Doc Data Oversight Crucial for Medicaid

About 15 million new enrollees are expected to flood Medicaid in 2014, a massive 30 percent increase. Health plans have been preparing for some time, because states, already burdened by the program, are looking to managed care to help control costs. (

Provider data management will be crucial to making managed Medicaid work, says Michael Siegel, MD, corporate medical director at Molina Healthcare, a health plan with Medicare and Medicaid plans in 16 states. For one thing, it will pinpoint doctors who need help.

“For instance, if we see that a physician has a high ER usage, we can work directly with this physician to identify the causes and encourage specific members to get preventive care,” says Siegel. “Ultimately, this allows us to create a better medical home.”

A challenge of this type of data collection may be presenting the data in a clear format that allows providers to act accordingly, he adds.

Matthew Haddad, JD, president of Medservant Technologies, a physician data management vendor, says that “for those MCO medical and pharmacy directors charged with ongoing provider quality assurance, compliance monitoring, claims fraud detection, and a million other details, the influx of new patients and providers, compounded by the addition of ever-changing Medicaid rules and regulations, can become simply overwhelming.”

The new federal rules bump eligibility for the program to include adults with incomes of up to 133 percent of the federal poverty level, a move that could bring in younger and healthier adults.

Arnold W. Cohen, MD, chairman of the department of OB/GYN at Albert Einstein Medical Center in Philadelphia, says that in such an environment, “Data availability in a format that is user friendly is necessary for any medical director to determine how to manage care or to decrease costs. If we perceive something to be a problem, such as the number of ultrasounds per pregnancy, there is no way to convince doctors that there really is a problem unless you have data to confirm the problem.”

This, of course, is yet another function that plans can elect to do either in-house or through a vendor. “At Molina, we collect the data in-house,” says Siegel. “The advantage of contracting this service is that it would allow us to free up analytical resources for other purposes. The advantage of doing it in-house is that we’re able to verify the credibility of the results quickly and efficiently.”