Magellan Complete Care Program Integrity

Magellan Complete Care’s program integrity activities consist of a robust compliance, oversight and accountability, and Fraud, Waste and Abuse (FWA) program that has received high marks from state partners over the years. Our comprehensive approach to program integrity, from new-hire and annual refresher training to payment integrity auditing and delegated vendor management, protects our Medicaid and Medicare members while saving taxpayer dollars.

Components of Magellan Complete Care's Program

Compliance plan and FWA policies

Our compliance and FWA plan, reviewed annually, outlines our comprehensive program for preventing, detecting, monitoring, resolving and reporting FWA. It follows guidance published by the U.S. Department of Health and Human Services (HHS) Office of the Inspector General (OIG), the Centers for Medicare and Medicaid Services (CMS), and the U.S. Department of Justice (DOJ) Federal Sentencing Guidelines and includes:

  • Ongoing compliance monitoring
  • Policies and procedures, including special and/or additional provisions for our providers, program-specific false claims checklists and whistle-blower protection laws
  • Training customized to each of our customer’s state/federal laws and contracts

In compliance with the Deficit Reduction Act of 2005, we provide information regarding applicable federal and State laws and regulations on FWA to our providers, members, subcontractors, community partners and employees.

HIPAA and privacy/security compliance

We have policies outlining regulatory requirements of and processes to comply with HIPAA and all its implementing regulations (including the HITECH Act and the Omnibus Rule of 2013) and other privacy‐related requirements support. In addition, our IT Security Team ensures that Members’ health information is protected in our systems and when it is exchanged through electronic means. We have technical, physical, and administrative safeguards to enhance physical, personal, and information systems security.

Compliance training

Magellan Complete Care administers mandatory, online annual training on critical compliance- and FWA-related topics, including our Code of Conduct, and Fraud Identification and Recognition, upon hire and annually. Claims processing employees and staff in other critical functions such as medical management receive additional targeted training on recognizing and identifying FWA. We provide monthly employee training and updates during staff meetings. We train and regularly educate our members and providers on FWA compliance and ensure that training is administered to subcontractor employees, consultants, and governing and advisory body members.

Risk assessment and management

Magellan Complete Care has a formal risk management framework for identifying and remediating FWA compliance risks. This framework includes routine risk assessments conducted by/with business leadership and documented remediation plans.

Background checks

Magellan Complete Care conducts background checks on all employees as part of our initial hiring process. Monthly, we check the HHS-OIG List of Excluded Individuals/Entities (LEIE), the U.S. General Services Administration’s (GSA) Web-based Excluded Parties List System (EPLS), and applicable state exclusion lists for names of excluded individuals, contractors, Providers, and vendors barred from participation in Medicare, Medicaid, other federal healthcare programs, federal contracts and state healthcare programs.

Provider contracting and sanction monitoring

All Magellan Complete Care network providers are required to review and sign a contract that details their responsibilities in complying with our policies and procedures, including those requiring compliance with all federal, state, and local mandates and program requirements. Member-hired caregivers are obligated to follow all requirements in the Service Agreement to acknowledge their understanding of program integrity requirements. Credentials submitted by providers during contracting and recredentialing processes undergo primary source verification. Our Legal Team investigates any adverse action cited in legal documents, taken by licensing or professional societies, and other sanctioning information that is pertinent.

Collaboration and communication with customer agencies and departments

We routinely conduct joint investigations, audits, and site visits with state and federal staff as appropriate. Our local special investigations unit (SIU) staff ensures ongoing sharing of allegation and investigation information with state agencies and HHS-OIG, and provides other support to regulatory and law enforcement teams.

FWA hotline

Magellan Complete Care’s Corporate Compliance Hotline allows for anonymous reporting of potential FWA. Compliance also maintains an email box for reporting compliance concerns. Similarly, our SIU has a fraud hotline and email box. Contact information for these communication vehicles is provided to employees, providers, subcontractors, and members on a regular basis in various written and online materials and/or training.

FWA investigation

In compliance with state and federal requirements, Magellan Complete Care’s SIU conducts investigations of allegations and performs the appropriate follow-up internally and with state agencies and HHS-OIG within prescribed timeframes. We work with other Magellan, Inc., company departments and functions as appropriate in conducting investigations and reporting to state and federal entities.

Reports and trends

Magellan Complete Care routinely generates reports that identify trends in FWA, complaints, grievances and other reported concerns from members, providers, employees, contractors and other and stakeholders. These reports inform our program integrity efforts, which involve the SIU, our quality departments and other areas who address trends and implement remediation and process improvements.

SIU analytics

The SIU analyzes claims post-payment for potential FWA using various statistical analysis tools, such as IBM SPSS Modeler, as well as other proprietary tools. Magellan Complete Care analyzes data monthly, looking for patterns of schemes and outliers in utilization and cost. We use methodologies such as predictive analytics and social network analysis, and develop new algorithms and analyses in response to identification of additional risk areas or FWA schemes. We also conduct custom analyses and provide reports on an ad-hoc basis for investigation- or customer-specific requests.

Clinical reviews

Magellan Complete Care ensures consistent application of clinical criteria through:

  • Training
  • System support
  • Case audits
  • Inter-rater reliability
  • Policies and procedures
  • Protocols for testing, monitoring, and training.

We continually review medical necessity decisions to mitigate under- and over-utilization risk.

Claims edits auditing

Magellan Complete Care conducts monthly post-payment audits on a random sample of claims for each health plan. Results are documented in the QA database, monitored for trends, and forwarded to the appropriate processing unit for review and followup. We require all subcontractors who process claims to follow this process.

Pro- and retrospective drug utilization reviews (ProDUR/RetroDUR)

As part of the ProDUR processes, Magellan Complete Care electronically evaluates all claims to identify potential issues related to FWA, such as matching the quantity billed to package size/unit of use and flagging therapeutic and drug class duplicates. We work with dispensing pharmacists to resolve and prevent issues.

For RetroDUR, we focus on polypharmacy, reviewing potential candidates for our lock-in program. We work with prescribers to refine and optimize drug regimens and minimize waste. A number of our standard and ad-hoc reports flag potential areas of FWA such as doctor-shopping, frequent 72-hour emergency dispensing, and the like, enabling us to monitor and quickly intervene if necessary.

Service verification audits

Magellan Complete Care conducts verification of service audits via direct requests to members to review billed services. We follow up with all members who indicate services were not provided, and refer cases of suspected fraud to our SIU.

Minimizing FWA in Long-Term Services and Supports (LTSS) and self-directed programs

Magellan Complete Care recognizes that FWA often occurs in the durable medical equipment and other LTSS spaces. We provide training, technical support, and consultation to our LTSS partners. We also conduct proactive audits of LTSS provider activities to ensure  appropriate use of funds. We collaborate with state and federal agencies on LTSS FWA issues as appropriate.

In the self-directed model, our role is to provide resources and support to ensure appropriate use of the funds to pay for these services. This includes collaborating with state and federal self-directed contracting and investigative units to assess if appropriate processes are in place and using data to identify areas requiring additional inquiry and followup.

Member and provider education

Magellan Complete Care helps our LTSS and self-directed members understand their part in program integrity. We help members understand their rights and responsibilities in ensuring that services are provided as required and billed appropriately. We make sure that members who are self-directing are using tools that clearly spell out their expectations of people/organizations that provide services to them.

Magellan Complete Care also uses providers who offer quality, accessible and timely services. We educate them on service delivery and coordination processes, understanding and using forms, receiving and billing within approved authorizations, submitting claims, electronic visit verification (EVV), and the importance of providing accurate information and how to do so.