Author: MM_ADMIN

[MM Curator Summary]: A CA MCO is investing in its tech stack to improve services to members.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

CalOptima sought to make claims processing and prior authorizations more efficient for members with public payer coverage by revamping its technologies.

 
 

Source: Getty Images

 
 

By Kelsey Waddill

March 30, 2022 – CalOptima—a county-organized health system that offers care through public payer coverage, including Medicaid, Medicare Advantage, and Medicare-Medicaid plans—is launching a five-year strategy to streamline claims reimbursements and authorization processes.

“As the single largest health plan in Orange County, CalOptima provides care for one in four residents. We take that enormous responsibility seriously, and our members are counting on us to help them access the right care at the right time,” said Michael Hunn, chief executive officer of CalOptima.

“Automated technology will allow members to receive same-day authorizations, helping them access needed treatments and specialist care on a timely basis.”

CalOptima will dedicate $100 million to the new strategy, which will go toward acquiring new technologies and establishing a health information exchange. The organization will take a cloud-first approach, which CalOptima assured would be HIPAA compliant and armed against cyberattacks. 

According to CalOptima, this move will make the organization the first in California to adopt real-time claims processing technology for the state’s federal Medicaid program.

“The changes articulated in the new vision will help reduce delays and barriers to care for our members, as well as attract more providers to work with CalOptima,” said Supervisor Andrew Do, chair of the CalOptima Board of Directors. “Understanding the life changes in our members will also allow CalOptima to help our members address insecurities in their daily needs that may impact their physical and mental health.”

The organization has modified its mission and vision statements to encompass these goals. The mission statement revolves around upholding human dignity, and the vision statement stretches into 2027.

“By 2027, remove barriers to health care access for our members, implement same day treatment authorizations and real-time claims payments for our providers, and annually assess members’ social determinants of health,” the new five-year vision explains. 

In addition to the $100 million investment, CalOptima will also dedicate $8 million to a program that will launch through the Orange County Interagency Council on Homeless Health Care (OCICHHC). 

OCICHHC brings together CalOptima and other healthcare stakeholders to address homelessness in Orange County, a region that experienced one of its highest death rates in the homeless community in 2021.

In response, OCICHHC launched a street medicine program. The program sends healthcare professionals and social workers in mobile teams out into the streets of Orange County to meet homeless individuals and connect them with necessary treatments. These efforts directly target the high mortality rate in Orange County’s unhoused community.

“The health care crisis among our homeless population has been a significant challenge,” said Supervisor Doug Chaffee, chairman of the Orange County Board of Supervisors and CalOptima board member. 

“However, we are moving in a proactive direction by forming the Street Medicine team, which will assist our Medi-Cal members who are experiencing homelessness. A vast majority of our homeless Medi-Cal members lack access to medical care, and this team will help address the need by eliminating barriers and linking them to much needed medical care and social services. My hope is that this initiative will help reduce the number of mortalities among the homeless population.”

Other board members applauded the investments in technology, citing the impact these advancements and the street medicine program could have on Orange County community health. They also noted the influence that the street medicine program could have by reducing barriers to access to care.

While CalOptima has tackled healthcare for the homeless through Medicaid coverage, other payer industry leaders have supported using Medicare Advantage special needs plans to provide access to care for the homeless population.

Other payers leverage community data to guide their philanthropic investments for the unhoused community.

Clipped from: https://healthpayerintelligence.com/news/org-streamlines-billing-authorizations-in-public-payer-coverage
 

[MM Curator Summary]: The state will give $22M to a plan it helped to put out of business; the remaining 4 employees will donate the money to a local Medical school.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

A long, acrimonious legal battle between state Medicaid contractor FamilyCare Inc. and the Oregon Health Authority has ended with the state agreeing to pay $22.5 million to the company.

FamilyCare has agreed to donate that money to a medical school in Lebanon, Oregon. The Oregonian/OregonLive reported. It was a Pyrrhic victory for FamilyCare’s founder and CEO Jeff Heatherington. The company has shrunk from 370 employees to four.

“Nothing will change the fact that we had the company going and we had 370 of the finest people I have ever worked with,” Heatherington said.

In 1989, the state created the Oregon Health Plan, an ambitious attempt to reform the healthcare system. The effort called for coordinated care organizations to be formed to administer the Medicaid system at a local level.

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FamilyCare was one of two such organizations in the metro area.

The company clashed with the health authority repeatedly over rates, saying the state allowed the other metro-area CCO to charge more than FamilyCare.

The state claimed Health Share deserved to be paid more because its customers tended to be poorer and sicker. FamilyCare sued in 2017.

The Oregon Health Authority admitted no wrongdoing in the settlement.

Oregon Health Authority Director Patrick Allen said, “I am glad we could resolve these proceedings with an agreement that invests in the future of Oregon’s healthcare workforce and strengthens our healthcare system.”

Clipped from: https://www.modernhealthcare.com/medicaid/oregon-pay-225m-settle-medicaid-contractor-dispute

[MM Curator Summary]: The current Governor wants to get the deal done; the legislature wants to punt it for the next guy (or gal).

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

Governor, Schmidt clash on legislative push for 1-year, no-bid extension

 
 

Democratic Gov. Laura Kelly and Republican Attorney General Derek Schmidt, likely opponents in the November election for governor, disagree on whether the Legislature can force extension of the state’s $4 billion Medicaid contract for one year. (Tim Carpenter/Kansas Reflector)

TOPEKA — The administration of Gov. Laura Kelly sent a letter to leaders of the Kansas Legislature urging removal of a budget provision mandating a one-year extension of the $4 billion Medicaid contracts because the move raised constitutional questions and conflicted with decisions of the Kansas Supreme Court and past opinions of the state attorney general’s office.

Will Lawrence, chief of staff to the governor, forwarded Monday a letter to more than a dozen legislators and Attorney General Derek Schmidt pointing to legal risks of a moratorium on rebidding the contract for services to approximately 500,000 Kansans enrolled in Medicaid. GOP legislators sought delay of work updating the KanCare contract until after the November election in which voters will decide whether to re-elect or replace the Democratic governor. Schmidt is campaigning for the GOP nomination for governor.

Legislation introduced in the House to freeze the contract with three managed-care companies until the end of 2024 generated no public support, but passed a GOP-led committee. Instead of campaigning for that bill, Republican lawmakers simply dropped a provision into a budget bill requiring the delay.

The Kansas Department of Health and Environment would be required to request permission from federal regulators at the Centers for Medicare and Medicaid Services for a delay in renewing the contracts. In addition, KDHE would negotiate to lengthen contracts with KanCare’s managed-care companies — Sunflower State Health Plan, United Healthcare and Aetna Better Health of Kansas.

Four House Democrats uncertain if it was legal to circumvent scheduled expiration of the state’s Medicaid contract asked Schmidt for a legal opinion on Feb. 15. On Friday, Schmidt responded by declaring the Legislature possessed authority to prevent the Kelly administration from proceeding with work on revising and rebidding the Medicaid contract.

Schmidt said there wasn’t a constitutional or statutory requirement that state contracts go through a competitive bidding process. He said the Legislature, as the appropriating authority for the state, had “constitutional power to determine how state funds are allocated and spent.”

“The Legislature may lawfully alter the procurement process for a state agency through new legislation,” the attorney general said. “This includes modifying, delaying or eliminating the competitive bid process and directing the (state agency) secretary in its management of the KanCare system.”

 
 

On the other hand

Lawrence’s letter said Schmidt’s “cavalier-at-best” response omitted previous attorney general opinions and a decision of the Kansas Supreme Court indicating intrusion by the Legislature into the executive branch’s contracting responsibilities violated the Kansas Constitution. The state’s highest court said nearly half a century ago the issue boiled down to separation of powers, he said.

“For the intrusion by one branch into the duties of another to be unconstitutional, the intrusion must be significant,” Lawrence said. “Here, the intrusion of the Legislature into the administration, as opposed to just the funding of the state’s Medicaid program, is a significant intrusion.”

The bill and budget proviso regarding the Medicaid contract envision the full Legislature or the Legislative Coordinating Council, which includes House and Senate members of both political parties, would assume responsibility for reviewing all major adjustments of KanCare until Jan. 1, 2025. The Kelly administration or a successor governor would be stripped of that power.

Lawrence said an attorney general opinion in 2006 indicated what the Legislature contemplated and Schmidt endorsed was unconstitutional. The issue raised in the past centered on an office lease entered into by a state agency. An attorney general opinion said the Legislature could block funding for a lease. However, the opinion said the Legislature couldn’t prospectively mandate an executive branch agency secure approval of a legislative committee before entering a contract for office space.

Lawrence said the House bill and the companion budget provision regarding Medicaid would “go well beyond legislative oversight of already approved contracts to an attempt to expand its role to one of shared administration.”

Lawrence took issue with Schmidt’s placement in a footnote of his opinion the potential of the U.S. Department of Health and Human Services withholding federal funding from Kansas if the state extended the contracts without permission of Medicaid regulators.

“There is very little rationale as to why a bill which had no proponents and a multitude of opponents has advanced this far,” Lawrence said. “We have moved from a discussion of bad policy to one of severe legal consequences.”

He said the budget proviso regarding the Medicaid contracts should be deleted from the state appropriations bill and House Bill 2463 accomplishing the same objective ought to be abandoned.

 
 

KDHE secretary’s thoughts

Janet Stanek, secretary of the state Department of Health and Environment, amplified on Lawrence’s letter by wading into complexities of the Legislature unilaterally altering the state’s procurement process by extending terms of the competitively bid Medicaid contract.

She said in a lengthy letter to the attorney general that allowing direct involvement of legislators in administration of KanCare by reviewing “substantive” or “material” changes would impair KDHE’s duty to function as the state Medicaid agency.

Stanek said the mandate “dangerously” relied on the assumption contract extensions with the three for-profit KanCare companies could be negotiated and that the federal CMS would agree to the change.

Here is what the federal government says about usurping KDHE authority of KanCare: “If other state or local agencies or offices perform services for the Medicaid agency, they must not have the authority to change or disapprove any administrative decision of that agency, or otherwise substitute their judgment for that of the Medicaid agency with respect to the applications of policies, rules and regulations issued by the Medicaid agency.” 

 
 

Clipped from: https://kansasreflector.com/2022/03/29/kelly-administration-counters-ags-opinion-on-extending-4-billion-medicaid-contracts/

[MM Curator Summary]: OH Medicaid is refusing to publish normal reports on MCO MLR rates.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

Won’t disclose federal information meant as ‘guardrails’ to protect Medicaid

 
 

Dozens of disabled people staged a protest against proposed cuts to Medical, Medicare and Medicaid programs. File photo by Justin Sullivan/Getty Images.

After refusing to disclose federal watchdog reports, the Ohio Department of Medicaid last week claimed that the relevant information it “makes available to the public appears to include at least as much, if not more information.”

It pointed to some of that information Monday, but it’s hard to evaluate whether it meets or exceeds that released in other states’ reports. And the department again declined to give specific examples of the kinds of information in the reports that are trade secrets.

The actions raise questions about the department’s openness and its efforts to police its contractors.

At issue are reports that the department’s billion-dollar contractors are required to file. Known as “medical-loss ratio” reports, they’re meant to ensure that managed-care contractors aren’t excessively profiting off of taxpayer dollars meant to provide health care to the poor and disabled.

The Ohio Medicaid department, which frequently brags about its claimed transparency, was asked in a December open-records request for copies of the federally required reports. Three months later, the department responded by saying it wouldn’t release the reports because the contractors they’re meant to keep tabs on said they contain trade secrets.

The Medicaid Department — a $35 billion a year agency — did release report summaries for 2019, more than two years ago. 

They showed in percentage terms what each of the agency’s five managed-care contractors spent on health care and how much they kept in the form of profit and administrative costs. But the summaries didn’t show the underlying data.

The refusal to release those data raised eyebrows among some who follow the arcane, massive-spending world of Medicaid.

“Withholding these routine, mandatory Medicaid (managed-care organization medical-loss ratio) reports is mystifying,” tweeted Kip Piper, a former director of the Wisconsin Medicaid department and former senior advisor to the administrator of the Centers for Medicare and Medicaid Services, the federal agency in charge of the programs. “This is not trade secret or proprietary data. Odd, troubling, ill-advised decision, frankly.”

More thoughtful reporting, thanks. Withholding these routine, mandatory Medicaid MCO MLR reports is mystifying. This is not trade secret or proprietary data. Odd, troubling, ill-advised decision, frankly.

— Kip Piper (@KipPiper) March 18, 2022

In an interview last week, Piper explained that in turning over the management of care to private companies, governments want them to find efficiencies without being too prescriptive. The MLR reports are meant to act as guardrails to ensure that the vast bulk of the money is being used to pay for health care, he said.

“The importance of the medical-loss ratio is it’s a backstop for the (managed-care) plans,” Piper said. “You don’t want to micromanage how you get from A to B, you want to sit down and agree on what B is.”

Also raising questions about Ohio Medicaid’s claim that the medical-loss ratio — or MLR — reports amount to trade secrets is the fact that some other states post the reports on their websites.

Medicaid spokeswoman Lisa Lawless was asked last week why her department considered the reports to contain trade secrets while states such as Arizona do not.

“Ohio makes detailed MLR information available and the data we publish likely exceeds the information made available by most other states,” she said in an email Friday. “MLRs are calculated in different ways from state to state and relative to the federal (Centers for Medicare and Medicaid Services) submission. As one example, expenditures related to quality improvement activities are a common difference, variably defined from state to state and sometimes included, sometimes not.”

Lawless didn’t explain, however, how such differences in reporting related to trade secrets or the public’s right to know how its billions are being spent. 

Nor has she named any of the kinds of data in the Ohio MLR reports that would amount to trade secrets — information that would give competitors of a managed-care organization an unfair advantage if they knew it. Piper, the Medicaid expert, said the kinds of data the federal government requires for the reports are aggregate and thus unlikely to be specific enough to be considered proprietary.

Lawless added that even though her department won’t turn over its MLR reports, it’s making more information public than some that do.

“Based on a preliminary review of the Arizona reports, the MLR information that ODM makes available to the public appears to include at least as much, if not more information,” she said.

Pressed on the matter, she pointed to Medicaid managed-care “dashboards.” One is the financial dashboard for calendar year 2020. It shows medical, administrative and other expenses for each of the state’s five managed-care plans. But the information doesn’t appear to be as granular as in this MLR report of an Arizona Medicaid managed-care plan.

There are reasons to believe that the federal agency in charge of Medicaid intends for the MLR reports to be public. The Medicaid and CHIP Payment and Access Commission, a non-partisan congressional agency, addressed the issue in a January issue brief. It said that the reports are “intended to allow comparisons of plan performance among the major health care programs and across states.” 

Further supporting the idea that MLR reports are intended for public consumption, the congressional brief adds, “… due to delays in developing standardized reporting templates, 2022 will be the first year that states are required to submit these reports to CMS and publish them.” 

Both statements imply that the federal government intends the reports to be shared with the public, and Lawless said her department is preparing to submit this year’s MLR reports using the new, standard federal template.

Clipped from: https://ohiocapitaljournal.com/2022/03/30/ohio-medicaid-claims-its-more-transparent-than-other-states/

[MM Curator Summary]: The state gave Centene 21 days to pay $9M in fines related to unpaid claims to providers and has stopped auto-assignment until issues are addressed.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

Florida’s largest Medicaid managed care vendor, which came under scrutiny for failing to pay claims for sick children over several months, is being fined a record $9 million by the Agency for Health Care Administration (AHCA).

State regulators also are placing sanctions on Sunshine State Health Plan and requiring the managed care plan to take a series of “corrective” actions before members can be auto-assigned to the plan.

The temporary enrollment ban impacts the Medicaid managed medical assistance and Medicaid managed long term care plans.

“The Agency for Health Care Administration takes our obligations seriously to ensure high quality health care is delivered to all enrollees in the Florida Medicaid program,” states the letter levying the sanctions. That letter was sent by Brian Meyer, assistant deputy secretary for Medicaid, to Sunshine President and CEO Nathan Landsbaum late last week.

The letter to Sunshine stated there were more than 121,000 claims from health care providers in which payments were either delayed or not made at all. The claims were identified either through complaints from providers or by the health plan itself.

 
 

Immediate attempts to get comment from Sunshine Health Plan about whether they would appeal were unsuccessful.

Sunshine officials have previously stated that the errors were a result of a software issue following the company’s merger last year with WellCare, the state’s second largest Medicaid managed care plan.

Previous news accounts
detailed how, for months, Sunshine had failed to pay providers for some of the state’s severely sick children that receive coverage as part of Medicaid’s children’s medical services portion. At least one provider shut down.

A review of the data shows that 48,694 long-term care claims were denied for allegedly having wrong diagnosis codes. That’s 40% of the 121,227 unpaid claims. That six-figure total, revealed by AHCA, is higher than Sunshine had previously acknowledged.

AHCA levied a fine of $75 for each claim and is asking the company to explain in detail how it has fixed the claims payment process and whether claims have been reprocessed and paid. State officials also want Sunshine to show it can process claims promptly while moving forward and to hold weekly phone calls between AHCA and company officials to update the agency.

 
 

The state is giving Sunshine 30 days to pay the fine of $9,092,025. Sunshine has 21 days to contest the fines and sanctions.

Though Sunshine representatives have said the held-up payments have been processed, some organizations told Fresh Take Florida that payment issues continue to pop up. Brendan Ramirez, CEO of Pan American Behavioral Health Services LLC in Orlando, said it took months to negotiate with Sunshine to receive payments his organization was entitled to.

With that payment came a nondisclosure agreement that would have barred Ramirez from speaking publicly.

“They said, ‘Before we wire money into your account, we want you to sign this document,'” Ramirez said, according to Fresh Take Florida.

“I called them back and I said, ‘I’m not signing this. I’m not comfortable with signing this. It’s almost like a document from litigation, and we’re not in litigation. I’m just trying to get money that you guys owe me.'”

He eventually got the more than $230,000 owed to him without signing the nondisclosure agreement.

AHCA does not routinely issue “sanctions” against Medicaid managed care plans, nor are corrective action plans often required.

It is not clear how long the corrective action plan will be in effect, but it won’t be lifted for at least one month. AHCA has put five requirements on the managed care company in the corrective action plan, including a mandate that “at a minimum” the plan shows its processing systems are able to pay claims. Sunshine must also show that the claims processing systems work for at least a 30-day period.

The corrective action plan also requires the health plan to provide a detailed summary showing that all the claims had been reprocessed and paid. Sunshine must provide a detailed description of the steps taken to resolve all identified system issues. Finally, the state is requiring the health plan to offer training to providers on proper claims submission processes.

There are more than 5 million people enrolled in Florida’s Medicaid program today. Most of them are required to enroll in a Medicaid managed care plan. Sunshine Health Plan is the largest Medicaid managed care plan in the state.

Clipped from: https://floridapolitics.com/archives/510955-florida-medicaid-hits-sunshine-health-with-9m-sanction-for-not-paying-providers-claims/