Last updated: July 18. 2013 11:19PM - 160 Views
Amelia Holliday
Staff Reporter



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The Medicaid managed care program has caused its fair share of headaches for providers and patients alike since its implementation in 2011, however a bill filed Thursday may be giving providers the ability to find a cure for this persistent headache.


House Speaker Greg Stumbo, D-Prestonsburg, filed HB5, a bill aimed at streamlining the complaint procedures for the Medicaid system and would also set a six-month maximum time limit in which managed care organizations (MCO) could deny payment.


“Now that we are more than a year into Medicaid managed care, we’re seeing where things are going well and where improvement is needed, and one major roadblock is the backlog of complaints we’re hearing about payment,” Stumbo said.


Dr. Syamala Reddy, an ophthalmologist at the Hazard ARH, knows all too well about the backlogs and roadblocks that come along with trying to get payment from the MCOs.


Reddy, who has been a provider to some of his patients for over 30 years, many of them Medicaid users, said one of the main issues with the MCOs is the pre-certification process and wait time. Before any Medicaid patient can be seen, or procedure or test can be started, even something as simple as a check-up, the patient must be pre-authorized and certified to ensure that their care will be covered by their MCO.


The average wait time for a pre-certification is around 48 hours, Reddy said, that is not adding in the amount of time it could take to get through to the company to start the pre-certification process.


“Imagine the hardship the patient goes through when they come in for a check-up, and I send a request for a pre-cert, come back after two days to hear a response,” Reddy said. “On average, it takes seven minutes of my time to get any telephone call to talk to somebody. Not to count the number of hours my staff has taken.”


Reddy said he has allocated one staff member, Keila Pigman, solely for the job of handling all Medicaid calls and pre-certifications because it is too much of a hassle to have everyone on staff trying to add that to their workload.


“You fight tooth and nail and stay on the phone for four hours for them to tell you that they’re not going to approve it. It’s not worth it,” Pigman said. “They don’t care about the patients’ health; they just care about how much money it’s going to cost them.”


Reddy said he has also had issues with what medicines the MCOs will cover for his patients. Fourth-generation antibiotics and medicines, which are the newest and strongest medicines in the field right now, are not being covered most of the time. MCOs will only cover older generations of medicine, Reddy said, and he has even been denied coverage for a first-generation medicine, Neosporin, an over-the-counter antiseptic costing anywhere from $2-5.


Dr. J.D. Miller, ARH’s vice president of medical affairs, said the problems with the new system are making everything difficult for everyone involved in the process.


“Even if you did provide care, if they can’t get their medicines and can’t do the other things, they’re still not going to get the kind of care they need,” Miller said.


Reddy explained that he and other doctors are unable to prescribe any brand name medicine if there is a substitute or generic version available. He said most substitutes and generic versions of medicines are cheaper because the quality is much lower, and thinks the MCOs should not compromise their patient’s care just to save a few dollars that could have to be spent anyway if the patient lets their condition worsen due to frustration with the system.


One out of every six patients Reddy sees, he claimes, drops out of his care because they are frustrated with wait times or non-coverage.


Miller said the new system has been causing the process of getting patients treated to slow down, so much so sometimes that patients will often not return to be treated after waiting to be pre-certified.


Miller said, “Truly, I think the name of the game is to make it harder to receive services because that costs less.”


Reddy attended all of the introductory sessions with the new MCOs when it was announced the changes to the system would happen, and at each one he was told providers would be looking at very minimal changes to the way they handled Medicaid, if any at all. Now, Reddy said the organizations have not kept their promises.


He said with the previous Medicaid system, providers knew who they were talking to when they called the Medicaid office in Frankfort for assistance or pre-authorization for their patients. Now, however, the Medicaid MCOs each have their own separate call centers, which he said do not communicate with each other.


“Things were pretty clear, what we can expect, where we don’t have coverage, where we have coverage, what kind of coverage we have. Today, the three managed care companies we call, we don’t know whom we’re talking to; these call centers could be just anywhere on the planet,” Reddy said.


Reddy and Miller are members of the Medical Staff Leadership Council for the ARH hospitals. Those members from the Kentucky River area, including Reddy and Miller, came together last week and wrote and signed a letter to the editor addressing some of their concerns with the Medicaid system.


Calls made to the Medicaid managed care program in Frankfort were not returned this week, while calls made to the three MCOs, Kentucky Spirit, ConentryCares, and WellCare, were also unsuccessful.


Reddy, who suggested writing the letter, said he hopes this gives his patients a voice that they might not think they have.


Another House bill aims to address issues with MCOs


Another House bill might also help give Medicaid users, like Reddy’s patients, more of a voice as well if it is passed.


State Representative Rick Nelson, a Democrat representing Bell County and part of Harlan County, is the sponsor for HB42, a bill he said could give a solution to what he called an emergency situation.


“It’s obvious that the managed care companies, that something has to be done,” Nelson said.


The bill would allow medical providers, doctors, hospitals, and others the ability to get out of their contracts with the Medicaid managed care organizations (MCOs). Whether the provider works with any of the three MCOs — CoventryCares of Kentucky, Kentucky Spirit Health Plan, or WellCare of Kentucky — if the organization commits what the bill calls a “breach of contract” then the provider can terminate their contract and essentially start using the Medicaid system that was in effect before Jan. 1, 2011.


Nelson said he originally had the idea for the bill because health departments in the state were having to cut programs like school nurses because they were not receiving payment from the MCOs.


“It’s a big deal to have nursing centers in the schools,” Nelson said. “Bell County Health Department is $90,000 behind in their managed health care payments.”


Nelson said the bill identifies multiple ways the MCOs could commit a breach of contract, including failure to pay the provider and failure to provide a medically necessary service to a Medicaid member.


Nelson pre-filed the bill in December, and it was brought before the House Health and Welfare Committee in early January. There has been no vote taken on the bill yet, but Nelson said he is optimistic that it will pass based on the amount of support he has received from other lawmakers.

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