Tag: Medicaid Managed Care

MM Curator summary

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.

 
 

[MM Curator Summary]: Rinse, repeat.

 
 

Clipped from: https://www.beckerspayer.com/payer/centene-to-pay-oregon-17m-in-latest-medicaid-overbilling-settlement.html

Centene will pay Oregon $17 million to settle allegations the payer overcharged the state’s Medicaid program for pharmaceutical services, the Oregon Justice Department said Dec. 6. 

The payer has settled with several other states over similar allegations, including Arkansas, Illinois, Kansas, Massachusetts, Mississippi, New Hampshire, New Mexico, Ohio, Texas and Washington. 

According to Kaiser Health News, Centene has paid settlements to other states not disclosed. 

According to a 2021 Securities and Exchange Commission report, Centene created a $1.25 billion reserve to pay for these settlements. 

MM Curator summary

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.

 
 

[MM Curator Summary]: VA is pulling together their 2 different Medicaid managed care programs.

 
 

Clipped from: https://dailyprogress.com/news/state-and-regional/medicaid-managed-care-merger-starts-jan-1-in-virginia/article_72f8c64c-d60a-5c26-a520-2f5c53469c9e.html

Virginia health care providers want the next multi-billion-dollar, Medicaid managed care contract to tackle longstanding complaints about insurers’ practices – but the state and insurers say the imminent merger of the state’s two managed care programs could fix many of those.

On Jan. 1, the state will merge the two programs, which cover virtually all the 1.8 million Virginians whose health care is paid for by the $18.7 billion, joint federal-state system.

It contracts with six insurers, formally called “managed care organizations” or MCOs, to run the plans the two programs offer Medicaid recipients.

But what insurers’ guidelines for their coverage can differ depending on which program their plans come under, even if the insurers have plans for both programs, said Doug Gray, executive director of the Virginia Association of Health Plans.

“I think that’s where a lot of confusion comes up,” he said.

Providers sometimes think they’re dealing with one program when their patients are actually in the other, he said.

On Jan. 1, the new “Cardinal Care” will merge the Medallion 4 managed care plans that serves children, pregnant women and adults – that last category has grown with Medicaid expansion, since in years past only very low income parents qualified – and the Commonwealth Coordinated Care Plus plans that serve older adults who also are on Medicare, children and adults with disabilities, and individuals in long term care.

Cardinal Care won’t change or reduce any existing coverage, the state’s Medicaid agency, the Department of Medical Assistance Services, said.

But looking ahead to the negotiations for a new five-year managed care contract with insures, providers at a DMAS advisory group, said it needed to be written to address their complaints about denials of coverage for specialized services.

The state plans to begin negotiations on a new five-year contract next year and to nail down an agreement by 2024. That contract will succeed the current contract which expires in fiscal year 2026.

It will involve a complicated juggling of the interests of several actors — patients, doctors and other providers some of whom are often at cross-purposes, MCOs — and the state agencies involved with the program — DMAS, which handles the money and sets the rules and the Department of Social Services, which determines which individuals are eligible for coverage.

Providers and insurers clash most often.  

Providers are often ignored when they bring issues to an insurer, said Marcia Tetterton, executive director of the Virginia Association for Home Care and Hospice.

Jennifer Faison, executive director of the Virginia Association of Community Services Boards, said the new contract needs to ensure more accountability over insurers’ utilization review – the process by which the firms decide whether or not a service will be covered.

The kind of work that’s the focus of Virginia’s community services boards — mental health care outside of hospitals – will be a major emphasis in the new contract, Secretary of Health and Human Resources John Littel has said.

This year has already seen a major step up in Medicaid’s mental health coverage with last December’s expansion of coverage for multisystemic therapy, intensive treatment for youth aged 11 to 18; functional family therapy, short term treatment for disruptive youth; 24-hour-a-day mobile crisis response; community stabilization for people recently receiving crisis care and short term residential stays in a crisis stabilization unit.

Craig Conners, director of payer relations at the Virginia Hospital and Health Care Association said standards for when an insurers’ network of doctors, hospitals and other caregivers is deemed adequate needs to be looked, while coordinating care when a patient is discharged is a problem.

Cardinal Care should make it easier to manage gaps in care, the Medicaid agency says, and it will provide care coordination services as needed.

The unification of Medallion 4.0 and Commonwealth Coordinated Care Plus into Cardinal Care should also simplify processes for contracting with providers and their credentialing, the Medicaid agency said.

MM Curator summary

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.

 
 

[MM Curator Summary]: ProMedica swears its not on the ropes. But that whole losing Ohio thing really didn’t help.

 
 

Clipped from: https://www.toledoblade.com/business/development/2022/11/28/analysts-worry-about-long-term-viability-promedicas-paramount-health-plan/stories/20221128131

 
 

David Barkholz

The Blade

dbarkholz@theblade.com

Though analysts have applauded ProMedica’s plan to divest 147 money-losing nursing homes, the handoff to new operators will be expensive and the long-term viability of ProMedica’s Paramount health plan has become a concern, according to a new report from Moody’s Investors Service.

Paramount has just 88,000 health plan members today after losing about 256,000 Medicaid members last year when the state of Ohio declined to award it a new Medicaid contract under competitive bidding. It also has about 303,000 less-lucrative dental plan members.

In a report on November 17, Moody’s noted there is “uncertainty about the health plan’s long-term viability given its low remaining membership and high competition for commercial and Medicare products.”

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The credit-rating agency also indicated that Paramount will lose revenue next year when an administrative contract runs out that it had with Anthem to transition the Medicaid members it lost in Ohio. Anthem paid ProMedica $50 million in the first quarter for access to that book of business.

Health plans like Paramount need at least 150,000 members to be viable long-term and not be at risk to adverse selection of patients who run up outsized medical costs, said Kevin Holloran, a senior healthcare analyst with Fitch Ratings.

He said Paramount’s 88,000-member health plan count “is really on the small side.”

When Ohio did not re-award a Medicaid contract to Paramount, it cost the insurer about $1.57 billion this year in annual premium revenue. Paramount also announced about 200 job cuts after the loss.

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In an email statement, ProMedica said Paramount is competitive and there are no plans to sell it or its various product lines.

“There is no present consideration of divesting any Paramount health plans,” the statement said.

“While we are transitioning out of the Ohio Department of Medicaid’s managed care program on Feb. 1, 2023, we continue to have competitive Medicare Advantage plans, Marketplace Health Insurance, employer-sponsored health plans and dental insurance to grow Paramount Health Care.”

Paramount has been profitable throughout 2022. For the nine months ended Sept. 30, Paramount posted operating income of $39.1 million, a decrease of $24.1 million compared with the prior-year period.

Mr. Holloran said Paramount can gain the size it needs by acquiring another health plan or organically seeking new contracts with businesses and individuals.

If ProMedica doesn’t want to go down either of those avenues, selling Paramount eventually could be an option as well, Mr. Holloran said.

Moody’s said ProMedica also is looking at additional spending to provide “operating reserves” for the new operators of 147 skilled nursing homes that ProMedica has agreed to divest.

ProMedica has not revealed how much it has agreed to pay. But it easily could be more than $100 million given the scope of the operations being divested, Mr. Holloran said.

In December, ProMedica is expected to close the deal, in which it essentially agreed to give the 147 money-losing skilled nursing homes to a joint venture between Toledo-based Welltower and Integra Healthcare Properties of New York City.

It is surrendering a 15-percent stake worth about $412 million it had in a Welltower joint venture to own and operate the 147 nursing homes. ProMedica and Welltower initially purchased the nursing homes in a $3.3 billion deal for HCR ManorCare.

That turned out to be the price for getting out from under operating losses at the nursing homes. Those nursing homes were responsible for the bulk of losses in ProMedica’s senior care division that totaled $229.3 million in the first half of 2022.

In its report Nov. 17, Moody’s maintained ProMedica’s Ba2 rating on its borrowings but switched its status from under review to a negative outlook going forward. Ba2 is a notch below investment grade or junk bond status.

Part of the agency’s reasoning is that though operating losses and cash burn will be reduced by the divestiture, results are expected to fall at Paramount and ProMedica will likely take a writedown of its nursing home assets that may leave the hospital company perilously close to violating covenants on bonds and bank loans.

On the plus side, ProMedica returned its 11 hospitals to operating profitability in the third quarter. The core hospital division eked out an operating gain of $5 million in the quarter after operating losses in the first half of 2022. That $5 million operating gain compared with a $26.1 million operating gain posted in the year-earlier third quarter.

In its statement, ProMedica said it will continue “to take the requisite steps to strengthen our balance sheet throughout 2023.”

“ProMedica respects the revenue bond rating given by Moody’s Investors Service. As shared previously, we have not been immune to the challenges facing the healthcare industry, such as high inflation and persistent workforce shortages,” the statement said.

First Published November 28, 2022, 3:45pm

 
 

MM Curator summary

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[MM Curator Summary]: The mayor did the right thing and fired a staff member who announced he was going to work for one of the winning MCOs.

 
 

D.C. Mayor Muriel E. Bowser (D) fired the interim director of her administration’s Office of Policy and Legislative Affairs this week. (Bill O’Leary/The Washington Post)

A week after the D.C. Council awarded multibillion-dollar contracts for insuring D.C.’s Medicaid patients to three insurers, seeming to finally end a years-long struggle to right the city’s Medicaid system after court and council fights, Mayor Muriel E. Bowser has called for a new ethics investigation related to the recently completed procurement.

Bowser announced this week that she fired the interim director of her administration’s Office of Policy and Legislative Affairs (OPLA) after he announced he took a new job with the parent company of one of the three insurers just awarded a lucrative Medicaid contract. Bowser (D) referred him to the city’s ethics board and inspector general.

Bryan Hum was promoted in February to the role at the agency, which is tasked with policy analysis and developing Bowser’s legislative agenda. Bowser on Tuesday indicated that Hum had worked on the contracts but said he was not involved in negotiations or deciding on them.

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In an Oct. 23 letter to the city’s Board of Ethics and Government Accountability as well as D.C. Inspector General Daniel W. Lucas, Bowser said Hum had given his two-week notice to the city two days earlier, saying he would be joining Elevance Health, the parent company of Amerigroup. Earlier that week, the D.C. Council voted to award the city’s Medicaid contracts to Amerigroup, MedStar and AmeriHealth after a contentious, years-long procurement process.

Tony Felts, a spokesman for Amerigroup, said Hum applied for the job in response to a public job posting in August — after D.C.’s Office of Contracting and Procurement had already made its decision on awarding the Medicaid contracts, though the contracts had not yet come before the council for approval.

The city’s ethics rules restrict officials from obtaining future employment that overlaps with their responsibilities in government; two years ago, for example, a high-level Bowser appointee was fined $2,500 for taking a job at Howard University after negotiating a tax break for the school in his city position.

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Bowser said Hum did not recuse himself from any work related to the Medicaid contracts before announcing his new position.

“While he is not a procurement official engaged in the evaluation or negotiation of contracts, Mr. Hum, in the course of his duties in transmitting and shepherding contracts to and through the Council, may be privy to non-public information,” Bowser wrote, while referring the matter to the agencies.

Hum began working in the Bowser administration in 2018 and held various roles with OPLA before he was named interim director. He did not immediately respond to a request for comment Wednesday.

CareFirst, an insurance company that lost its bid to win one of the Medicaid contracts after lobbying the D.C. Council and advertising on social media in an attempt to persuade council members that Amerigroup was unsuitable, sent a statement to The Washington Post on Wednesday saying that the contracts should not move forward in light of the request for an investigation into Hum’s conduct.

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“We appreciate Mayor Bowser’s call for an investigation by the Inspector General and urge the District to halt the contracting process until officials and the public have a full understanding of the extent of Mr. Hum’s involvement in the procurement and approval of these contracts,” CareFirst spokeswoman Jen Presswood wrote.

Bowser’s spokesperson declined to comment on the call to halt the procurement.

At a news conference Tuesday, Bowser said she “won’t tolerate people who don’t follow ethics rules, even upon their exit.”

“People can go onto other jobs, but that’s why we have [the Board of Ethics and Government Accountability] — you can call BEGA and get advice on how you should proceed,” Bowser said. “But it should be obvious to everyone that you can’t be working on one matter while at the same time accepting an employment offer — especially relating to a contract that you have worked on.”

 
 

Clipped from: https://www.washingtonpost.com/dc-md-va/2022/10/26/bowser-fires-official-medicaid-contracts/