A rocky start for the state’s new Medicaid Provider Enrollment and Management System (PEMS) frustrated a number of practices around the state – and caused some worries that care they provided might go unpaid.
But the Texas Medical Association stepped in to help, alerting the Texas Health and Human Services Commission (HHSC) and Texas Medicaid & Healthcare Partnership (TMHP) to multiple confounding technological roadblocks and helping the agency get PEMS on a better path.
The enrollment system, which TMHP maintains on HHSC’s behalf, launched in mid-December 2021 without enrollment capabilities that were necessary for practices like Austin Regional Clinic (ARC), which helped bring the issues to TMA’s attention. Anas Daghestani, MD, chief executive officer of ARC, lauded TMA’s help – and the state’s response.
“[HHSC] genuinely wanted this program to work; they genuinely invested in the program to make the [enrollment] process easier; and they genuinely acknowledged that while that was the intention, some of that failed and the rollout process actually ended up being counterproductive and delayed credentialing,” he said. “TMA also played a role in reaching out to them. … So we had all the ingredients to make this a collaborative and effective interaction.”
In particular, TMA worked with HHSC and TMHP to solve two major problems:
Aligning enrollment dates – Most physicians are required to enroll and be accepted in Medicare before they can even submit an application for Texas Medicaid. Prior to the launch of PEMS, Texas physicians’ ultimate enrollment date in Medicaid would retroactively align with their enrollment in Medicare. That way, they could get paid for Medicaid care they delivered in the interim.
But PEMS, as launched in mid-December 2021, had no way of closing that gap because of federal guidance intended to avoid the potential for fraudulent claims during the gap period. After TMA brought this issue to its attention, HHSC worked quickly to identify a new approach that would be consistent with federal guidance and still allow Texas Medicaid to align physicians’ effective dates for Medicare and Medicaid.
TMHP hopes to implement the new policy in April and then “reprocess any claims that were denied,” according to a February “post-deployment update” from TMHP. Helen Kent Davis, TMA’s associate vice president of governmental affairs, says it will apply to the overwhelming majority of physicians.
Multi-location physicians – Since its Dec. 13, 2021, launch, PEMS hasn’t allowed practices that have multiple locations to enroll a physician for more than one location at the same time. TMHP said in the post-deployment update that it already has begun a system upgrade to “allow concurrent enrollment.” “Please note that a new provider must be enrolled completely before they can be associated with multiple locations or groups with concurrent applications,” TMHP said.