Tag: Providers

 
 

MM Curator summary

[MM Curator Summary]: Nearly 60% of all providers listed in directories were not actually providing services to Medicaid 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.

 
 

 
 

 
 

Dive Brief:

• Researchers found significant discrepancies between provider directories and the actual availability of providers in a large study examining access to mental health services among Medicaid recipients in Oregon. Directories full of “phantom” providers may prevent patients from obtaining necessary mental health care in a timely manner, the study authors said.
• The inaccurate listings may be especially harmful for Medicaid enrollees, who already face high rates of serious mental illness, according to the researchers at Oregon Health and Science University and Johns Hopkins University.
• “Constraining or disguising supply is an insidious barrier to realizing access to mental health treatment,” Howard Goldman, of the University of Maryland in Baltimore, wrote in an opinion piece accompanying the research findings in the July issue of Health Affairs.

Dive Insight:

Medicaid patients are disproportionately likely to have severe, persistent mental health disorders, in addition to complex social and medical needs, according to the non-partisan Medicaid and CHIP Payment and Access Commission.

Medicaid is the single largest payer for mental health care in the U.S. Yet with high demand for those services, there is low provider participation and facility shortages in rural areas, the researchers at Oregon Health noted.

Research from Yale and Cornell universities, published earlier this year in Health Affairs, showed that managed care provider directories may overstate the availability of doctors to see Medicaid patients and suggested that private insurers may be padding networks with physicians unwilling to treat program beneficiaries.

U.S. lawmakers held a hearing earlier this year focused on a U.S. mental health crisis that was exacerbated by the COVID-19 pandemic, shining a spotlight on rising rates of depression, anxiety and suicidal ideation, as well as widespread inequities in insurance benefits.

The Oregon Health study, though limited to one state, shows federal and state efforts to enforce network adequacy standards may be falling short, the authors concluded.

The study compared listings of providers in network directories against provider networks constructed from administrative claims among members under the age of 64 who were enrolled in Oregon’s Medicaid managed care organizations in 2018. Provider directory files included 7,899 unique primary care providers, 722 mental health prescribers and 6,824 mental health non-prescribers in Medicaid managed care networks. 

Overall, 58% of network directory listings were “phantom” providers who did not see Medicaid patients, including 67% of mental health prescribers, 59% of mental health non-prescribers, and 54% of primary care providers.

The influence of provider networks is potentially greater in the Medicaid program than in commercial insurance, the study found, because out-of-pocket payment is often unaffordable, and enrollees are generally limited to contracted providers and do not have cost-sharing options for going out of network for non-emergency care.

 
 

Clipped from: https://www.healthcaredive.com/news/phantom-provider-networkst-medicaid-mental-health-care-access-Health-affairs/626617/

MM Curator summary

[MM Curator Summary]: Long term care providers are sounding the alarm about funding needed to meet new requirements- They say they need $434M more each year; the Good Guvn’r has offered $91M.

 
 

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.

 
 

 
 

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HARRISBURG — Gov. Tom Wolf is asking the Pennsylvania legislature to spend millions to raise a key reimbursement rate for skilled nursing homes in the state to help offset costs from proposed new regulations that would increase daily required care.

With the state’s June 30 budget deadline quickly approaching, the Democrat wants to appropriate $91.25 million to increase the amount of money skilled nursing homes receive for residents on Medicaid.

Roughly 11,000 long-term care residents in Pennsylvania have died since the start of the COVID-19 pandemic, a toll that brought renewed attention to longstanding issues such as dangerously low staffing requirements and outdated regulations.

Groups including the Pennsylvania Health Care Association, which lobbies on behalf of long-term care providers in the state, say the state’s low Medicaid reimbursement rate is a major roadblock to providing higher levels of care. The current rate, they say, can leave nursing home facilities without funding to raise employee wages or buy supplies for patient care.

The association estimates that Wolf’s investment would raise the daily Medicaid reimbursement rate to about $210 per resident on average from the current $199.96 average rate. Neighboring states such as Ohio, Maryland, and New Jersey, have higher rates.

But while PHCA sees Wolf’s proposal as a welcome first step, the organization argues it’s not nearly enough. The trade group estimates the regulatory changes would require hiring 10,000 additional workers and spending $434 million more annually. That has led some to reject the plan as an unfunded mandate.

According to the Pennsylvania Department of Health, there are 683 nursing homes in the state serving about 80,000 total residents. That number is expected to rise in the coming years as the state’s population over the age of 65 grows. According to PHCA, about 66% of residents living in nursing homes across the state have their stay paid for by Medicaid. Medicare accounts for an additional 13%.

There does appear to be agreement among legislators that more investment is needed, but how to do so is still being debated. If funding for nursing homes remains as is, advocacy networks, experts, and nurses on the ground fear facilities may be ill-equipped to support the aging population.

“We’ve come to a place where we either need to make an investment in long-term care in this year’s state budget, or the entire system could collapse,” said Zach Shamberg, president and CEO of Pennsylvania Health Care Association. “That would be disastrous for our older population.”

Why do reimbursements matter?

With the way that Medicaid and Medicare funds are distributed, many nursing home facilities seek to take in Medicare-funded patients rather than Medicaid-funded ones.

“We’ve decided in this country not to cover long-stay nursing home care under Medicare,” said David Grabowski, a professor of health care policy at Harvard Medical School. “So it’s really the one major piece of services that are pushed today over to Medicaid.”

Medicare is a federal insurance program that typically covers short-stay patients, such as patients in physical therapy or post-surgery care.

Medicaid is a state-run assistance program that — following guidelines from the federal government — supports low-income people and typically covers long-stay patients. The reimbursement rate is what each nursing home is paid on behalf of the qualified patient by the state government.

According to Grabowski, the low Medicaid reimbursement in Pennsylvania encourages nursing homes to seek out Medicare patients planning on short stays rather than accepting Medicaid patients who will require long stays.

This dynamic, he continued, makes the federal government “a very generous payer,” and that windfall allows care facilities to typically hit double-digit margins on short-stay patients. Meanwhile, Medicaid patients usually result in negative margins for facilities, he said, causing a gap between the cost of care for residents and the amount of state funding.

According to a February study conducted for LeadingAge PA, a trade association that represents about 380 providers in the state who serve older adults, the daily gap between what nursing homes received for Medicaid residents versus what they spent was $86.26 per resident on average.

Grabowski said increasing the Medicaid reimbursement rate could relieve some of the problems. Lobbyists and advocates for the industry in Pennsylvania are asking for a $294 million investment, rather than Wolf’s proposed $91.25 million.

Grabowski argues any investment in the industry should also involve some form of accountability to make sure the funds improve the quality and are not misused.

“I do think we’re going to have to rethink what it means to both live and work at a nursing home,” Grabowski said. “Because the current economic model is definitely broken.”

More money, more oversight

Wolf’s $91.25 million pitch comes with proposed regulations that would require nursing homes to provide more hours of direct care to residents.

Spokespersons for state House and Senate Republicans confirmed the caucuses will consider the proposal and continue to make investments in nursing homes, but did not provide details.

In 2020, Spotlight PA reported on long-criticized staffing and training regulations that were exposed by the pandemic. Shamberg said that PHCA has found that, on top of rising costs nationwide, nursing homes face these same issues today.

Since the start of the pandemic, the state has earmarked nearly $500 million to nursing homes through Acts 24 of 2020 and 2021. These funds were intended to help ease the burden of additional COVID-19-related costs. But as one-time infusions, PHCA said the money did not address the Medicaid reimbursement rate gap, and therefore did not increase staffing.

Karen Hipple, a licensed practical nurse at Oil City Healthcare and Rehabilitation Center in Venango County, said staffing ratios are too high — with one certified nursing assistant caring for 20 to 30 patients, in facilities she’s worked in and visited. She said that staffing increases need to be the top priority, which requires more funding.

Hipple blames the shortage on the low wages that many workers face in nursing homes. According to data from the U.S. Bureau of Labor Statistics, the average pay for a nurse assistant is $16.44 an hour.

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Clipped from: https://www.spotlightpa.org/news/2022/06/pa-nursing-home-staffing-proposal-91-million-wolf/

MM Curator summary

[MM Curator Summary]: After 17 years of no rate raises, dentists will get a 30% bump next year, adding $116M to the Medicaid spend.

 
 

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.

 
 

CHARLOTTESVILLE, Va. (WVIR) – In the past few years the gap between private insurance and Medicaid has been growing in reimbursement for dentists. The new budget sets aside $116 million in state and federal funding to help fix it.

“The governor is going to sign this on July 1 that will give us a 30% increase in Medicaid reimbursement rates,” Charlottesville Pediatric Dentist Dr. Barrett W. R. Peters said.

Virginia’s new budget increases reimbursement rates by 30%. A change it hasn’t seen in years.

“For the past 17 years, there has not been an increase. The cost of doing dental business has increased about 60% in that period of time. So it’s very expensive to run a practice,” Peters said.

He says this raises benefits patients and providers.

“This reimbursement increase is humongous. It not only helps many patients across the commonwealth, but many children that need help, many adults that need help,” Peters said.

It incentivizes more providers to accept any Virginian who has dental insurance under Medicaid.

“They’re going to find more providers, more people that are willing to participate in a program, because they feel like they can run their business effectively, and take care of the patients that so desperately need this,” Peters said.

Peters encourages insurance companies to take a look at their own plans, so they can prevent toothaches before they even happen.

“So often, in my own practice, I find some basic things are not covered, fluoride twice a year, sealants, just very basic, preventive things, and I think insurance companies really need to work more with providers, and those of us on the ground of how we can best serve you,” Peters said.

This reimbursement increase will go into effect when the new budget does on July 1, 2022.

 
 

Clipped from: https://www.nbc29.com/2022/06/26/virginia-budget-increases-reimbursements-medicaid-dental-care/

MM Curator summary

[MM Curator Summary]: More details on the plan to increase nursing home facility pay and continue the underlying provider “tax” mechanism used to pay for it all. Punchline- meet 70% of CMS staffing guidelines and get bonuses.

 
 

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.

 
 

 
 

 
 

Gov. J.B. Pritzker (D)

A $700 million Medicaid funding boost is coming to Illinois providers after Gov. J.B. Pritzker (D) on Tuesday signed nursing home reform legislation that ties the Medicaid increases to higher staffing levels. 

The legislation was specifically highlighted by top leaders at the Centers for Medicare & Medicaid Services earlier this year as it looks to better support states and implement new payment frameworks for providers. 

The measure was originally passed in April before being signed into law this week. Under the law, Illinois will increase its $2.5 billion in annual nursing home funding by roughly $700 million, with $100 million coming from the state and the rest from federal Medicaid and provider assessments. 

It also calls on nursing homes to meet at least 70% of federal staffing level guidelines in order to qualify for bonus reimbursements. Nursing homes’ star ratings also will be taken into consideration for reimbursement increases. 

Providers and resident advocates both have hailed the reform measure.

“Everyone deserves quality affordable healthcare,” Pritzker said Tuesday. “With [the] signing, Illinois will no longer tolerate an emphasis on profits over people, especially at the expense of our most vulnerable seniors.”

CMS Administrator Chiquita Brooks-LaSure in April said CMS is “moving in an additional direction to make sure the dollars that are being spent are going to direct care.”

New York also has pushed ahead with legislation that ties funding to direct care at nursing homes. The state in February passed legislation that requires providers to spend a minimum of 70% of revenue on direct care — with at least 40% of that going to direct care workers.

 
 

Clipped from: https://www.mcknights.com/news/governor-signs-bill-that-gives-nursing-homes-700-million-funding-boost/

MM Curator summary

[MM Curator Summary]: PA is struggling to deal with a flailing long-term care workforce.

 
 

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.

 
 

 
 

Dauphin County, PA — Pennsylvania has lost nearly 20% of its long-term care workforce since the pandemic started two years ago, according to the Pennsylvania Health Care Association.

The Association reports 11 nursing homes have shut down, including two in recent weeks. Officials say this is creating an access to care crisis. Nursing home providers have been turning away 20 seniors per month on average since December.

It’s a concern with the state’s aging population in mind. The Health Management Associates performed an independent study recently, identifying more than 1.18 million Pennsylvanians will need long-term care over the next 20-30 years.

“If nursing homes, personal care homes and assisted living communities continue to lose workers, who will care for our aging population?” Pennsylvania Health Care Association President and CEO Zach Shamberg said.

“Throughout the state, nursing homes are turning away someone’s parent, grandparent, aunt or uncle because there aren’t enough workers to care for more people,” Senate Aging and Youth Committee Chairwoma Sen. Judy Ward continued.

The Pennsylvania Health Care Association and some legislators are calling for a $294 million increase in the state’s Medicaid reimbursement to sustain a future for long-term care. They also want American Rescue Plan funds to support recruitment and retention.

Medicaid reimbursement hasn’t been increased in the state since 2014 and the rate currently falls about $50 short per resident per day.

 
 

Clipped from: https://local21news.com/news/local/pas-long-term-care-crisis-and-how-a-push-to-increase-medicaid-reimbursements-could-help

[MM Curator Summary]: Headline should read: “Pritzker signs bill that keeps $3.9B in hospital Medicaid payments flowing.” Not exactly the same thing as “helps Medicaid patients.”

 
 

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.

 
 

 
 

Gov Pritzker signs Hospital Assessment Program(WIFR Newsroom)

CHICAGO, Ill. (WIFR) – Governor JB Pritzker signed a bill Tuesday extending and expanding the Hospital Assessment Program in Illinois.

The current program, which signed into law in 2020, runs through the end of 2022. It brought additional funding and improved Medicaid responsiveness in areas of the state most affected by COVID-19.

This bill will help establish refined payment structures for each hospital class and maintain the existing assessment tax structure. The renewed Hospital Assessment program waives $240 million in the assessment imposed on hospitals. It also aligns hospitals with payment and Medicaid needs, as well as offering tax exemptions and waivers to help hospitals recover from the effects of COVID-19.

Pritzker commented Tuesday saying “The Hospital Assessment program was an important support to hospital’s critically in need of additional funding during the worst of the COVID-19 pandemic,”. He’s also optimistic about the impact of the bill, saying “This extension continues to support them on the path to recovery and offers expanded services and Medicaid support to more hospitals to ensure people across the state have access to affordable, high-quality health care.”

House Majority Leader Greg Harris says “The Hospital Assessment program brings an additional $3.9 billion dollars into Illinois’ Medicaid program”.

 
 

Clipped from: https://www.wifr.com/2022/05/17/pritzker-signs-bill-that-helps-medicaid-patients/

[MM Curator Summary]: A CO school will re-sign up to get Medicaid funding for healthcare services after a 10 year break and starting a new plan on how to manage the funding stream.

 
 

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.

 
 

After a hiatus of more than a decade, Poudre School District is rejoining Colorado’s Medicaid reimbursement program for school districts. Through the program, PSD will receive partial reimbursements from the state for the cost of providing Medicaid-eligible health services to some students. 

Reimbursements to PSD will be based on the cost of delivering services given by eligible service providers — including nurses, social workers, health aides, occupational therapists and more — but it is not limited to services provided to students who are enrolled in Medicaid individually. Rather, the program partially reimburses health services provided to general education students who qualify through certain health or behavioral plans. 

The program will serve as “a sustainable source of funding that supports the enhancement and expansion of mental and physical health services in schools,” according to a presentation recently given to the Board of Education.

The money the district receives in reimbursements must be spent on health services for all PSD students, not just those who receive the reimbursement-eligible services. This shift is something PSD spokesperson Madeline Noblett said was one of the main reasons the district wanted to join the program again now. 

“We’re really looking at this as an opportunity as a district to be able to grow revenue to support all of our students,” she said, adding that the “mental, social, emotional (and) academic needs of kids have increased.”

“Our needs have continued to increase every year, and our staff are doing incredible work, but they are stretched thin, and they’re supporting so many kids … So we’re constantly just looking to see what the resources available to us are that we may not already be tapping into.”

Though PSD’s new Medicaid Coordinator Corey Henry said they haven’t yet determined what this money will be spent on, it can be used for things such as hiring additional nurses or mental health staff, getting more equipment or engaging with outreach workers to connect families to their needs. A requirement of the program is that the district form a team to assess its needs and how best to spend the money. 

Currently, PSD has just 14 nurses for its 53 schools, according to Kim Granger, health services coordinator.  

“It just feels like the right thing to do to not leave money on the table when we’re (already) providing the services,” Granger said. “It was kind of a no-brainer in my mind.”

How are PSD students doing?:From attendance to social emotional skills, here are 5 takeaways from PSD’s annual report

PSD was most recently a participant in the Medicaid program in 2009. In the 2016-17 school year, former Superintendent Sandra Smyser considered rejoining the program but ultimately put it on hold.

Noblett said that back in 2009, the district left the program because leaders felt it wasn’t “as expansive as possible for the ultimate amount of money that we were generating as a district.” 

However, the program has since started using a cost reconciliation method to calculate reimbursements and, in 2020, it expanded to include reimbursement for Medicaid-eligible health services to more students. Prior to that change, the program allowed reimbursement based on care given to students with individualized education plans or individualized family service plans, but it now includes students with 504 plans, behavior intervention plans and other health care plans, Noblett said.

These changes streamlined the program and allowed districts to claim more costs for the health services they provide to students, according to district officials. 

For subscribers:31 charter schools closed in the last decade. Still, school choice demand is peaking.

When will the program be in place?

PSD expects the program will be fully in place by Oct. 1 this year, but it won’t see regular revenue to cover the initial investment costs for about three years. The only initial investment required by PSD was the cost to fund Henry’s position and an administrative assistant to help get the program running.

Though district officials cannot predict the exact amount of money it will bring in annually until closer to that three-year mark, neighboring districts and those of similar size have received anywhere from $1.2 million to $2.5 million.

Over the summer, Henry and her implementation team will work to create training schedules for staff, have orientation for administrative teams and begin program training in August and September.

Henry and Granger expect that the biggest change for current PSD providers will be the kind of documentation required to access the reimbursement money, though it’s too early to know what the day-to-day lift will look like. 

“There will be some (service providers) with larger caseloads that will probably have more time to spend on their documentation, and some of that won’t take as much time as they think,” Granger said. “I think there’s a ton of fear out there that it’s going to take a huge amount of time, (but) the program is different than what they knew before.”

In the meantime, the biggest lift for Henry and her team will be supporting the staff throughout training and ensuring they understand their roles in the program moving forward. 

“We’re really hoping to make this as successful as possible, build a program where staff feels supported through training, have clarity around what their work looks like as service providers and really, again, generate money that PSD has not been accessing so that we can help our students,” Noblett said. 

PSD news:Liberty Common Elementary School announces expansion, likely into former charter building

Molly Bohannon covers education for the Coloradoan. Follow her on Twitter @molboha or contact her at mbohannon@coloradoan.com. Support her work and that of other Coloradoan journalists by purchasing a digital subscription today.

 
 

 
 

Clipped from: https://www.coloradoan.com/story/news/2022/04/26/psd-rejoining-colorados-medicaid-reimbursement-program/7374814001/

 
 

[MM Curator Summary]: LA will implement a single provider enrollment and credentialling system across all MCOs.

 
 

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.

 
 

 
 

First-year implantation phase to begin in July for fee-for-service provider screenings. 

The Mississippi Division of Medicaid plans to implement a centralized credentialing process for managed care providers enrolling in MississippiCAN or Children’s Health Insurance Program (CHIP) coordinated care organizations (CCOs).

This is part of an on-going effort to cut down on red tape and reduce administrative overhead for health care providers.

 
 

Drew Snyder, Director of the Division of Medicaid

“The Division has made it a priority to better understand the challenges voiced by providers and sought to work together toward meaningful change in support of our shared goal of better outcomes for beneficiaries,” said Drew Snyder, executive director. “Streamlining provider credentialing will be a huge step toward focusing on patients instead of processes, and we are grateful to the Legislature and provider community for their partnership on this initiative.”

The implementation will take place over 12 months beginning in July of 2022. Providers will follow the DOM’s current screening process to qualify for Medicaid fee-for-service and MississippiCAN. This will allow for immediate admin relief and will not jeopardize health plan accreditation if approved by the National Committee for Quality Assurance (NCQA).

There are three CCOs administering MississippiCAN: Magnolia Health, UnitedHealthcare Community Plan, and Molina Healthcare. CHIP is administered by Molina Healthcare and UnitedHealthcare Community Plan.

Providers who wish to enroll in those networks are required to complete a separate credentialing process with each plan to verify that they are qualified providers. Additionally, they must undergo re-credentialing every three years to ensure their information is still accurate and up to date.

The traditional “credentialing” process, which is required of all health plans by NCQA is lengthy and often requires the submission of additional documentation and related paperwork. Also, providers must currently credential with multiple entities as described above.

Through bills from the Legislature the DOM is able to simplify the operation by enabling providers to credential through one single avenue that will not only qualify them, but allow them to contract with any CCO. DOM screens providers enrolling in fee-for-service Medicaid but has not been required to credential.

When the implementation period ends on June 30, 2023, providers will have a centralized hub for credentialing in Medicaid-related benefit programs.

 
 

Clipped from: https://yallpolitics.com/2022/04/18/medicaid-to-utilize-centralized-credentialing-process-for-managed-care-providers-this-summer/