Report says officials working to address concerns with Medicare oversight

Jan. 05--BACKGROUND

Since the beginning of the privatization of Iowa's Medicaid managed care, Iowans have called for more oversight.

Lawmakers, providers and patients have criticized the program since then-Gov. Terry Branstad switched it from a fee-for-service model two and a half years ago in effort to save money. The change has involved what Iowa Department of Human Services Director Jerry Foxhoven describes as "bumps in the road."

The program, which provides medical coverage for thousands of poor and disabled Iowans, switched from being a state-run system to being managed by three insurance companies -- called managed care organizations -- in 2016.

Currently, there are two managed care organizations left in the program: Amerigroup of Iowa and UnitedHealthcare of the River Valley. A third company called Iowa Total Care, a subsidiary of Centene Corporation, is joining the state July 1.

More than 600,000 Iowans rely on Medicaid for their health insurance, according to Human Services data from July 2018.

Since the switch, health care providers across the state claim they are being reimbursed incorrectly or not at all by the insurers, and patients say needed health services are wrongfully denied.

Human Services officials have pledged more oversight of the managed care organizations, and stated they have included more requirements in the most recent contracts to guarantee that higher standards are met.

"We have to be firm," Foxhoven said in 2017.

WHAT'S HAPPENED SINCE

Human Services released a report at the end of December on efforts to provide oversight of the $5 billion program.

The report summarizes "existing strategies that have been or are being implemented to oversee Iowa's Medicaid managed care programs and to explore possibilities of utilizing clinical outcome-based research in the development of a set of measures to complement existing systems."

It also describes the annual and quarterly reports Iowa Medicaid Enterprises, within the Human Services department, requires from the managed care organizations, in addition to the quality improvement data insurers must submit under state and federal rules.

The report lays out all requirements managed care organizations must meet, which include timely access to care and services, care coordination and evidence-based clinical practice.

State standards require that a variety of providers be within a reachable distance from enrollees, according to the report. And state officials work to address provider concerns and ensure health care services "are not arbitrarily denied or reduced in amount, duration or scope," it said.

The reports states Iowa Medicaid Enterprises monitors reports on several items, including the number of claim denials, grievances received, prior authorizations submitted and approved as well as the most frequent reasons for prior authorization denial and modification.

While providing coverage for enrollees, Medicaid insurers must present continuous improvement in the health outcomes of individuals, especially those in "low income and vulnerable populations."

The report states improvements should be based on needs assessments, social determinants screenings and data sharing with behavioral health providers.

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