In MLTSS, states substantially delegate responsibility for critical incident management to the MCO. They require the MCO to receive critical incident reports from providers, and investigate and/or review critical incident reports to ensure that member health and welfare is safeguarded.
States vary in their approach to defining which incidents must be reported. All have protocols for reporting and addressing instances of abuse, neglect and exploitation. Several states also require that additional incidents be reported. In other states, the MCO is allowed to specify additional types of incidents that they will report.
Some states establish critical incident procedures that MCOs must follow, yet others allow the MCO to develop its own approach. For example, Arizona requires MCOs to document all the steps in the investigation and resolution process for each incident, including follow-up with the participant to ensure that needs have been met and any required corrective action steps have been taken. On the other hand, in Tennessee MCOs must develop their own critical incident management protocols, but they are still required to report to the Medicaid agency any incident that significantly impacts the health/safety of a member. As is the case in most states, MCOs in Arizona are bound by law to report incidents to the state's protective service agency for qualifying incidents, but Arizona MCOs must also submit a copy of protective service reports to the Medicaid agency as well.
States also have different requirements for the timeframes within which specific incidents must be reported to them. Wisconsin, for example, requires the MCO to report "egregious" incidents immediately. Michigan requires MCOs to report certain deaths within 24 hours (i.e., those that occur as a result of suspected provider action/inaction and those that are the subject of a recipient rights, licensing or police investigation). In Tennessee, the MCO must report any death or incident that could significantly impact the health or safety of a member within 24 hours.
In Pennsylvania, the state operates a centralized electronic web-based critical incident reporting and management system. The MCO must report critical incidents using the web-based system within 24 hours of receipt of the report. Actions taken to ensure the safety of the member are also recorded in this system. This approach provides both the state and the MCO the ability to review and monitor in virtually real-time whether critical incidents experienced by members are being addressed appropriately and in a timely manner.