Oklahoma’s Oversight of Medicaid Outpatient Services for Opioid Use Disorder was Generally Effective

The State agency is responsible for administering the Medicaid program, including processing and paying claims for behavioral health services. Its goal is to facilitate quality health care services that will produce positive health outcomes for Oklahoma. The Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) has oversight responsibility for behavioral health services in Oklahoma. Its mission is to promote healthy communities and provide the highest quality care to enhance the well-being of all Oklahomans. ODMHSAS is primarily State funded (approximately 71 percent); the rest of its funding comes predominantly from Medicaid for individual beneficiary services (17 percent) and Federal grants (11 percent).The State agency and ODMHSAS have an interagency agreement to ensure that individuals being served by both organizations receive appropriate behavioral health care and to provide reimbursement to ODMHSAS for administrative costs, among other things. The agreement identifies the various roles each organization performs in providing and overseeing behavioral health in Oklahoma.The State agency has four key control activities to ensure that behavioral health services meet State requirements: (1) provider enrollment, (2) behavioral health program integrity audits, (3) claim processing edits, and (4) pharmacy requirements for medications used to treat OUD (OUDdrugs).ODMHSAS also has four key control activities to ensure that behavioral health services meet State requirements: (1) certification of agencies that provide services, (2) annual contract reviews at agencies that provide services, (3) beneficiary prior authorization to receive services, and (4) automated claim analyses to ensure that paid claims meet certain payment rules.Counseling helps people with OUD change how they think, cope, and react, and acquire the skills and confidence needed for recovery. CMS, numerous addiction treatment authorities and nationally recognized evidence-based guidelines, such as the American Society of Addiction Medicine’s (ASAM’s) National Practice Guidelines for the Use of Medications in the Treatment of Addiction Involving Opioid Use, and SAMHSA’s Treatment Improvement Protocol (TIP) 40 indicate that counseling for individuals taking OUD drugs can be helpful in treating OUD.8 SAMHSA’s TIP 63, Medications for Opioid Use Disorders, indicates that although counseling greatly benefits many patients, treatment should target the patient’s needs and, therefore, counseling should not be required.ODMHSAS’s objectives include providing the highest quality care to enhance the well-being of all Oklahomans. To help ensure quality of care and fulfill its oversight role of behavioral health services, ODMHSAS performs annual reviews at outpatient facilities that contract with it to provide the services. During the reviews, ODMHSAS staff evaluate a random sample of 10 non- Medicaid client files to ensure that the facilities appropriately provided and documented their services. ODMHSAS determines whether the services were performed, and it reviews clinical records to determine whether the services were individualized and were client and assessment driven. Review of clinical documentation may include, but not be limited to, screenings, assessments, treatment plans, corresponding progress notes, and other documentation, as necessary.