Health News
- State Senate Passes Bill For Independent Appeals Process For Managed-care Claims; Hearing Gets Into Details Of The Problem
By Melissa Patrick Kentucky Health News Managed-care organizations' contracts allow them to deny Medicaid claims and not reimburse for services if they deem them not medically necessary. That means health-care providers often don't get paid for...
- Bill To Make Medicaid Managed-care Firms Pay Up, And More Promptly, Nears Final Form In House And Will Get Attention In Senate
By Molly Burchett and Al Cross Kentucky Health News The complaints by many health-care providers about Medicare managed-care firms' delay or denial of payment claims appears to be generating a bipartisan solution in the General Assembly. A bill on...
- Cabinet Must 'wield The Stick' To Get Managed Care Under Control, State Auditor Says
Though the state has a solid contract "filled with all the mechanisms you need for enforcement, from the carrots to the sticks," the Cabinet for Health and Family Services has to be more aggressive in cracking down on the managed care organizations (MCOs)...
- State And Companies Were Unprepared For Quick Move To Managed Care, State Auditor Concludes
Kentucky officials and the companies in charge were unprepared for the switch to Medicaid managed care, State Auditor Adam Edelen said Wednesday. He sent the Cabinet for Health and Family Services 10 recommendations to improve the system, which provides...
- Medicaid's Move To Managed Care Delayed Until Nov. 1; Hospitals Need More Time To Sign Contracts
The move to managed care, which the state has touted as the answer to improve the quality of its Medicaid system and solve a budget deficit, has been delayed by a month in response to the Kentucky Hospital Association saying hospitals need more time to...
Health News
Medicaid managed-care firms get new contracts with new rules aimed at resolving health-care providers' issues with program
Kentucky has signed new contracts with five managed-care firms that will manage Medicaid coverage for more than 1.1 million Kentuckians. Contracts were awarded to Anthem, Coventry Cares, Humana, Passport and Wellcare.
Kentucky changed Medicaid to managed care from a traditional fee-for-service model in 2011 to save money, and officials say it has worked. Health-care providers remain unhappy about denial and delay of claims by the managed-care organizations (MCOs).
?Statistics confirm that moving to a managed-care model has saved Kentucky taxpayers more than $1.3 billion in state and federal funds while simultaneously improving the delivery of health-care services to our Medicaid population," Health Secretary Audrey Haynes said in a news release.
At the same time, managed care has been a good deal for the companies, except Humana. "Last year, [they] cleared more than $500 million in income above expenses, according to statements companies must file with the Kentucky Department of Insurance," Debby Yetter reports for The Courier-Journal. "Some of the profits ranged from 7 percent to nearly 18 percent in 2014," but the new contracts limit that to about 6 percent.
Two passionately debated bills in the recent legislative session challenged some of the practices of the current MCOs: one seeking an appeals process for denial of payment and the other removing a cap of "triage fees" for emergency room services that MCOs later deem not to be emergencies.
Both issues were addressed in the new contracts. Now, MCOs must make sure they are using appropriate medical specialist to determine "medical necessity," initially and in any review process, and the cabinet will be responsible for reviewing denials of "medical necessity" appeals and denials of payment for emergency-room use.
Sen. Ralph Alvarado, R-Winchester, co-chair of the joint House-Senate Medicaid Oversight Committee, told Yetter that "he hopes the new contracts will clear up the problems" and he also hopes "the state succeeds in controlling profits of the managed-care companies, calling it an outrage that some companies are reaping millions off the program while denying care or delaying payment."
The new contracts also include incentives for MCOs and Medicaid members to decrease use of emergency rooms, and encourage the expansion of behavioral health services.
They offer incentives to to MCOs to continue to improve health outcomes for their members, and spells out new, stringent standards for companies that don't comply with their contracts.
The contracts are for one year beginning July 1, with the option of four annual renewals.
Kentucky changed Medicaid to managed care from a traditional fee-for-service model in 2011 to save money, and officials say it has worked. Health-care providers remain unhappy about denial and delay of claims by the managed-care organizations (MCOs).
?Statistics confirm that moving to a managed-care model has saved Kentucky taxpayers more than $1.3 billion in state and federal funds while simultaneously improving the delivery of health-care services to our Medicaid population," Health Secretary Audrey Haynes said in a news release.
At the same time, managed care has been a good deal for the companies, except Humana. "Last year, [they] cleared more than $500 million in income above expenses, according to statements companies must file with the Kentucky Department of Insurance," Debby Yetter reports for The Courier-Journal. "Some of the profits ranged from 7 percent to nearly 18 percent in 2014," but the new contracts limit that to about 6 percent.
They also require 82 to 87 percent of the payments to the MCOs to be spent on direct services to its members. The payments are per-person fees, based on the number of people whose care is being managed.
Haynes said the contract improvements "should please consumers, advocates and our health care providers" and "will translate into more options and improved services from our managed care companies."
The new contracts also address many of the issues about which hospitals and other providers have been unhappy, such as slow and reduced payments, complicated paperwork and other procedural differences among the companies.
The new contracts require a standardized contract and standardized forms for prior-authorization requests, grievances, appeals and claims.
The new contracts also address many of the issues about which hospitals and other providers have been unhappy, such as slow and reduced payments, complicated paperwork and other procedural differences among the companies.
The new contracts require a standardized contract and standardized forms for prior-authorization requests, grievances, appeals and claims.
Two passionately debated bills in the recent legislative session challenged some of the practices of the current MCOs: one seeking an appeals process for denial of payment and the other removing a cap of "triage fees" for emergency room services that MCOs later deem not to be emergencies.
Both issues were addressed in the new contracts. Now, MCOs must make sure they are using appropriate medical specialist to determine "medical necessity," initially and in any review process, and the cabinet will be responsible for reviewing denials of "medical necessity" appeals and denials of payment for emergency-room use.
Sen. Ralph Alvarado, R-Winchester, co-chair of the joint House-Senate Medicaid Oversight Committee, told Yetter that "he hopes the new contracts will clear up the problems" and he also hopes "the state succeeds in controlling profits of the managed-care companies, calling it an outrage that some companies are reaping millions off the program while denying care or delaying payment."
The new contracts also include incentives for MCOs and Medicaid members to decrease use of emergency rooms, and encourage the expansion of behavioral health services.
They offer incentives to to MCOs to continue to improve health outcomes for their members, and spells out new, stringent standards for companies that don't comply with their contracts.
The contracts are for one year beginning July 1, with the option of four annual renewals.
- State Senate Passes Bill For Independent Appeals Process For Managed-care Claims; Hearing Gets Into Details Of The Problem
By Melissa Patrick Kentucky Health News Managed-care organizations' contracts allow them to deny Medicaid claims and not reimburse for services if they deem them not medically necessary. That means health-care providers often don't get paid for...
- Bill To Make Medicaid Managed-care Firms Pay Up, And More Promptly, Nears Final Form In House And Will Get Attention In Senate
By Molly Burchett and Al Cross Kentucky Health News The complaints by many health-care providers about Medicare managed-care firms' delay or denial of payment claims appears to be generating a bipartisan solution in the General Assembly. A bill on...
- Cabinet Must 'wield The Stick' To Get Managed Care Under Control, State Auditor Says
Though the state has a solid contract "filled with all the mechanisms you need for enforcement, from the carrots to the sticks," the Cabinet for Health and Family Services has to be more aggressive in cracking down on the managed care organizations (MCOs)...
- State And Companies Were Unprepared For Quick Move To Managed Care, State Auditor Concludes
Kentucky officials and the companies in charge were unprepared for the switch to Medicaid managed care, State Auditor Adam Edelen said Wednesday. He sent the Cabinet for Health and Family Services 10 recommendations to improve the system, which provides...
- Medicaid's Move To Managed Care Delayed Until Nov. 1; Hospitals Need More Time To Sign Contracts
The move to managed care, which the state has touted as the answer to improve the quality of its Medicaid system and solve a budget deficit, has been delayed by a month in response to the Kentucky Hospital Association saying hospitals need more time to...