Medicaid Officials Seek TMA Input on Red-Tape Relief

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Legislative Affairs Feature — January 2016

Tex Med. 2016;112(1):37-42. 

By Amy Lynn Sorrel
Associate Editor

The state got the message loud and clear: Physicians and patients are sick and tired of the myriad administrative roadblocks that came along with the expansion of Medicaid managed care in Texas and the toll they take on access to care. Thanks to relentless advocacy by the Texas Medical Association's Medicaid Congress and cooperation from new Medicaid leadership, relief may finally be in sight.

In October, Texas Medicaid officials asked for input when they met at TMA with physicians from diverse specialties and geographic regions across Texas. They got it in the form of more than a dozen recommendations for reforms researched and developed by the Medicaid Congress. And they are paying attention to them.

The Texas Health and Human Services Commission's (HHSC's) newest executive commissioner, Chris Traylor, acknowledges that simplifying the Medicaid program is like "untangling a bowl of spaghetti." But he also says the state is committed to a new recipe. 

The shift to managed care "calls for us to reassess how we do business with managed care organizations at HHSC and how managed care organizations do business with you as providers," he said. With nearly 5 million Texans in Medicaid and the Children's Health Insurance Program (CHIP), "if we don't begin to understand how stretched our networks are and begin to address these issues now, we are going to get further behind in access. And the first thing to do is to ask you [physicians] about the challenges you are having because the goal at the end of the day is to have a much more beneficial provider experience and participation in the Medicaid program" so patients get the care they need.

Hang-ups with enrollment and credentialing, confusion with claims submissions, and problems obtaining prescription drugs are just a few of the issues topping physicians' fix-it list. 

The Medicaid Congress' recommendations largely target regulatory changes HHSC can tackle on its own in the short term. But physicians' work does not stop there, and TMA will continue to develop and advocate long-term solutions that require future legislative action, namely, improvements in physician pay and patient coverage.

"All we want to be able to do is sign up, take care of our patients, and get paid. What we have instead is probably one of the most complicated systems," said San Antonio radiologist Adam V. Ratner, MD. 

The time physicians spend on claims processing, prior authorizations, and other red-tape rules that vary among the state's 20 Medicaid HMOs also cuts into the perpetually low payment rates Medicaid offers and further discourages physicians from entering the program, says McAllen ophthalmologist Victor H. Gonzalez, MD.

With physician participation near an all-time low at 37 percent and a March 24 federal deadline looming for Medicaid to reenroll those already in the program, "cutting administrative costs is the first big step Texas can take to boost enrollment," he said. "We've been talking about this for a while, and that's one big way to give providers some relief. That's the message we need HHSC to take back." (See "Hassle Factors.")

For their part, managed care companies say they are willing partners in resolving administrative problems that affect them, too.

Open Dialogue

At the Texas Legislature's direction, HHSC's outreach to TMA — as well as hospitals, home health facilities, plans, and consumers — is part of a broad initiative to simplify Medicaid and improve physicians' and patients' experiences in the program. 

A series of TMA-backed bills passed during the 2015 legislative session call on HHSC to ramp up plan oversight, improve quality, and adopt numerous administrative reforms in Medicaid managed care, now the preferred state model for the program. Texas lawmakers are keen on using managed care to try to reduce costs and improve care delivery in a growing program that now consumes more than a quarter of the state budget.

The congress' list encompasses a number of reforms and encourages adoption of best practices and care delivery improvements across the Medicaid program and participating HMOs. They include:  

  • Simultaneously processing physician credentialing once the enrollment process starts; 
  • Simplifying the Medicaid Vendor Drug Program; 
  • Eliminating payment recoupments for services physicians already provide to Medicaid-eligible patients;
  • Waiving prior authorization for simple in-office procedures and for physicians with a history of providing high-quality, low-cost care;
  • Promoting adoption of new care delivery and payment models and care coordination benefits and payments; and
  • Improving data sharing among health plans and physicians. 

Austin pediatrician Maria Scranton, MD, says her staff spends at least 10 percent of its time getting claims paid. In one instance, Medicaid denied her claims for certain lab tests and asked for additional codes that did not exist. 

"A majority of physicians are doing this correctly," she said. "At least commercial plans pay a higher rate that makes up for the hassle. On the Medicaid side, we've either milked the turnip or the turnip is gone." 

In addition to making sure Texas Medicaid recognizes appropriate claims modifiers, the congress recommended revising policies to pay physicians for in-house lab tests they perform. 

Physicians take issue, too, with HMO payment claw-backs for services doctors already provided because of patient enrollment errors on Medicaid's end — a problem state officials recognized as a top complaint. Some HMOs recoup payments as much as two years after treatment.

Because patients generally do not lose their Medicaid eligibility if mistakenly enrolled in the wrong plan, for instance, the congress says the state and HMOs should be coordinating patients' benefits and sorting out who's responsible for payment, removing practices from the middle.

Common Ground

Meanwhile, a slow and cumbrous enrollment process frustrates physicians and plans by keeping doctors from getting into the program — and HMO networks — in the first place. For instance, Medicaid requires individual physicians and the groups they’re in to enroll separately, and then everyone — including HMOs — must wait on the agency to issue various enrollment identification numbers (Texas provider identifier [TPI] numbers) before credentialing and claims submission can even begin. 

Many physicians like San Antonio neonatologist Alex Kenton, MD, have multiple TPI numbers because they belong to different physician groups, have several office locations, or participate in multiple Medicaid programs. 

Not only is that time spent away from patient care just to enroll, Dr. Kenton says, but also a single error could disrupt the entire process, and the lag time between enrollment and credentialing delays physicians' ability to practice for months. "So you can see the frustration we face day in and day out," he told Commissioner Traylor. "How are we supposed to encourage doctors to participate when they can't even enroll?" 

Athens family physician and TMA Board Trustee Douglas Curran, MD, recently hired two new physician partners, and it took almost a year for Medicaid HMOs to fully credential them. "The doctors took call during that time for zero money. How am I supposed to recruit?"

Some of the HMOs' difficulties also stem from hang-ups on HHSC's end, says Mary Dale Peterson, MD, president and chief executive officer of Driscoll Children's Health Plan in Corpus Christi and a member of TMA's Medicaid Congress. "I'm not allowed [based on state rules] to pay until I get the doctors' Medicaid number. And I have physicians I need to be in network, too." 

To shorten the timeframe for physicians to join HMO networks and allow them to see patients more quickly, the congress recommends Medicaid trash the TPI numbers, use only physicians' national provider identifier, and require all HMOs to process physician credentialing applications at the same time the state processes enrollment. 

Physicians and HMOs also agreed on the need to streamline the state's preferred drug list and updates to it. 

Even though plans administer the drug benefits, HHSC determines the drug list and any edits, often creating a disconnect between the state and health plans and approval delays and communication gaps with physician practices. Physicians must research each individual HMO website to find out if a preferred drug's status has changed. Plans, on the other hand, must consult the state before they can let doctors know if a particular drug is available. 

"I just want somebody to give my patient the medicine they've been on for so long," said San Antonio pediatrician Ryan Van Ramshorst, MD.

Especially if there is a drug shortage, plans also "need a way to communicate quickly with prescribers," Dr. Peterson said.

Chipping Away

Outgoing HHSC Associate Commissioner and state Medicaid Director Kay Ghahremani says medicine's input will help further refine efforts already under way to chip away at the red tape and "really focus on the management of the health plans and allow us to have alternate ways to verify what health plans are telling us. There is a lot of responsibility on our shoulders to make sure members are served well, providers are looked after, and we are responsible with taxpayer dollars." 

The agency is upgrading what Medicaid officials conceded was an "outdated" enrollment system with front-end enhancements to the electronic portal and back-end changes that cut down on clunky, redundant processes like those Dr. Kenton describes. The move coincides with Affordable Care Act requirements that all Medicaid health professionals reenroll in the program at least every five years. Physicians are next on the list, and anyone who enrolled before Jan. 1, 2013, must do so again by March 24, 2016.

The enrollment upgrades parallel another statewide effort to centralize the credentialing process among Medicaid HMOs. Thanks in part to TMA recommendations throughout the sunset review process, lawmakers this year passed Senate Bill 200. Under that new law, physicians would go to one place to submit their information; health plans would go to the same place to retrieve what they need to complete their credentialing processes; and Medicaid would create an interface between the statewide credentialing organization and the enrollment file so all parties have the most updated information. 

Ms. Ghahremani also acknowledges TMA's long-standing concerns over outdated state network adequacy standards for Medicaid HMOs that contribute to known shortages in specialty care. But she says new legislation, TMA-backed Senate Bill 760 by Sen. Charles Schwertner, MD (R-Georgetown), allows HHSC to develop better access criteria with medicine's input, based more on physician-patient ratios and less on the miles patients must travel to find care. The new law also enhances public reporting by HMOs. 

Other HHSC improvements under way that align with TMA's ongoing advocacy efforts include: 

  • Beefing up Medicaid's call center to help address physician complaints;
  • Automatically enrolling women into the newly consolidated Healthy Texas Women program when they lose Medicaid pregnancy coverage; and
  • Coordinating state quality improvement initiatives, such as the 1115 Medicaid waiver, with existing health plan efforts.  

Dr. Curran says quality improvement also hinges on increased communication between health plans and physicians, which he called "the breakfast of champions." The congress fix-it list urges Medicaid to require HMOs "to share meaningful and actionable data with network physicians," such as notification of patient emergency department usage and prescription data. 

Some physicians also reported difficulties partnering with plans to test new care models, prompting the congress' recommendation for more collaboration on care coordination, value-based payments, and other strategies to improve quality and reduce costs. For instance, Medicaid managed care already requires plans to assign care coordinators as a part of patients' benefits, but physicians said few HMOs promote the service or tell them how to bill for it. 

An Ongoing Conversation

Administrative relief is especially critical, physicians say, given the legislature's refusal to reinstate a 2013-14 federal pay bump raising Medicaid primary care payments to Medicare levels, and lawmakers' repudiation of an expansion of the program per ACA. 

Nevertheless, TMA and the Medicaid Congress plan to continue their advocacy for legislative changes physicians consider critical to sustaining the program, namely:   

  • Fair payment for physicians' services; and 
  • Coverage for the more than 1 million Texans who make too much money to qualify for Medicaid and too little to receive subsidies in the private federal health insurance exchange.   

Given lawmakers' reluctance to put more money into a program that consumes the largest portion of the state budget behind education, TMA Vice President for Advocacy Darren Whitehurst says, "The timing may be right to look at how we allocate resources to Medicaid and determine a better way to allocate those resources." 

In between legislative sessions, for example, Lt. Gov. Dan Patrick charged the Senate Health and Human Services Committee with evaluating how billions of state dollars poured into the 1115 waiver — most of which goes to hospitals — are translating into lower costs and better access to quality care. 

That same interim charge opens the door to exploring alternatives to an ACA Medicaid expansion to fill Texas' coverage gap: Come 2017, ACA allows states to pursue new waivers to redesign private exchange coverage to fit local needs.

Amy Lynn Sorrel can be reached by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.

SIDEBAR

Take Action

TMA continues to solicit practical ideas to make it easier for physicians — and their patients — to participate in Medicaid. In addition to telling TMA what is not working, please tell us what is working so we can advocate replications of best practices among Medicaid HMO plans. To submit an idea, email Helen Kent Davis

SIDEBAR

Hassle Factors   

Medicaid HMO administrative burdens physicians find "extremely difficult"  

  • Finding in-network specialty care: 53%
  • Prior authorization for medical services: 47%
  • Paperwork: 46%
  • Recoupments: 40%
  • Coordination of benefits: 36%
  • Prescription drug process: 34%
  • Eligibility verification: 33% 
  • HMO credentialing process: 30% 

What physicians like about Medicaid HMOs 

  • Nothing: 67%
  • Care coordinators: 17%
  • Enhanced pay for care quality/management: 13%
  • Value-added services for patients: 12%
  • Enhanced pay for after-hours care: 11%
  • Alerts when patients are admitted to hospital or emergency department: 9%
  • Disease management: 3%  

Source: Texas Medical Association's 2014 Survey of Texas Physicians  

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Last Updated On

May 25, 2016