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Ohio Physicians Give Feedback on Medicaid Managed Care Program

The following was submitted to Maureen Corcoran, Director Ohio Department of Medicaid:

As the state’s largest physician-led association, we appreciate this opportunity to share feedback from Ohio’s physicians. Many of our members provide daily patient care to Ohio’s Medicaid population and thus are uniquely qualified to provide meaningful information to assist the Ohio Department of Medicaid in its upcoming competitive Medicaid managed care procurement process.

The comments we received from our members generally centered on areas where improvement is most desired, including plan accountability, grievances and appeals, provider support, benefits and delivery, and care coordination and management. Additionally, we’ve encouraged our members to respond individually to your request for information so that they might provide specific examples from their specialty and practice setting and location.

Plan Accountability 

  • There must be more transparency as to the performance of the plans. This will assure the plans are fully accountable in regards to patients gaining access to necessary quality medical care and that the insurers are following best practices. It is often unclear to providers who is actually holding the plans accountable because of the frequency of delayed payments, claims retribution, or prior approval for patient care.

  • The plans should also be made to provide data points to prove that they are making timely payments to providers. Too often our members are forced to wait several months to receive payment on approved claims. Plans too often rely on the habitual response of a backlog that is being slowly addressed.

  • The plan contracts should have clear, standardized guidelines for how providers are to file claims and stipulate the process for how claims will be processed.

  • Firm requirements for network adequacy in relation to time and distance for all levels of care should be established to assure patient access to quality medical care. There have been situations where a plan does not have enough providers in a specific specialty to handle the patient pool in a given geographic area of Ohio.

  • Stiffer penalties should be levied against the plans for failure to meet transparency and accountability measurements.

Grievances & Appeals 

  • If a claim is denied, the plans must provide prompt explanations for the denial, including specific codes, descriptions and rationale for the denial and outline a reasonable remedy process and period. While the claim is pending, the provider should still be paid from 14 days of the claims submission. Too often, plans will delay provider payment for undetermined periods while claims are pending even if when the delays are not directly attributable to the actions of the provider.

  • The claims appeal process should be clarified and standardized across all plans. Many providers interact with more than one insurer and thus more than one plan. Providers have grown frustrated over having to learn one set of rules for filing claims, appeals, and grievances and then have to learn a separate process for another plan.

  • A response to an appeal should arrive no more than 30 days after the appeal is submitted. The appeals should be allowed to be filed online and a confirmation email indicating the date and time the appeal was received should be sent to the provider.

  • The plans should not be allowed to maintain a backlog of appeals, which directly leads to delayed payments and sometimes delayed patient care. While some plans will acknowledge that an appeal has been received, action on that appeal is often not taken for several weeks or months.

Provider Support 

  • Each plan should employ a dedicated ombudsman department to help providers fully understand and navigate their plan contracts as it relates to coverages, adjustments, claims submission, appeals process, prompt payments, and prior authorization issues. Among the chief complaints from providers is that they too often cannot find anyone associated with the plan who can give them answers to pressing questions related to the topics above. The OSMA, in particular, receives more than a dozen calls a month from providers directly related to their inability to find an accountable person to address their concerns. This leads to delayed medical service for patients and delayed payments to providers.

  • Each plan should have a dedicated provider representative available to each physician who is easily accessible and knowledgeable to answer questions pertaining the plan the provider’s contract.

  • While Ohio has a prior authorization law, many providers say that the process remains inefficient. Common among complaints is that they do not receive a response within the 10 day allotted period, or within 48-hours for emergency situations, as required by law. Or, they will receive a denial but aren’t given enough information at the time of denial to be able to properly address the matter in a timely fashion. Full enforcement of Ohio’s prior authorization law is necessary. And stiffer penalties for the plans who do not adhere to the law should be enforced.

  • Epinephrine injectors are most often used in emergency situations and can be life-saving tool. Prior authorization for use of these injectors should be removed.

  • Providers should be allowed to have 365 days from the date of service to submit claims, same as the Medicaid fee for service standard.

  • Plan policy changes that impact a provider’s contract with the insurer or patient access to care should be made available to the provider 120 days prior to implementation. The changes should be noted both on the plan’s website and in direct emails to the provider so that there is ample time for necessary adjustments.

Benefits & Delivery 

  • Look for ways to increase reimbursement rates for complex services to entice more providers to provide coverage for Medicaid patients, including increased reimbursement for complex specialty care medical procedures. Many providers decline to accept a larger pool of Medicaid patients because they do not feel they will be properly reimbursed for the service provided. This could also lead to patient access issues and inefficient medical service delivery.

  • Require payment to providers to be sent within 14 days of claim approval or be required to provide an explanation for delayed payment. (Also, see Grievances and Appeals above.)

  • Set firm guidelines for plan recoupment of overpayment. Any effort to recover payment should be detailed the patient’s name, service date, amount sought for recovery, and explanation for need to repayment. Also, Ohio’s recoupment statute of limitations should be changed from five years to two years to mirror equitable standards in other states.

  • Credentialing of physicians associated with these plans should be managed by Ohio Medicaid. Too often, providers are delayed responses for questions pertaining to patient coverage, prior authorization or reimbursement for medical services rendered because the plan has outdated contact and identifying information for the physician. Sometimes the plan will apply these credentialing issues retroactively, denying a provider several months of payments that had been expected.

Patient Care Coordination & Management

  • To make medical services more efficient, require the plans to provide interpreting services to help meet the needs of a growing multi-cultural Medicaid patient-base. With more patients requiring these services and the expense providers incur in delivering the service, there needs to be a requirement in the contract that interpreting services are provided by the plan for any scheduled patient appointment.

  • Similarly, the plans currently provide transportation services for patients who otherwise are unable to travel to their medical appointments. This service should remain part of the plan contracts.

  • For diabetic patients, Medicaid currently only covers three test strips per day. Providers say this is dangerously insufficient for patients requiring multiple insulin injections each day to address low glucose levels. These patients will need to test their levels at least four times a day. Also, the strips sometimes malfunction and do not provide an accurate reading and a re-test is needed. The only alternative for these patients in need of more than three strips per day is for them to pay out of pocket, which is not always a feasible option.

Thank you for allowing the Ohio State Medical Association (OSMA) and Ohio physicians to provide valuable input into this process. We hope this information and feedback provided directly from our members will benefit your procurement process. Physicians are on the frontlines of healthcare so we greatly appreciate your full consideration for the items listed above as a means for further improving Ohio’s system of healthcare. Should you need additional information, please email Todd Baker. 

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