Oregon Health Authority Audit Release: Constraints on Oregon’s Prescription Drug Monitoring Program Limit the State’s Ability to Help Address Opioid Drug Misuse and Abuse


Report Highlights

The Prescription Drug Monitoring Program provides an important tool to address prescription drug abuse, including opioid abuse, and help improve health outcomes. Oregon’s laws have put constraints on the program that limit its effectiveness and impact. Restrictions are placed on what data are collected, analyses that can be done with the data, and with whom information can be shared. Correcting weaknesses in Oregon’s program will maximize its potential and help address opioid and other substance abuse issues the state faces.

Background

Oregon has the highest rate in the nation of seniors hospitalized for opioid-related issues such as overdose, abuse, and dependence. The state also has the sixth highest percentage of teenage drug users. The Oregon Health Authority (OHA) manages the state’s Prescription Drug Monitoring Program (PDMP), which collects information on controlled substance prescriptions within the state. The program was designed to promote public health and safety and to help improve patient care. It was also developed to support the appropriate use of prescription drugs.

Purpose

The purpose of this audit was to determine if Oregon can better leverage its PDMP to help with the opioid epidemic.

Key Findings

  1. OHA could better use PDMP data to analyze trends in prescribed drugs, including identifying patterns of possible opioid misuse and abuse. State laws prevent OHA from sharing information with key stakeholders, such as health licensing boards and law enforcement, on questionable activity. Our analysis found people who have received opioid prescriptions from excessive numbers of prescribers, as well as instances of dangerous drug combinations and prescriptions for excessive dosages of drugs. One person who received an excessive amount of opioid prescriptions had some of those prescriptions paid for by Medicaid.
  2. Oregon is one of only nine states that does not require prescribers or pharmacies to use the PDMP database before an opioid prescription is written or dispensed. Mandating use can be effective in reducing opioid misuse and other health related outcomes.
  3. Due to statutory restrictions, Oregon’s PDMP does not collect some prescription information that could be critical in preventing prescription drug abuse. This includes prescriptions filled by pharmacies other than only retail, veterinarian prescribed prescriptions, prescriptions for Schedule V drugs and drugs known to be abused or misused such as gabapentin, and prescription details such as method of payment, lock-in status, and diagnosis information.

Recommendations

Our report includes 12 recommendations to OHA for optimizing the state’s PDMP. OHA can implement some of
these within existing statutes and rules, and for others it needs to work with the Legislature. OHA agreed with
all of the recommendations, but stated that because seven fall outside the scope of its statutory authority, its
ability to implement them is limited. The agency’s response can be found at the end of the report.

Read full report here.

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Audit Release: Oregon Health Authority Should Improve Efforts to Detect and Prevent Improper Medicaid Payments

Report Highlights


Our audit found that Oregon Health Authority (OHA) recovery efforts are appropriate and reasonable, but the agency should strengthen efforts to detect and prevent improper payments in Oregon’s $9.3 billion per year Medicaid program. Prevention of improper payments is more cost-effective than attempting to recover improper payments. We also found that delays in processing eligibility for thousands of Oregon’s Medicaid recipients resulted in millions of dollars of avoidable Medicaid expenditures, a critical issue the agency failed to disclose until raised in a May 2017 Auditor Alert. Furthermore, OHA did not timely disclose relevant information, which impeded our audit work. OHA’s new management has been more proactive and transparent in addressing these issues.

Background

An improper payment is defined by the federal government as “any payment that should not have been made or was made in an incorrect amount (including overpayments and underpayments) under statutory, contractual, administrative, or other legally applicable requirements or where documentation is missing or not available.”

Purpose of Audit

The primary purpose of the audit was to determine if the Oregon Health Authority could improve processes to prevent, detect, and recover improper Medicaid payments. The secondary purpose was to follow-up on OHA’s progress to resolve issues we raised in our May 2017 Auditor Alert.

Key Findings

Within the context that Medicaid is a very complex and challenging program to administer, we found:

  1. OHA has gaps in procedures for preventing certain improper payments. Insufficient management of the agency’s processes for identifying and resolving payment and eligibility issues, prioritization of staffing resources, and efforts to address technology issues put taxpayer dollars at risk.
  2. OHA lacks well-defined, consistent, and agency-wide processes to detect certain improper payments, especially related to coordinated care. We identified approximately 31,300 questionable payments based on our review of 15 months of data. OHA needs to continue researching these claims to determine how many were improper; OHA reported that only a small percentage were improper based on preliminary research of 2,700 claims.
  3. OHA recovery efforts appear appropriate and reasonable, but may be underutilized due to OHA’s limited procedures for detecting improper payments.
  4. OHA reported completing the action plan to determine eligibility for the remaining backlog of 115,200 Medicaid recipients. Approximately 47,600 (41%) were deemed ineligible as a result, although this figure may decrease slightly through the end of November. Failure to address this issue in a timely fashion resulted in approximately $88 million in avoidable expenditures.

Recommendations

Drawing from national leading practices, our report includes eight recommendations to OHA focused on strengthening efforts to detect and prevent improper payments. Oregon Health Authority agrees with our recommendations. The agency’s response can be found at the end of the report.

Read full report here

 

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Audit Release: Automated Medicaid eligibility is processed appropriately at OHA, yet manual input accuracy and eligibility override monitoring need improvement

AUDIT PURPOSE

In Oregon, over one million individuals have Medicaid coverage. Medicaid expenditures totaled $9.3 billion in fiscal year 2016, including $1.2 billion in state general funds. We conducted this audit to determine if two critical automated computer programs managed by the Oregon Health Authority accurately verify Medicaid client eligibility and accurately issue payments to healthcare providers. If these programs do not function properly, clients may inappropriately receive, or be denied, Medicaid benefits.

FINDINGS IMPACT

Manual input errors and lack of monitoring of overrides can cause inappropriate eligibility determinations and payments to providers. If agency leadership implements more effective monitoring of caseworker eligibility overrides and improves manual input accuracy, the state will better comply with eligibility requirements and increase accuracy of payments. Inaction will allow overrides and manual input errors to continue causing inappropriate payments to providers.

Read full report here.

KEY FINDINGS

  • Two critical automated computer programs appropriately determined eligibility, enrolled Medicaid clients in coordinated care organizations, and made appropriate payments to those organizations based on eligibility information received.
  • Automated computer processes appropriately validated the Social Security number and citizenship status of applicants over 99.7% of the time in our review of over 425,000 records.
  • We reviewed 30 eligibility determinations and found seven (23%) had manual input errors. While only one error resulted in a client being determined eligible when they were not, each of the errors related to application information that could have resulted in inappropriate eligibility determinations.
  • Although their volume has significantly decreased over time, overrides of eligibility are not sufficiently monitored, meaning unauthorized overrides of Medicaid eligibility could occur.
  • Our review of 72 overridden eligibility segments showed caseworkers did not take proper action to clear 25 (35%). Overridden segments are not subject to automated processes that redetermine eligibility for certain clients.
  • Our 2011 audit recommendations to OHA and DHS concerning access to the Medicaid Management Information System have not been fully implemented, increasing security risk.

RECOMMENDATIONS SUMMARY

  • OHA should continue efforts to improve caseworker manual input accuracy through additional training, and implement a review process for input where errors negatively affect eligibility determination.
  • OHA managers should monitor eligibility overrides to prevent unauthorized validation and ensure state resources are spent appropriately.
  • OHA and DHS should fully implement our 2011 audit logical access recommendations.
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