Texas providers: Managed care is hurting Medicaid patients, businesses

Austin American-Statesman (TX)

Aug. 30--Several South Texas health care providers told state legislators on Wednesday that private companies contracted by the state to deliver Medicaid services pay providers late, overload them with paperwork and deny their patients access to critical care.

The complaints were a familiar refrain for the Texas House Committee on Human Services, which has been scrutinizing the oversight of Medicaid managed care organizations. Over the last two decades, the state of Texas has been slowly transitioning the administration of Medicaid services to managed care organizations to improve quality of care as well to save money. Over the last two years since children with disabilities were rolled into managed care, families and providers say they've seen more problems with Medicaid.

"Texas Medicaid managed care system faces great but surmountable challenges that must be addressed with all due haste, beginning with enhanced scrutiny not only of the health plans but also how the state's own actions -- including deep funding cuts and insufficient agency staff -- jeopardize Medicaid's ability to care for the neediest among us," Carlos Cardenas, an Edinburg gastroenterologist and a member of the Texas Medical Association, told the committee.

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Committee members held Wednesday's hearing in the Rio Grande Valley, among the last parts of the state to transition to managed care. Committee Chairman Richard Peña Raymond, D-Laredo, kicked off the hearing, saying lawmakers will work to improve the system when the Legislature meets next year.

The problems that South Texas providers said they have faced with managed care echo problems Central Texas providers have experienced. The American-Statesman last month reported that at least four Austin-area providers had recently notified their patients they would stop serving children with Blue Cross and Blue Shield of Texas Medicaid plans after complaints that the managed care organization had failed to pay the providers for certain services, among other problems.

Providers asked lawmakers Wednesday to force the more than dozen managed care organizations across the state to adopt similar processes and standards. Providers said the companies differ in what they consider a medically necessary service and will ask for different types of documents before approving a service, for example.

The burdensome paperwork has led to delays and denials of services for children who need them as well as payments to providers, providers said.

Dina De La Cruz, a speech language pathologist, told lawmakers the managed care companies have delayed services for children by requesting certain information already provided but that the companies had overlooked.

"A lot of the times requested information is in the reports, that's just not being read carefully," she said. "I don't create a different letter any more. I just circle the (information), but ... we still have to wait, and the kid is regressing each day they're not receiving therapy."

Perla Tamez, owner of a rehabilitation facility, also said children have been denied therapy services because a nurse, whom the managed care organization had tasked with making decisions on whether services are medically necessary, doesn't have the expertise. She said it's disrespectful for the managed care company to ignore a physician's order for therapy.

"It's not advocating for the need of this child," she said.

Other providers complained of insufficient pay for their therapists, who are leaving in droves; delays in communication between managed care organizations whenever a patient changes managed care plans; and a managed care organization abruptly dropping a provider without a clear explanation.

Members of a few managed care companies told lawmakers they would be willing to work together to standardize processes to eliminate paperwork for providers and offered to address providers' specific complaints at the hearing.

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Stephanie Muth, deputy executive commissioner with the Texas Health and Human Services Commission, the state agency that oversees Medicaid managed care, said it is working to improve the appeals processes for denials, streamlining processes at the different managed care organizations and identifying inconsistencies in denials of service among the companies.

The health commission has assessed more fines each year against managed care organizations. In 2009, the agency assessed $1.6 million in liquidated damages, and in the first three quarters of 2017, the agency assessed $27.4 million, the state reported last month.

The agency freed up $4.5 million to add 98 employees over the next two years to contract oversight.

"We're really here in a listening mode," said Jamie Dudensing with the Texas Association of Health Plans, which represents all commercial health insurance and managed care companies. "We're committed to making the Medicaid program in Texas the best Medicaid program in the country."

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