behavioral casemanagement to ensure that allmembers have access tocomprehensive prevention andtreatment services.2020 Compliance Report – United HealthcareReviewDeterminationComments (Note: Forany element that is lessthan fully compliant, anexplanation of thefinding and arecommendation mustbe documented below)requirement does notapply to theMedicare/Medicaid dualeligible members whoreceive this handbook.File Review ResultsOf the ten (10) casemanagement filesreviewed, 9 met therequirement foraccessible andcomprehensivetreatment services and 9met the requirement forreferrals made asnecessary.Of the ten (10)behavioral health casemanagement filesreviewed, 6 met therequirements for carecoordination and forreferrals as needed.RecommendationThe MCO should deployquality improvementtools such as processflow diagrams to identifybarriers to carecoordination consistentwith the policies for theChronic Illness ProgramProcess, the WPC Model,the IntensiveMCO Response and Plan ofActionannually thereafter.Scheduled team meetingswill be used to deep dive intothe Plan of Care to allow staffthe opportunity to fullyunderstand the purpose andhow to utilize this tool todrive practice.A comprehensive audit toolthat incorporates all thecompliance priorities is indevelopmentIncreased auditing will occuras follows:*Increase peer auditing*Increase self-audits*Each Manager will reviewstaff audits for accuracy andcompliancePeer Audit results will beshared with staffconfidentially in their 1:1meeting with their Manager.Development of Process Flowdiagrams to identify and planfor addressing barriers is inprogress.Page 12 of 198
ContractReference6.28.2.3Contract RequirementLanguage(Federal Regulation:438.114, 438.208)Care coordination andreferral activities, inperson ortelephonicallydepending onmember’s acuity,incorporate andidentify appropriatemethods ofassessment andreferral for membersrequiring both medicalSuggestedDocumentationand reviewerinstructionsCM recordsP/P for carecoordinationIncludes CareManagement FileReview2020 Compliance Report – United HealthcarePrior Review ResultsFinal Review Determination:No change in determination. Therewas no MCO Response and Plan ofAction.SubstantialThis requirement is addressed in theCS WPC Chronic Illness PrgrmMgmt Policy and Procedure,CS PCCM Med Behavioral CaseConsult Policy and Procedure, andCS WPC IntensiveOpportunity Prgrm Mgmt Policy andProcedure, as well as in the entitled2018 Annual Collaborative AnalysisContinuity and Coordination betweenBehavioral Health and Medical CareReviewDeterminationSubstantialComments (Note: Forany element that is lessthan fully compliant, anexplanation of thefinding and arecommendation mustbe documented below)Opportunity ProgramManagement policy, andthe Case ManagementProcess policy andprocedures. The focusshould be on behavioralhealth case managementcases, althoughenhanced processesshould be applicable toall members in casemanagement. Examplesof barriers to considerinclude whether staffassignments areappropriate in terms ofclinical knowledgerequired and whethercurrent systems ofcommunication anddocumentation aresufficient to ensurecontinuity andcomprehensiveness ofcare.This requirement isaddressed in the ChronicIllness Program Policyand Procedure, theIntensive OpportunityProgram ManagementPolicy and Procedure,and the CaseManagement ProcessPolicy and Procedure.File Review ResultsMCO Response and Plan ofActionEach staff will undergo reeducation through thefollowing ve
United Healthcare . 2020 Compliance Audit . Review Period: April 01, 2019 - March 31, 2020 . Final Report Issued February 2021 . Prepared on Behalf of . The State of Louisiana . Louisiana Department of Health. 2020 Compliance Report - United Healthcare Page 2 of 198 . Table of Contents
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