Budget, managed care expansion among topics highlighted by Medicaid panel

Budget, managed care expansion among topics highlighted by Medicaid panel

Panelists analyzed the impact of the recently signed state budget and the expansion of Medicaid managed care, including lingering concerns over claims denials and adequate networks, at a Health News Illinois event Wednesday.

Speakers included:

  • Stephanie Altman, Senior Director of Policy, Shriver Center
  • Rep. Tom Demmer, R-Dixon
  • Samantha Olds Frey, Executive Director, Illinois Association of Medicaid Health Plans
  • Rep. Greg Harris, D-Chicago
  • AJ Wilhelmi, CEO, Illinois Health and Hospital Association

Edited excerpts from the panel are below.

On Gov. Bruce Rauner signing the state’s budget this week:

“First off, we did not enact the cuts to Medicaid that the governor had recommended. I think that’s critical, especially at this time of transition with the 1115 waiver and the hospital assessment and the MCO transition. To begin to cut rates would have been totally the opposite of the right thing to do. In fact, if we’re going to make these things a success, we’re going to need to at some point address raising provider rates because if we look at any survey for any industry within the healthcare silo, Illinois ranks at the bottom. If we’re wanting our providers, whether it’s a hospital or community-based provider or substance abuse treatment or a mental health provider, to step up and do this new work, we’re going to have to be sure they’re adequately compensated.”

– Rep. Greg Harris, D-Chicago

“I think we’re beginning to rebuild some of the trust that was strained significantly during the budget impasse over the last several years. And I think that if we can build off of that trust, other difficult conversations become a little bit easier.”

– Rep. Tom Demmer, R-Dixon

“We’re not going back to the last two years of court cases and real uncertainty for Medicaid recipients on whether there’d even be providers for them to go to. But now we need to build on it.”

– Stephanie Altman, senior director of policy at the Shriver Center

On the impact of the Medicaid managed care expansion:

“I think it’s too early to tell what the outcomes are going to be. I think we’re going to have to wait a little longer until we have adequate data to assess the outcomes, simply because the rollout of this, in my opinion, was done too quickly, without the involvement and consultation of the various industries and stakeholders who had to be involved. And it really seemed rush.”

– Harris

“With any large rollout like this, you’re going to have speed bumps. I think that the department’s responded effectively to it though by implementing where there was comfort and network adequacy to implement and delaying populations where they weren’t quite there yet. I think that’s the appropriate thing to have happen…we can’t measure the success of managed care versus an ideal alternative. We have to look at it relative to where we were and what’s a realistic alternative. I think that there’s been an improvement over what realistically would be the alternative.”

– Demmer

Concerns about claims denials:

“The reality is that we’ve made some progress and we have a lot more work to do. So, let me talk about two specific issues. Number one, with respect to the level of claims denials. We’re hearing back from our members, many of whom are here today, that the rate of denials is about 20 to 25 percent. That’s just simply too high, right? That is not acceptable. I don’t think anyone would want to see that going forward. So how do we address that? How do we bring that rate of claims denials down? One is through the transparency… let’s get to the root cause of the denials. What does the data show and reflect? So that’s number one. Number two, with respect to how we make sure that we look at operational challenges. So we talked about the reimbursement challenges. There are also operational challenges. And the more we can standardize some of the processes around physician rosters, discharge planning, billing guidelines, so we’re all working from a uniform set of processes, that will greatly help.”

– Illinois Health and Hospital Association CEO A.J. Wilhelmi

“I agree with A.J. in terms of the priorities, in terms of standardizing where we can as long as we keep in mind that a one-size-fits-all program failed Illinois and we moved away from that. And we’re not, as long as I’m in my position, going back to a one-size-fits-all program because who ends up suffering there is the Medicaid member. We need to keep in mind that the care we provide is member-focused. We partner with our providers, but the member should be our primary focus…the area of opportunity is where there are so many denials of what I would call sort of those administrative areas of concern. Perhaps a code was put in the wrong place, not every piece of information was included, there were eligibility issues. That’s where that partnership with the IHA and IAMHP and with state to really address this billing issues and get that information out there—because the processes are for the most part standardized—really will start to see those denials go down.”

– Samantha Olds Frey, executive director of the Illinois Association of Medicaid Health Plans

Concerns about plans being able to build adequate networks:

“I think that there were concerns. I think there’s still a lot of effort around building adequate networks, partnering with certain providers, who have decided and who have said, ‘We are only going to partner with one or two health plans in the region’ when we know there are five large statewide health plans. And that creates an issue, an access issue for our Medicaid members. Our health plans are meeting with those providers every day in their offices, trying to find a way to make those contracts work.”

– Frey

“We have some hospitals, some systems that are owed significant dollars for the services that they’ve already provided to Medicaid beneficiaries. And the plan comes forward and says, ‘We’ll pay you 20 percent, 50 percent of that total amount.’ And so we want to get to a place where the plans are showing that they truly want to partner with the hospitals across the state, right? So that at the end of the day, we can have those adequate networks.”

– Wilhelmi

On law firms representing low-income Illinoisans taking legal action due to delays in processing Medicaid applications:

“When they’re working out the computer glitches and hiring new staff and trying to figure out how to process these applications, we have pregnant women who are giving birth before they get onto Medicaid. The hospitals can’t handle that. We have newborns who have been waiting for five months for their Medicaid cards. We have people who are getting out of mental health facilities and can’t get medication. They’re not even in the managed care organization yet to get their care coordinated because they can’t get Medicaid. So the state must implement a system that they’re required to do, giving people temporary Medicaid coverage and other things that they can do in order to reduce churn, where people are going on and off Medicaid. And we need the state to do that now.”

– Altman

Health News Illinois is a nonpartisan, independent news service covering the Illinois healthcare beat. Sign up for a free trial to the newsletter here.

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