For doctors, problems with getting insurers to pay claims promptly and properly are nothing new. But in 2018, struggles with one particular health plan brought unprecedented consequences.
Never before had a health plan’s erroneous claims-processing dragged out for more than nine months and cost Houston’s Oncology Consultants more than $3 million in backlogged claims. Never before had Yuval Raizen, MD, a hematologist at Oncology Consultants, watched one of his cancer patients front $25,000 of his own money just to make sure his treatment could continue — after the health plan mistakenly dropped his physician from its network.
“We’d had an established relationship, and basically we were in the midst of therapy and [he] wasn’t willing to take the time [for the insurer] to solve that,” Dr. Raizen said in January. “And I’m glad he didn’t — because we still wouldn’t be anywhere now.”
For independent practice association (IPA) Jefferson Physician Group and its president, Guy Culpepper, MD, never before had an insurer offered to expedite backlogged claims in exchange for waiving penalties it was supposed to pay and interest on its debt — a proposal that could easily be perceived as using claims for negotiating leverage. (See “How Prompt Pay Penalties Work,” page 24.)
These tales of physician aggravation arose out of what a slew of practices say was a problem with insurer Molina Healthcare of Texas in 2018, prompting the Texas Medical Association and Harris County Medical Society (HCMS) to intervene with state insurance regulators. At press time, although practices who spoke to Texas Medicine were still waiting to get paid, there were indications that a resolution might be at hand.
Although the extent and nature of Molina’s problems may be outliers, it isn’t the only insurer to give physicians prompt-pay problems, and it won’t be the last. Some of the practices trying to recover payments blame not just the health plan, but also the extended response time from the state regulator overseeing insurance products and conduct: the Texas Department of Insurance (TDI), which says it’s hiring staff and making other changes to improve that response.
Stephanie Goodman, TDI deputy commissioner of public affairs, says Insurance Commissioner Kent Sullivan made improved complaint processing a priority after Gov. Greg Abbott appointed him in 2017.
“We understand there are times right now it can take months to hear back from us, and that’s not acceptable. We get that,” Ms. Goodman told Texas Medicine. “It’s just working through that backlog is going to take us a little bit of time.”
Physicians on the other end of the complaint, meanwhile, are left out in the cold to resolve their claims payments on their own.
“The amount of manpower that we have to spend to go back and try and get payments for services, 180 days and beyond, it’s just too much,” Dr. Raizen said. “We don’t have time to do that, but we’re talking about sometimes millions of dollars. So you can’t just let it go. But there is a lot of manpower spent in that. And it’s across multiple payers.”
The Molina saga points to a general problem with prompt-pay enforcement, which for Dr. Culpepper comes down to physicians having “absolutely no hammer — no empowerment” when dealing with insurance companies.
Oncology Consultants’ problems started in early 2018, according to contracting and business development director Katherine Grigsby. That’s when the practice discovered Molina had erroneously dropped several Oncology Consultants physicians out of its network.
Ms. Grigsby says she approached Molina in March 2018 about fixing the error, which the health plan told her was a computer problem. From there, Ms. Grigsby says, came a degree of unresponsiveness that she’s never seen in her 28-year career. After months and months of prodding Molina — and about $3.5 million in accumulated claims — Oncology Consultants was still waiting as the calendar flipped to 2019.
“They would tell me, ‘We’re going to go fix it, we’re going to go fix it.’ Then the provider representative, we’d follow up with her, and she’d have to follow up with the other department,” Ms. Grigsby said. “We never could get answers.”
Meanwhile, Dr. Raizen’s cancer patient had to front the money for his chemotherapy drugs while his physician waited to officially rejoin Molina’s network.
“This is not a patient that’s well-to-do,” Dr. Raizen said. “This is someone that kind of scrounged together everything he could find to be able to afford the payment.”
According to Ms. Grigsby, HCMS arranged for several practices, including Oncology Consultants, to meet with Molina Chief Operating Officer John McGuinness in late 2018.
“He was very professional,” she said. “But what’s interesting is they asked me for certain information, and I sent them a formal letter on it after the meeting [to] follow up, and have yet to hear back. And I’ve followed up twice in an email.”
However, Ms. Grigsby said she had recently heard from Molina that the problem was fixed. At press time, the practice was waiting for the monetary evidence that that’s true.
Dr. Raizen says the issue with Molina seemed to result from systemic disorganization, rather than one specific problem.
“But at the same time, it’s not just the lack of organization. It’s the feeling that there’s not much sense of urgency to take care of the problem,” he said. “Not only are they disorganized, we don’t get a response in a prompt manner. The resolution is not acceptable; there is no resolution, and it doesn’t seem on their end that they have any real drive to take care of the problem. And at the end of the day, it’s the patient care that’s suffering.”
Molina responded to Texas Medicine’s request for an interview with a short statement saying it’s always been committed “to being a strong partner for providers and regulators alike.”
“We have consistently paid over 98 percent of our facility and physician claims in less than 30 days, and nursing facility claims within 10 days,” the statement said. “Molina has also consistently outreached to contract with providers so our members have access to high-quality, affordable health care. We welcome the opportunity to partner with [payers], providers, and the legislature to address issues that continue to be problematic in Texas’ ACA Marketplace, such as clearly defining parameters for out-of-network reimbursement and addressing surprise balance billing that impacts so many consumers.”
A questionable waiver request
Although Dr. Culpepper’s account of his initial problem is similar, he says what Molina later asked of his IPA marked a strange turn.
Dr. Culpepper is president of both Jefferson Family Group and Bent Tree Family Physicians, which he calls “a neighborhood family practice.” After he learned from Bent Tree’s accounts receivable team that Molina wasn’t paying claims, Dr. Culpepper contacted the insurer himself. According to him, Molina said a system change-over had caused it to inadvertently delete Bent Tree from its list of in-network practices, along with other physicians. Molina apologized, he said, and vowed to process the claims.
From there, he says, there was no progress amid a sequence of personnel turnover at Molina. Each new person Bent Tree dealt with seemed unaware of the mistake and told Bent Tree its physician wasn’t listed as participating in the network, Dr. Culpepper says.
“And you have to go through it all over again to tell them, ‘No, we’ve already had it acknowledged that the computer over there was broken.’ This goes on for four or five months,” Dr. Culpepper said. “Meanwhile, at our family practice, we have approximately $58,000 of debt from Molina. And for our primary care practice, that’s big. For any business, that’s big.”
Eventually, he says he discovered that at least a half-dozen practices in the Jefferson IPA were having similar problems. In several emails provided to Texas Medicine, Molina representatives contacted Jefferson and said the plan would expedite the claims for the Jefferson practices — if the IPA would get those practices to agree to waive penalties or interest on the debts. Doing so, said one email from Molina, would “allow the claims to process quicker.”
Given that IPAs aren’t allowed to negotiate the terms of contracts they sign on behalf of their practices, Dr. Culpepper found that request “weird,” and it prompted him to contact TMA.
“Why would anyone there think that we should negotiate then in reverse on behalf of Molina, and go to our members and have them waive the right that’s been instituted by the state legislature?” he asked.
Houston Eye Associates was another of several practices that contacted HCMS about problems with Molina. Houston Eye says it received erroneous claim denials for failing to meet prior authorization requirements. It contacted a Molina claims representative, who “kept making promises that it would get corrected and they would get these claims reprocessed,” says Jeri Lynn Patterson, Houston Eye’s patient account representative and supervisor.
But after a March 2018 meeting with Molina representatives, Ms. Patterson said, “We couldn’t get contact from anybody — no response.” She filed a complaint against Molina notifying TDI that Houston Eye had more than $253,000 in claims outstanding. According to Houston Eye, the unpaid claims included Medicaid as well as commercial plans.
In January, Houston Eye told Texas Medicine it was on the verge of finalizing a settlement agreement with Molina over the unpaid claims. But settlement negotiations came with their own difficulties, practice representatives said.
“Molina was definitely trying to be savvy,” said Chris Ombrog, Houston Eye’s revenue cycle operations manager. “Because they just said, ‘Hey, we’re going to settle for this amount,’ and they didn’t include any line-by-line details. We had to demand that information to understand, ‘What are you paying, and what are you not paying?’ And they kind of sat [on it]; they didn’t really respond. So it took a while to get that line by line.”
TDI: Trying to get caught up
The Molina mess became a problem not only for doctors, but also for TDI. Payment delay and lack-of-payment complaints are old hat to the department, which has received 5,649 of them over the past five calendar years, according to TDI statistics. Blue Cross and Blue Shield of Texas topped the list over that time period with more than 1,200 complaints. (See “Payment Delay Complaints: The Top 10,” page 23.)
TDI’s struggle to address complaints about Molina is a sore spot for affected practices. Ms. Grigsby said Oncology Consultants still had yet to hear an initial acknowledgment from TDI on its complaint from late summer 2018. Mr. Ombrog says Houston Eye got initial confirmation its complaint was filed, but he held TDI partially at fault for moving slowly.
“If there’s multiple people complaining about the same issue, the same things that are happening, [TDI] should be moving on those, and that should be the first thing on their plate, to go and research and investigate and get Molina to respond,” Mr. Ombrog said.
Ms. Goodman from TDI says the state is devoting more staff solely to handling health insurance complaints. Only about 16 percent of Texans have state-regulated plans, Ms. Goodman says. But many times, TDI must weed out complaints about federally regulated plans.
“The numbers are headed the right way in terms of our working through the backlog on complaints and having better response times,” she said. “It’s just going to take us longer to see the kind of results in that section that we have in some other areas, where the process itself isn’t so involved.”
According to TDI staff, some health plans that largely had sold Medicaid and CHIP products — where no prompt-pay penalties exist — had trouble transitioning when rolling out commercial and exchange products. Ms. Goodman believes that’s the case with Molina, which had already established a history of claims problems. In December 2016, a TDI consent order fined Molina $200,000, finding in part that the insurer had processed claims late, had failed to pay prompt-payment penalties, had wrongly paid some claims based upon its nonparticipating provider payment rate, and had committed network adequacy violations.
For TDI’s enforcement aims, seeing Molina’s name pop up again indicates “just a larger issue of better monitoring, spotting issues quickly, following up when you have an order like that,” Ms. Goodman said. “In that case, we did follow up, but to be honest, we gave them too much time.
“That’s one of the things that Commissioner Sullivan has really focused on. He’s actually created a unit to say, ‘Let’s better monitor all the information and data that flows into the agency so we can spot issues quickly, so that if we see an increase in complaints or confirmed complaints or whatever it is, we can identify that hopefully before people even need to file a complaint with us.’”
“We’re talking about real patient care”
Ms. Goodman told Texas Medicine the department has requested detailed data from Molina to figure out what penalties it owes. HCMS, meanwhile, says rather a computer problem, it’s heard from Molina that the company’s own staff dropped the ball on keeping its networks up to date. HCMS says Molina has claimed it’s in the process of fixing that issue.
It’s rare that TMA needs to intervene in a complaint involving Texas prompt-pay laws, says Genevieve Davis, TMA’s associate vice president of payment advocacy. Most complaints TMA receives about payment timeliness are related to federally regulated, self-funded plans, because most state-regulated insurers have processes in place that make sure they pay or deny a fully insured claim on time, she says.
“TMA values the relationship we have with TDI, and we appreciate them engaging us in discussions of this issue and others that impact Texas physicians,” Ms. Davis said. “The prompt-pay laws are very clear on the health plan’s responsibility to pay claims in a timely manner. We would expect to see TDI hold the plan accountable for complying with the laws. TMA will also watch for any additional enforcement action TDI may take against the plan.”
If you’ve filed a complaint with TDI against a health plan, she added, let TMA know so the association can act as an intermediary on your behalf if you don’t hear back soon on your complaint. To notify TMA, email genevieve.davis[at]texmed[dot]org.
Dr. Raizen says the stakes are high for patients and physician practices.
“We’re not talking about hypothetical situations. We’re talking about real patient care, real dollars, and something that would be hugely valuable to have taken care of [within weeks],” he said.
“As a practice, if we’re hamstrung by lack of payments and inability to get reimbursed for services that we’ve already provided and already paid for, that limits our ability to take care of someone quickly and effectively, properly. And I don’t think it’s in the best interest of anyone other than the health plan.”
Bent Tree’s only recourse in the Molina situation was to stop seeing new Molina patients, which it did, Dr. Culpepper said.
“That’s why we’ve had rules like this put in by the legislature, because they recognize that we as small businesses don’t have the power to get paid properly,” he said. “It’s a basic right in contract law that you’re going to get paid.”
Tex Med. 2019;115(3):20-25
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