Health department: Kentucky Spirit payments are lagging [Messenger-Inquirer, Owensboro, Ky.]

Jan. 11--The Green River District Health Department has billed Kentucky Spirit more than $825,000</money> for medical services it has performed since Nov. 1, 2011, but has been reimbursed only a portion of that amount by the managed care organization.

Health department Director Deborah Fillman isn't sure her agency will receive any more money from the MCO, although GRDHD will continue serving Kentucky Spirit patients.

Kentucky Spirit announced it will leave the state's MCO program next July and, according to Fillman, the for-profit business hasn't been responsive to her department's request to discuss billing issues and reimbursements.

Kentucky Spirit, one of the state's three MCOs, initially advanced GRDHD $500,000 for anticipated bills, and that money has already been spent by the health department to meet its obligations. However, Kentucky Spirit did not start processing claims until September 2012, 11 months after the MCO program began, and Fillman said some of the claims GRDHD submitted may yet be denied by Kentucky Spirit and the money recouped.

GRDHD has not been reimbursed $325,000 for services it performed and is using its own reserve fund to pay those bills. Fillman said she isn't sure GRDHD will see anymore money from Kentucky Spirit before it leaves Kentucky.

"We're hoping for the best," she said.

Fillman said the MCO system is "worse than we expected."

"It's a complex situation, and we struggle understanding it on a daily basis," she said. "Needless to say, we've been frustrated.

"We've been in touch with Medicaid, the managed care organizations and legislators to try to communicate that we're having problems. We're not the only ones. It's all across the state."

GRDHD Administrative Services Coordinator Angel Thompson, who oversees the department's billing, said "We knew what Medicaid would and wouldn't pay. Medicaid was an efficient (billing) system."

But with rising medical costs, Kentucky changed to a managed-care organization system hoping to save the state money. A MCO is a private company that manages health care for most recipients of Medicaid. Medicaid provides health care coverage to eligible low-income Kentucky residents. It covers families with children and pregnant women, medically needy individuals, the elderly and people with disabilities.

The switch to the MCO system took effect Nov. 1, 2011.

Some people remain on Medicaid, but most have been autoassigned to one of three MCOs -- Coventry Cares, WellCare and Kentucky Spirit. During a yearly, three-month open-enrollment period, patients may elect to change their MCO and join a different one in that group.

Patients were autoassigned to certain MCOs based on their physicians' affiliation. Patients were also split among the MCOs based on federal rules.

Fillman said she thinks the MCOs "didn't have a good idea of what Kentucky public health is all about." Certain programs that Medicaid allowed, and health departments continued operating since the switch, were eye-openers for the MCOs, but Fillman said Coventry Cares and WellCare have been cooperative in working through the details.

"For example, we have a perinatal home visitation program in which an employee goes into the home to check on a baby and work with the parents," Thompson said. "It's a home-based visit, and one of the problems the MCOs have with that is they say you have to get prior approval for that kind of service, and they want the prior approval to go through them.

"But that was paid under Medicaid prior to the MCOs."

Fillman said the MCO's also question the school health program.

"We have nurses in 35 schools in the (seven county) district, and they provide onsite services, such as treating kids with diabetes, asthma and a variety of things, even if they need a Bandaid," Fillman said.

Said Thompson, "If kids have had insurance in the past (Kentucky Spirit) won't pay us until we can prove (they don't have it now). But Coventry has worked with us on that, and WellCare said they're going to follow suit, but it hasn't yet.

"Kentucky Spirit, we can't even get a phone call back. We can't get one of their (representatives) here. We can't get any communication with them whatsoever."

Kentucky Spirit said it was not aware of contractual obligations to pay for school health services.

Kentucky Spirit said faulty information provided to it by the state has contributed to losses of $120 million since its work began Nov. 1, 2011. The Cabinet for Health and Family Services responded saying, Kentucky Spirit looked over the data and "willingly signed a binding, three-year contract with the commonwealth."

Fillman said even though Kentucky Spirit is lagging behind in processing claims and sending reimbursements, the health department will continue seeing patients covered by that MCO.

"The health of the patients comes first," Fillman said.

Once a patient is deemed eligible for services, the health department sees the patient and a bill is submitted through that patient's MCO. Bills are submitted weekly. Payment is either made or the claim is denied by Medicaid or the MCO. The transition has not been smooth, health department officials said.

"In the beginning, we had a lot of denials because MCOs weren't set up to handle us as providers for Medicaid," Thompson said. "The MCOs had to make a lot of changes to their system to accommodate us, and we're still working through some of those issues.

"If a claim is denied, we have to figure out whether it's an issue with the MCO, whether they haven't changed their system to accommodate us yet or if it's a problem on our end. There have been a lot of technical issues that have taken a long time to address, but we're working closely with the department of health in Frankfort to work through them."

The state's health department has a contract with the MCOs, so GRDHD can't opt out if it isn't satisfied with an MCO's performance.

Fillman said now that the MCOs have entered the picture, there are four different ways to bill for a service, which adds time and frustration to the health department staff.

"It takes three times as long to do the paperwork now," Fillman said.

When Kentucky Spirit leaves the state, its members will be moved to either Coventry Cares and WellCare.

Rich Suwanski, 691-7315, or [email protected]

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