Care tenuous for Texas children on Medicaid managed care plans

July 29--At least four Austin-area pediatric specialists in recent months notified their patients they would stop serving children with Blue Cross and Blue Shield of Texas Medicaid plans after complaints that the company had failed to pay the providers for certain services.

One practice, Central Texas Pediatric Orthopedics, the only specialist of its kind in the Austin area that accepts Medicaid, is finalizing an agreement to continue accepting Medicaid plans under Blue Cross and Blue Shield, one of three managed care organizations that administers children's Medicaid in the Austin area, according to the insurance company.

Neurology Consultants of Austin and Children's Urology reached an agreement with Blue Cross and Blue Shield to continue providing Medicaid after families complained to state lawmakers in May.

Corridor Pediatrics in Hays County stopped accepting almost all children's Medicaid plans from Blue Cross and Blue Shield.

The troubles underscore the challenges Texas families covered by Medicaid face in finding adequate medical care, particularly for children with disabilities. Parents blame, in part, the managed care system, which hands the responsibility of administering Medicaid from the state to the private companies.

State lawmakers have scrutinized managed care for the past several months amid complaints that managed care organizations, in an effort to cut costs, are frequently denying services, including at-home nursing care, medical equipment, physical and occupational therapies, and prescription drugs.

The American-Statesman reported this month that between June 7 and July 13, Superior HealthPlan, a managed care organization, had denied requests for Medicaid services to foster care children statewide 394 times, according to state data. The company has disputed the figures.

"If you have a medically complex child, you feel like you're a project manager on top of everything else," said Austin resident Jill Bradshaw, whose 5-year-old daughter with deafness and blindness has more than six therapy appointments each week. "When there's uncertainty about providers ... it just throws you into extra work that is really unnecessary and disruptive."

Families have said that finding providers has become more difficult over the past two years, but officials with the Texas Health and Human Services Commission, the state agency that oversees managed care, said provider access has always been a problem for Medicaid.

"Having an adequate network of providers is a longstanding challenge for Texas that predates managed care. Lack of access to specialists, particularly pediatric specialists, is a health care challenge for Texas that is mirrored in the Texas Medicaid program. Similar challenges exist in private insurance systems, as well. HHSC will continue to evaluate and monitor managed care provider networks, including BCBS, so that members have access to the care they need," Christine Mann, spokeswoman for the commission, said in a statement.

Payment concerns

Several parents of children covered by Medicaid, including Bradshaw, were told this month that they'd lose their only pediatric orthopedic provider in the Austin area, effective Aug. 22. Bradshaw's daughter was scheduled to see a specialist for drooping in her right shoulder.

In a July 6 letter to families, Central Texas Pediatric Orthopedics physicians said they will no longer accept Blue Cross and Blue Shield Medicaid plans, which cover 3,900 children in the Austin area, because the company failed to pay physicians for "many patient visits" over the course of a year.

"We have had multiple attempts to find a workable solution, but Blue Cross and Blue Shield has been unable to resolve this issue on an ongoing basis," the physicians said in the letter, adding that they also would no longer accept commercial Blue Cross and Blue Shield plans. The company would not reimburse them at a rate similar to rates of other commercial insurance carriers in the Austin market, according to the physicians.

Laura Romero's 12-year-old daughter with cerebral palsy and scoliosis is scheduled to have major spinal surgery in December. If the group no longer accepts her Blue Cross and Blue Shield Medicaid plan, Romero said her options are to travel to Houston or Dallas for the surgery, pay for it out of pocket or forgo it altogether.

"It makes me sick to my stomach to think that I have a child who is in serious need of medical care and we're put in a situation where we might not be able to get care for my child," Romero said. The state "needs to hold both physicians and insurance companies accountable for making sure these kids are taken care of."

Although the July 6 letter from Central Texas Pediatric Orthopedics suggested the practice was done negotiating, Blue Cross and Blue Shield officials said they were nearing a final agreement Friday, a day after the Statesman first contacted the insurance company about the issue.

"Blue Cross and Blue Shield of Texas is committed to expanding access to quality, cost-effective care to as many people as possible in Texas. BCBSTX and Central Texas Pediatric Orthopedics Group have reached an agreement in principle. The details of the agreement will be finalized in the next few days," the company's statement said.

Central Texas Pediatric Orthopedics declined to comment.

In May, families told the House Health and Human Services Committee that two other Austin-area providers -- Neurology Consultants of Austin and Children's Urology -- were no longer going to accept Blue Cross and Blue Shield Medicaid plans in part because the physicians weren't being paid on time or at all for certain services. According to Blue Cross and Blue Shield, issues were resolved, although officials didn't provide further details.

Corridor Pediatrics in Hays County stopped accepting most Blue Cross and Blue Shield Medicaid plans as of Dec. 31, but continues to accept Superior HealthPlan and Dell Children's Health Plan.

"If you look at the income physicians are traditionally making, pediatricians are second to the lowest after family practice. I didn't go into this field for money. I genuinely care for my patients and find value with working with families and watching the kids grow and thrive," said Angela Black, a pediatrician for Corridor. "Nevertheless, we have to pay to keep our health care business running and pay our nurses."

The pediatric group has about 40 employees, including physicians.

Corridor Pediatrics officials said Blue Cross and Blue Shield initially didn't pay 300 to 500 claims -- the average claim is about $100 -- over the years, said Michelle Comstock, the practice's business manager. Blue Cross and Blue Shield eventually paid the claims but created an administrative nightmare, Comstock said.

The practice still works with Blue Cross and Blue Shield for a few patients who have special needs.

"This was a two-year process to finally terminate. It's not like we woke up one day and say we're done. We were pretty tolerant because we didn't want to put difficulties on patients," Comstock said.

Blue Cross and Blue Shield did not comment on the Corridor contract.

'Opportunities for improvement'

During the May hearing at the Capitol, physical therapists and nursing home providers told lawmakers they also had problems with some managed care organizations reimbursing in a timely manner. Rodney Gray, who owns a company in San Antonio that helps pediatric patients on ventilators make the transition to their homes, said managed care organizations owe him $1.5 million. He received a letter from a managed care organization that indicated the company was overwhelmed by a recent increase in claims, Gray said.

Texas Health and Human Services requires managed care organizations to "adjudicate" 98 percent of claims within 30 days or face fines paid to the agency, but providers have questioned the effectiveness of the policy.

Inadequate payment is among the biggest reasons physicians stop accepting Medicaid, which reimburses half of what commercial insurance plans reimburse, said Ryan Van Ramshorst, a pediatrician and chairman of the Medicaid committee for the Texas Medical Association.

"Managed care does present some very unique opportunities which are good. Trying to work together to improve care and making sure we're using our limited dollars responsibly are important," Van Ramshorst said. "That being said, there are many opportunities for improvement."

He applauded Driscoll Health Plan, a managed care organization in South Texas, for paying case managers to go to physicians' offices to communicate with patients directly.That should be replicated across the state, Van Ramshorst said.

He said state lawmakers should increase payments and eliminate "red tape."

Hannah Mehta of Protect TX Fragile Kids, a network of 2,000 parents of children on Medicaid, said the state needs to do more to eliminate loopholes that allow managed care organizations to reduce their network of providers, standardize processes and procedures across all managed care organizations, contract with certain providers indefinitely, and protect those who make complaints against managed care organizations.

"There needs to be standards set because right now, it's like the wild West," Mehta said.

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