Iowa on track to save $22 million in Medicaid spending

Aug. 26--In the first three months of Iowa's Medicaid managed-care program, all three managed-care organizations resolved beneficiaries' grievances within 30 days of receipt. But one MCO received far more complaints during that time than the other two -- by more than 100.

That and other details were included in the Iowa Department of Human Services's first quarterly report since the state handed over its $5 billion Medicaid program with more than 560,000 recipients to the private insurers on April 1.

The report, released Friday, help shed light on what the first three months of Medicaid managed care looked like, detailing claims payments, enrollment figures and capitation rates for Amerigroup Iowa, AmeriHealth Caritas Iowa and UnitedHealthcare of the River Valley.

The state is projecting the move to managed care saved it more than $22.2 million in spending during its first three months, adding it is on track to save more than $110 million in the first year, the report said.

The DHS report comes out ahead of the first Health Policy Oversight Committee hearing set for on Monday at the State Capitol in Des Moines.

Highlights from the quarterly report include:

Grievances and appeals

A grievance is a written or verbal expression of dissatisfaction, while an appeal is a request for review of an MCO's denial, reduction, termination or delay of services. While all three MCOs resolved beneficiary grievances within 30 days of receipt, according to the report, one MCO, Amerigroup, received far more complaints than the other two.

Grievances:

--Amerigroup received 145 grievances during the quarter

--AmeriHealth received 42

--UnitedHealthcare received 39.

Appeals:

--Amerigroup received 14 appeals during the quarter

--AmeriHealth received 52

--UnitedHealthcare received 49.

Finances

Capitation rates -- or the per member, per month fees paid to the MCOs by the state -- equal more than $850 million. The capitation rates, which include federal dollars, break down as follows:

--Amerigroup -- $237,540,157

--AmeriHealth -- $408,575,970

--UnitedHealthcare -- $229,442,968

Claims

Providers across the state have reported late and inaccurate payments to state lawmakers and news outlets since the April 1 transition. Providers from speech therapists to social service agencies have told The Gazette that the problems range from what they've said are unresponsive MCO representatives, improperly loaded fee schedules or denial or payment despite obtaining prior authorization.

All three MCOs met the requirement of paying or denying 90 percent of "clean" claims -- properly completed claims -- within 14 days, according to the report.

But a more detailed look at the data shows:

--UnitedHealthcare had the highest number of denied or suspended medical claims, according to the data. In April, it only paid 49 percent of claims, while the other 51 percent were either suspended or denied.

A suspended claim means it is pending internal review for medical necessity or needs additional information. By June, UnitedHealthcare's paid claims increased to 67 percent, with the remaining 33 percent either denied or suspended.

--AmeriHealth reported paying 57 percent of claims in April, with about 30 percent of claims shown as suspended and 13 percent denied. In June, AmeriHealth had paid 75 percent of claims, suspended about 10 percent and denied about 15 percent.

--Amerigroup paid between 95 percent and 88 percent of claims in the first three months, the report shows. It had no suspended claims.

Varying Reimbursements

The dollar amount spent reimbursing providers varies widely among MCOs. The state pointed out that population difference between plans can be a factor in the levels of reimbursements.

--Amerigroup paid hospitals $58.8 million in claims during the first three months while AmeriHealth paid $23.4 million, and UnitedHealthcare paid $47.1 million.

--Amerigroup paid physicians $80 million in claims during the first three months, while AmeriHealth paid $20 million and UnitedHealthcare paid only $3 million.

--Amerigoup paid $24.9 million in home health claims during the first three months, while AmeriHealth paid $5 million and UnitedHealthcare paid $2.7 million.

Enrollment

The vast majority of Medicaid enrollees (at least 83 percent) stayed in the MCO assigned to them. Out of all three MCOs, AmeriHealth had the largest number of enrollees as well as the largest percentage of beneficiaries to self-select the insurer -- 17 percent (36,157) of AmeriHealth's more than 208,000 enrollees selected it.

That's compared to 10 percent (18,729) of Amerigroup's more than 184,000 enrollees, and 11 percent (18,684) of UnitedHealthcare's more than 175,000 enrollees.

Special needs populations

AmeriHealth has the largest number of individuals considered to be special needs -- people with intellectual or physical disabilities, brain injury and HIV diagnosis as well as those who may be receiving waiver or institutional services. About 9.315 special-needs adults are enrolled in the MCO and 1,804 special needs children are enrolled.

That's compared with 1,315 special-needs adults 490 children enrolled in Amerigroup, and 962 special-needs adults and 467 children enrolled in UnitedHealthcare. AmeriHealth also has nearly double the share of elderly beneficiaries -- 12,665 -- compared with 6,515 enrolled in Amerigroup and 6,105 in UnitedHealthcare.

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