“IT DELAYS CARE, AND IT DELAYS THE OPPORTUNITY FOR CARE, AND IT’S ULTIMATELY GOING TO COST MORE MONEY DOWN THE ROAD.”
beknownst to them, were reassigned to other HMO networks without con- sideration for where they already received care. For Dr. Holcomb, that meant fighting months-worth of claims denials because neither he nor his patients realized he was suddenly out of network.
BEEFED-UP OVERSIGHT
regularly visits Dr. Fisch’s office and responds quickly to his concerns. Another plan’s medical director finally showed up on his doorstep as this article was written. “Medicine is a per- sonal business, and we deal with our patients on a personal basis. It would be nice to deal with these [HMOs] on a per- sonal basis.” Dr. Fisch added he is pleased the state decided to retain one statewide drug formulary under the Medicaid HMO model instead of using multiple HMO formularies, but the plans’ dif- fering interpretations of what the formulary covers still con- fuses physicians and patients. With little to no outreach by HMOs, he frequently learns about a plan’s denial of a particu- lar drug variation when patients cannot get what they need at the pharmacy.
Nor do patients get much help with enrollment, Dr. Curran says. Many think they’ve signed up when they haven’t, and the system is “fairly complex and obstructionist and not user- friendly. And we are dealing with a population that needs user- friendly material, not more roadblocks.” Health plans’ slow-pay, no-pay tactics also pose a significant
roadblock for already cash-strapped medical practices, as well as for patients, he added. Simply paying practices more quickly would go a long
way, says Dr. Curran, who testified in support of legislation that would have required HMOs to pay error-free Medicaid claims within 15 days. The bill did not pass. Currently, Med- icaid HMOs have 30 days to pay clean claims. Because many already pay within 15 days, TMA recommended that be the industry standard. Quicker payment, “even though the pay- ment is still totally inadequate, helps practices with cash-flow” so they can keep their doors open to Medicaid patients, Dr. Curran said.
When one health plan stopped paying for the ventilator Dr. Holcomb’s patient was using, he turned to TMA to hunt down the plan’s medical director because the company’s website did not clearly list the information. When that same health plan turned around and asked Dr. Holcomb if he would participate in the HMO, his response was straightforward: “I had a bad experience.” For those and other reasons, Dr. Holcomb still chooses not to participate in Medicaid managed care and remains a fee-for- service Medicaid physician. In the early months of the 2012 rollout to rural and South Texas, some of his patients, un-
18 TEXAS MEDICINE October 2013
Those and other experiences leave physicians questioning the state’s oversight of the Medicaid managed care expansions, and the 83rd Legislature responded to TMA’s call for better protections. (See “2013 Legislative Session Yields Medicaid Wins,” page 17.)
One of those victories, Senate Bill 1150, requires HHSC to put in its contracts with Medicaid HMOs a so-called “provider protection plan” to ensure efficiency in enrollment, claims pro- cessing, and payment. The law took effect Sept. 1, and HHSC must implement it no later than Sept. 1, 2014. The provider protection plan must provide for:
• Prompt and proper payment; • Prompt and accurate adjudication of claims through edu- cation on proper submission of clean claims and appeals, acceptance of uniform forms through an electronic portal, and establishment of standards for claims payments;
• Adequate and clearly defined physician and provider net- work standards that ensure patient choice;
• Prompt credentialing processes; • Uniform efficiency standards and requirements for submit- ting and tracking preauthorization requests, and • Measurement of HMOs’ provider retention rates.
Bill author Sen. Chuy Hinojosa (D-McAllen) says the bill helps address what he agrees is an increasing amount of red tape keeping many physicians from participating in the Med- icaid managed care program. “There has been constant miscommunication and misunder- standing [between Medicaid HMOs and physicians]. Providers many times had to submit claims without really knowing what the rules were, and we tried to change that with SB 1150,” he said. “We tried to set up a system that’s more efficient, that is clear in terms of the rules and guidance for both sides of the equation: the managed care organizations and health care pro- viders. Once those rules are defined and put into the terms of the contract, you can enforce those provisions through HHSC and, if necessary, through litigation.” Senator Nelson added that SB 7 also prohibits HMOs from
reducing agreed-upon provider payments across the board without prior approval from HHSC. The provision came largely in response to a sudden decision by Molina Healthcare of Tex- as in 2012 to cut its payment rates to home health care work-
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