Dr. Crow says the department staff-
ers are able to aid physicians because of their extensive knowledge. “You don’t get $1 million without a lot of hard work, a lot of expertise, and a lot of different things that had to be corrected,” he said. “It’s not like it was just one carrier on one type of surgery in one location in Texas. It’s really from all comers, all payers, all specialties, and all regions of the state.” Dr. Crow says Payment Advocacy staff members have the breadth and depth of knowledge to assist “with pretty much any situation. As a member, that’s a great benefit. All of us at some time or another have those issues, and to have a resource like that is pretty incredible.” And, Dr. Crow says the health plans maintain a very collegial relationship with TMA in attempting to resolve claims and other issues. In fact, Blue Cross officials say they
created their Office of Physician Advoca- cy (OPA) specifically to work with TMA on resolving claims and other issues. “The Office of Physician Advocacy
here at Blue Cross appreciates the op- portunity to work with TMA’s staff in resolving ‘hassle factor’ issues,” said Dee Whittlesey, MD, Blue Cross vice presi- dent for OPA. “Because our OPA staff understands the importance of TMA’s work, our turnover time for resolution of ‘hassle factor’ claims is 1.5 days.”
programs to expand the physician work- force, public health initiatives, and qual- ity improvement programs.
“Based on our discussions over the
past several weeks, we are pleased with the progress [and] eager to continue to work,” Medicaid Director Cindy Mann said in the letter to the Texas associate director for Medicaid and the Children’s Health Insurance Program (CHIP). The new funding pools are essentially a work-around to keep money flowing to hospitals that managed care expan- sion otherwise would have canceled. Hospitals had expressed concern over whether the proposal would meet fed- eral approval. The Texas Health and Human Servic- es Commission (HHSC) initially sought approval by Sept. 1 to quell hospitals’ concerns before phase I of the expansion began on that date. Phase II will begin on March 1, 2012. Without CMS approval, the hospitals
were at risk of losing some $2 billion in federal Upper Payment Limit (UPL) funds because of rules that require man- aged care payments to be actuarially sound. The UPL dollars are used to make up for the state’s low hospital Medicaid reimbursement rates. County hospi- tals finance the bulk of the program by transferring local tax dollars to the state to then draw down federal Medicaid matching dollars.
CMS said in the letter that it could
not promise a date for final approval, but indicated that it could come as early as Sept. 30.
Feds approve Texas Medicaid managed care expansion
The Texas Medicaid program can move forward with its managed care expan- sion thanks to the approval of a waiver request by the federal government. A September letter from U.S. Cen- ters for Medicare & Medicaid Services (CMS) officials said the agency had
“reached agreement in principle” on the Texas plan to expand Medicaid managed care across the state and create funding pools to finance infrastructure, including
22 TEXAS MEDICINE November 2011 Meanwhile, HHSC already tentative-
ly awarded contracts to health plans to implement phase II managed care in the Lower Rio Grande Valley and in rural counties. The Texas Medical Association did not support the expansion of Medicaid managed care during the 2011 legisla- tive session but it did not oppose it as it had done in previous sessions. John Holcomb, MD, of San Antonio, chair of TMA’s Select Committee on Medicaid, the Children’s Health Insurance Program, and the Uninsured, says there was little expectation that the managed care ex- pansion could have been avoided given the state’s fiscal crisis.
Fewer uninsured Texans in 2010
A group that advocates for a national health program says the number of un- insured Americans hit a 35-year high in 2010, but the number of uninsured Tex- ans appears to have declined slightly. Physicians for a National Health Pro-
gram (PNHP) says official estimates by the Census Bureau show an increase of about 1 million in the number of Ameri- cans without health insurance in 2010, about 16.3 percent of the population. But state-by-state data from the Cen-
sus Bureau indicate that the number of uninsured in Texas actually dropped from 6.29 million, or 25.5 percent of the state’s inhabitants, to 6.18 million, or 24.6 percent of the population. Texas still has the largest proportion of unin- sured residents of any state in the coun- try. Among children, Texas still has the highest percent of uninsured, but thanks to improvements in the state’s Medicaid and CHIP eligibility system, the overall numbers and percent of uninsured Texas children also dropped in 2010. Since 2007, however, the total num-
ber of uninsured Texas is up from 5.86 million, but the percentage is down slightly from 24.7 percent. Nationally, employment-based cover- age continued to decline, dropping from 56.1 percent in 2009 to 55.3 percent in 2010.
Garrett Adams, MD, president of the 18,000-physician PNHP, says even if the Obama administration’s new health law works as planned, the Congressional Budget Office estimates 23 million peo- ple will remain uninsured in 2019. The increase in the uninsured would have been significantly higher had it not been for an increase in the number of people covered by government health programs such as Medicare, Medicaid, and military health care, he says. n
Ken Ortolon is senior editor of Texas Medicine. You can reach him by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email at
ken.ortolon@texmed.org.
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56