Tag: Providers

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Insurance Policies May Drive Diagnoses for Medicaid Patients

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The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

[MM Curator Summary]: Hospitals who get more commercial revenue have more money to spend on software that helps them maximize their billings.

 
 

Medicaid patients admitted to hospitals with a larger proportion of private payers received more diagnoses on Medicaid insurance claims than those in hospitals with a lower proportion of private payers, according to a new study of more than 1 million Medicaid admissions in New York state.

Diagnostic coding software is an investment in infrastructure that may be utilized more often by hospitals with a higher proportion of privately insured patients with higher reimbursement rates, wrote Kacie L. Dragan, MPH, a PhD candidate at Harvard University, Cambridge, Massachusetts, and colleagues

 
 

“Provider-level variation in coding intensity has been documented to some degree for Medicare and commercially-insured groups, but little was known about diagnostic coding patterns for Medicaid-insured groups,” Dragan said in an interview.

“We also wanted to provide some evidence on the question of whether higher prices from private payers seem to incentivize hospital-level administrative investments, such as advanced EHRs or highly trained staff,” she explained. “If so, the impact of these administrative investments might spill over and be reflected in the number of diagnoses Medicaid patients receive.”

In a study published in JAMA Health Forum, Dragan and colleagues analyzed data from 1.6 million hospitalizations for Medicaid-insured patients between 2010 and 2017. The study population included Medicaid enrollees with at least two admissions in at least two different hospitals in New York state. The mean age of the patients was 48 years, 51.4% were women. Overall, 30.1% were White, 28.6% were Black, 23.3% were Hispanic, 4.6% were Asian, and 5.4% were other ethnicities.

Significantly more diagnoses were recorded when the same patient was seen in a hospital with more privately insured patients (0.03 diagnoses for each percentage point increase in the share of privately insured patients, P < .001).

Patients first discharged from hospitals in the bottom quartile of privately insured patients received 1.37 more diagnoses when subsequently discharged from hospitals in the top quartile, and those first discharged from hospitals in the top quartile of privately insured patients received 1.67 fewer diagnoses when discharged from hospitals in the bottom quartile (P < .001 for both).  

Payment incentives appeared to play a role in the diagnostic codes used, the researchers noted. Diagnoses in hospitals with a higher share of private payers were significantly more likely to involve conditions sensitive to payment incentives, such as neuropathy or depression.

“The probability of receiving a commonly up-coded supplemental diagnosis increased by 2.50 percentage points when a Medicaid-insured patient was seen in a hospital with 40% privately insured patients compared with when they were seen in a hospital with just 10% privately insured patients,” the researchers write.

The results persisted in subgroup analyses and in a replication of the study using data from 2016 to 2017, after the implementation of the diagnostic code set ICD-10, with a similarly large increase of 0.06 additional diagnoses for each percentage point increase in the proportion of private paying patients.

The study findings were limited by several factors, including the use of only claims through 2014 in the main analysis, and the inability to determine whether patients are selecting into well-resourced hospitals for more complex conditions, the researchers noted. However, “To the extent that diagnoses drive reimbursement and quality scores, this may create a feedback loop that further benefits highly-reimbursed facilities and exacerbates inequity in resources,” the authors conclude.

 
 

“We were somewhat surprised to see such symmetry and a ‘dose-response’ gradient in the relationship between a hospital’s private payer share and the number of diagnoses coded,” Dragan told Medscape. Although many studies have focused on provider upcoding, “this finding may suggest that there could also be under-coding happening at the opposite extreme, among providers with large shares of Medicaid-insured patients; however, our study cannot say what the ideal level of diagnostic coding would be.”

Impact of Incentives Remain Unclear

“The diagnoses documented for Medicaid patients might, in part, be a reflection of the hospital’s payer mix and associated administrative style, rather than a reflection of a patient’s true underlying health,” Dragan said in an interview. “Disease surveillance metrics or risk-adjusted quality measures, for example, may be impacted by this variation in code capture, calling for caution when relying on patient diagnoses,” she added. 

“Future research should aim to document whether this variation in diagnostic coding intensity has downstream implications for Medicaid patient treatment or outcomes,” said Dragan. “Additionally, it will be important to better understand what specific actions hospitals are taking in response to payer incentives, such as changing EHR [electronic health record] vendors or training staff, that might be behind this observed variation in coding intensity among Medicaid patients.”

Measure of Patient Risk is Needed

“Nearly all healthcare reforms require that we can accurately measure patient risk in order to compare providers or insurance plans,” Andrew Ryan, PhD, of the University of Michigan, Ann Arbor, said in an interview. “Factors other than true clinical severity that influence the measurement of patient risk, such as hospitals’ share of private patients, may result in inaccurate measurement.”

“This is a strong study,” said Ryan, a professor of health management at UM who was not involved in the research. “The authors found that a higher share of private patients led to greater risk coding for Medicaid patients; they attribute this effect to the fact that hospitals with a greater share of private (commercial) patients have stronger incentives to code,” he said.

However, “I’m not sure if this mechanism is driving the results,” Ryan noted. “For instance, I believe that the strongest incentives for upcoding risk is for Medicare Advantage patients, and these were categorized as public payers by the authors. Instead, I think that the likely mechanism for upcoding is that hospitals with more private patients are better resourced, and probably hired more coders.”

As for additional research, Ryan said he would be interested in seeing whether hospitals with more Medicare Advantage patients code more. “I would also be interested in understanding whether hospitals’ investments in coding staff drive the findings,” he said.

The study was supported by the Agency for Healthcare Research and Quality and the Commonwealth Fund. Dragan disclosed training fellowships from the Agency for Healthcare Research and Quality and from NIH’s National Institute of Mental Health. Ryan reports no relevant financial relationships.

JAMA Health Forum. Published online September 2, 2022. Full text

Heidi Splete is a freelance medical journalist with 20 years of experience.

For more news, follow Medscape on Facebook, Twitter, Instagram, YouTube, and LinkedIn

 
 

From <https://www.medscape.com/viewarticle/980721?icd=ssl_login_success_220916#vp_2>

 
 

 
 

 
 

From <https://www.medscape.com/viewarticle/980721?icd=ssl_login_success_220916>

 
 

 
 

 
 

Clipped from: https://www.medscape.com/viewarticle/980721

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MT/BH providers- Study proposes increases to Montana’s Medicaid provider rates

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[MM Curator Summary]: The consultants say the state is under paying MH providers by about $82M/ year.

 
 

 
 

 
 

For Dave Eaton, hiring enough staff to help developmentally disabled clients in Livingston with day-to-day tasks is a constant, brutal cycle. Out of every 10 people who come to work at Counterpoint Inc., the small nonprofit he leads, Eaton estimates three leave within a year.

Eaton, the organization’s longtime executive director, attributes the high turnover to one key factor: finding people who want to work a tough job for less than $16 an hour isn’t easy. 

“The work that we’re doing, it involves a lot,” he said. His employees help clients with essential parts of their lives, he explained, like shopping for groceries, applying for jobs and attending community events. Counterpoint’s starting wage is $15.72 an hour.

If he could, Eaton said, he would raise wages to stay competitive with other job options. But Counterpoint, like many other Montana health and social service providers, relies heavily on dollars from Medicaid, the state-administered, federally subsidized public health insurance program. While Montana is responsible for setting reimbursement levels for providers who accept Medicaid patients, money the state puts into its program is matched by federal dollars. 

Eaton estimates Medicaid payments make up about three-quarters of Counterpoint’s revenue, but says they ultimately don’t come close to covering the true cost of its services. The nonprofit routinely resorts to soliciting donations to make ends meet — otherwise, Eaton said, his wages would be even lower.

“We’re competing with organizations, fast food organizations or whomever, to try to pay a living wage,” Eaton said. “And it’s really been impossible for us to do that, given the Medicaid reimbursement.”

A new study, commissioned by the Legislature and supported by Gov. Greg Gianforte’s appointed leadership at the state health department, affirms what providers like Eaton have been saying for years: that Montana Medicaid has underpaid providers for the care they provide to seniors in assisted-living facilities, people with disabilities, and children and adults with mental illnesses and addiction.  

The 186-page report, authored by the international consulting firm Guidehouse Inc., found that Montana’s Medicaid rates for those types of providers are nearly 22% below what the consultants identify as “benchmark standards” for actual cost of care, based on provider records and comparable data from other states and health care organizations. For disability service providers like Counterpoint, Guidehouse calculated the state is underpaying by even more, nearly 26%.

READ THE STUDYDownload

The study says it would cost the state and federal governments an additional $82 million a year to bring Medicaid reimbursement rates up to par for child and adult mental health providers, addiction treatments, disability services and senior and long-term care facilities. The state’s share of that cost would be roughly $28 million annually. In comparison, lawmakers allocated about $856 million in state funds to the state health agency for the current fiscal year.

Department of Public Health and Human Services Director Charlie Brereton acknowledged the importance of the study’s findings in an emailed statement and said the health agency is considering the recommendations. 

“As expected, the preliminary results of our provider rate study demonstrate significant disparities in Montana’s Medicaid reimbursement rates,” Brereton said. “DPHHS is eager to use these evidence-based findings to inform its budget request for the next biennium and support potential rate adjustments that will further develop Montana’s continuum of care.”

The final Guidehouse report is based on a detailed survey of provider expenses, input from months of work group meetings with different provider categories, feedback from union leaders, and public comment. The study’s $2.75 million price tag will be covered by federal pandemic relief funds.

Providers say the problems identified in the study predate the pandemic by several years. When the study was authorized by the Legislature last year, some stakeholders were pessimistic about launching into an expensive and drawn-out process that might only confirm what providers already knew, said Patrick Maddison, CEO of Flathead Industries and board president of the Montana Association of Community Disability Services (MACDS), in an interview this month. But with the results now in hand, Maddison said the study could provide the Gianforte administration and Legislature the hard data they need to prioritize fixing the issue. 

“What the rate study really shows is how underfunded our system has been for over a decade,” Maddison said. “I’m very hopeful that the intent was really how to fix the problem and how to not kick the can down the road. Because I think this administration has inherited the can that’s been kicked down the road for a very long time.”

One of the earliest indications of the study’s impact will be whether Gianforte includes a proposal to increase Medicaid rates in his November budget draft before the 2023 Legislature begins in January. In an emailed comment, Gianforte press secretary Brooke Stroyke said the governor supports the state health department’s efforts “to modernize Montana’s provider rates, and looks forward to receiving the agency’s recommendations.” 

Maddison, Eaton, and other providers said implementing the changes proposed by Guidehouse would help their struggling institutions stay afloat and continue providing critical services. In a MACDS poll of 35 disability service providers last summer, Maddison said, the average staff vacancy rate was 25%. Finding workarounds to adequately staff group homes and outpatient services is complicated, he said, and the wait-list of people seeking services just keeps growing. 

“We are still expected to care for the same amount of people with a quarter less manpower that we need to do the job,” Maddison said. 

At Counterpoint, Eaton said, those staffing struggles are familiar. But increasing rates in line with the study’s recommendations, he said, would be “a game changer for our field.”

“It would be a chance for Montana to really do what needs to be done,” Eaton said. “These are really, really necessary and vital services to the people we work for.”

Providers in other parts of the health care industry, including the Behavioral Health Alliance of Montana, shared similar sentiments. Matt Bugni, CEO of the statewide mental health and disability service provider AWARE, said the Guidehouse rate recommendations “will be a great start to shoring up this system of care that is teetering on collapse,” if adopted in the governor’s budget and the Legislature.

The study’s final recommendations have yet to be dissected in public hearings before interim legislative committees. Rep. Matt Regier, R-Kalispell, who chairs the bipartisan budget committee with oversight of the state health department, said he plans to set aside “a couple hours” to discuss the report during the committee’s upcoming Sept. 14 meeting.

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Clipped from: https://montanafreepress.org/2022/09/07/study-proposes-increases-to-montanas-medicaid-provider-rates/

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LA- Louisiana Medicaid implementing new payment model for hospitals

[MM Curator Summary]: The move seeks to prevent disruption if /when current hospital sugar money strategies change at the federal level.

Payments will be made based on Medicaid utilization

Louisiana Medicaid has received approval from the Centers for Medicare & Medicaid Services (CMS) to implement a new payment model for hospitals that is based on Medicaid utilization.

 
 

The new payment model increases hospital supplemental payments and prioritizes maintaining adequate funding for safety-net hospitals across Louisiana, without requiring additional state general funds. Additionally, the model creates more uniform guidelines and stability for hospital payments.

 
 

Developing a standardized funding formula for hospitals is one of the 17 initiatives included in our FY22 Business Plan. 

 
 

“We are excited to begin implementing this new payment model that is sustainable and equitable for hospital providers,” said LDH Undersecretary Ruth Johnson. “This new model, called a state directed payment model, changes the way we reimburse hospitals for care provided to Medicaid patients to align with guidance issued by CMS. The new model is a critical part of our Business Plan and was a top LDH priority during the Spring 2022 Regular Legislative Session.”

 
 

“This change demanded careful, attentive work and strong partnerships,” said Johnson. “We are thankful for the support of Gov. Edwards, the advocacy of the Louisiana Hospital Association (LHA), input from our legislative partners and the painstaking work of our LDH team members that made this new model possible.”

 
 

LDH through its Medicaid program has been working closely with CMS, hospital providers, the LHA,  legislators, and other stakeholders to design this new payment model. 

 
 

“This was important to legislators which is why we passed House Concurrent Resolution 8 of the 2022 Legislative Session,” said State Rep. Clay Schexnayder. “We are grateful for the thoughtful and transparent process LDH used in the development of this new hospital payment model, which focuses on effectively and appropriately funding our vital network of hospitals.”

 
 

“Hospitals are critical to our comprehensive medical care, to respond to health crises, and so much more,” said State Sen. Page Cortez. “This new payment model supports hospitals to ensure that they continue to be available in our communities for access by all of our state’s residents.”

 
 

“The LHA sincerely appreciates the hard work performed by LDH and Milliman throughout this process as well as their transparency and engagement with LHA and its member hospitals,” said LHA President and CEO Paul A. Salles. “We also want to thank the Louisiana Legislature for voting to implement this directed payment model when unanimously passing HCR 8 by House Speaker Clay Shexnayder (R-Gonzales). This new program requires no additional state general funds and places Louisiana in stronger compliance with federal guidelines, while making it easier for Louisiana hospitals to continue caring for their communities.”

 
 

The increased payments will be based upon Medicaid inpatient and outpatient hospital, long-term care, free-standing rehabilitation and free-standing psychiatric hospital services across the state. 

 
 

The new payment model became effective July 1, 2022.

 
 

Clipped from: https://ldh.la.gov/news/6732

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Patient-level factors influencing adherence to follow-up imaging recommendations

 
 

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[MM Curator Summary]: Even after accounting for all other person-level variables, Medicaid members still don’t complete ordered imaging followups.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

Purpose

To determine which, if any, patient-level factors were associated with differences in completion of follow-up imaging recommendations at a tertiary academic medical center.

Methods

In this IRB-approved, retrospective cohort study, approximately one month of imaging recommendations were reviewed from 2017 at a single academic institution that contained key words recommending follow-up imaging. Age, gender, race/ethnicity, insurance, smoking history, primary language, BMI, and home address were recorded via chart extraction. Home addresses were geocoded to Census Block Groups and assigned to a quintile of neighborhood socioeconomic status. A multivariate logistic regression model was used to evaluate each predictor variable with significance set to p = 0.05.

Results

A total of 13,421 imaging reports that included additional follow-up recommendations were identified. Of the 1013 included reports that recommended follow-up, 350 recommended additional imaging and were analyzed. Three hundred eight (88.00%) had corresponding follow-up imaging present and the insurance payor was known for 266 (86.36%) patients: 146 (47.40%) had commercial insurance, 35 (11.36%) had Medicaid, and 85 (27.60%) had Medicare. Patients with Medicaid had over four times lower odds of completing follow-up imaging compared to patients with commercial insurance (OR 0.24, 95% CI 0.06–0.88, p = 0.032). Age, gender, race/ethnicity, smoking history, primary language, BMI, and neighborhood socioeconomic status were not independently associated with differences in follow-up imaging completion.

Conclusion

Patients with Medicaid had decreased odds of completing follow-up imaging recommendations compared to patients with commercial insurance.

 
 

Clipped from: https://www.clinicalimaging.org/article/S0899-7071(22)00184-X/fulltext

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Study assesses the acceptance of Medicaid insurance among patients diagnosed with cancers

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[MM Curator Summary]: If you have Medicaid, you are about 33% less likely to get care at the 334 cancer center reviewed.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

Although there has been a significant increase in the number of U.S. residents insured through Medicaid since the expansion of the Patient Protection and Afforadble Care Act (ACA) in March 2010, the ability of Medicaid-insured patients to access cancer care services has not been well understood. In a study published today in the journal JAMA Network Open, researchers at Yale Cancer Center assessed the acceptance of Medicaid insurance among patients diagnosed with common cancers.

We found that Medicaid acceptance differed widely across cancer care facilities, with a substantial number of centers not offering services to patients with Medicaid insurance.”

Michael Leapman, MD, MHS, Associate Professor of Urology, Clinical Program Leader for the Prostate & Urologic Cancers Program at Yale Cancer Center and Smilow Cancer Hospital, and senior author on the study

In the study led by first-author Victoria Marks, a second-year medical student at Yale, 334 Commission on Cancer-accredited facilities were sampled, of which, only 226 (67.7%) accepted new patients with Medicaid insurance for the four common cancers selected (colorectal, breast, kidney, and skin). Acceptance varied among the facilities, with 296 (88.6%) accepting Medicaid for at least three types, 324 (97.0%) for at least two, and 331 (99.1%) for at least one type. Collectively, these findings underscore the persistent gaps that exist for patients with Medicaid in utilizing services at hospitals distinguished for high-quality cancer care.

“This study underscores that having health insurance alone does not necessarily mean that patients can practically access healthcare. While major recent expansions of Medicaid have led to increases in health insurance coverage for Americans with cancer, we have to be aware and do more to ensure that insurance will actually translate to timely and high-quality care,” said Dr. Leapman.

Facilitates that were more likely than others to accept patients with Medicaid included National Cancer Institute (NCI)-designated cancer centers, 89.7% of which offered high access to patients with Medicaid, and academic centers (86.4%). Moreover, facilities located in states that expanded Medicaid were also more likely to offer high access to Medicaid patients, 71.3% versus 59.6%.

“The results of this study do not necessarily mean that patients will not be able to access care anywhere, but may require a circuitous and impractical path, and may not be seen at centers designated for cancer care,” Dr. Leapman explained.

According to Dr. Leapman, finding solutions that increase access for Americans with Medicaid will be complex. “Despite a large increase in the number of Medicaid-insured patients, most factors that limit a hospital or physician’s participation in Medicaid have not changed,” he said. “These include low reimbursement, high administrative burden, and limited specialist participation in managed care organization networks. Even modest increases in reimbursement may have a positive impact, and progress in payment structures that prioritize healthcare quality are promising as well. Still, identifying these gaps in access is an important first step that can direct awareness.”

Additional Yale authors include Michelle Salazar, Elizabeth Berger, and Daniel Boffa.

 
 

Clipped from: https://www.news-medical.net/news/20220715/Study-assesses-the-acceptance-of-Medicaid-insurance-among-patients-diagnosed-with-cancers.aspx

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MT Medicaid patients to see greater access to substance use disorder treatment

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[MM Curator Summary]: CMS is waiving the bed cap for another state (Montana).

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

Montana this week received federal approval for substance-use disorder treatment providers with 17 or more beds to bill Medicaid, an expansion providers called a “game changer” for combating addiction across the state.

“Until now, we’ve been limited in the number of Medicaid members that we’ve been able to serve, despite an increased demand for treatment,” said Lenette Kosovich, CEO at Rimrock Foundation, the state’s largest provider of treatment for substance-use and co-occurring disorders.

The governor’s office and the Montana Department of Public Health and Human Services announced the approval Wednesday. Federal law prohibits Medicaid payment to any institution for mental disease with 17 or more beds that provide substance-use or mental-health treatment. Last year, DPHHS applied for a waiver to expand the number of services not typically covered for Medicaid recipients. A DPHHS spokesperson said Wednesday during those negotiations, the department decided to ask the Centers for Medicare and Medicaid Services to specifically waive the 17-bed exclusion in order to get that piece in place sooner while negotiations continue.

That exclusion waiver granted this week allows larger treatment providers to receive Medicaid reimbursement for short-term acute inpatient and residential stays at facilities serving patients with mental disease.

“There’s more work ahead, but we’re certainly excited to announce this achievement today,” DPHHS spokesperson Jon Ebelt said in an email.

The CMS
letter dated July 1 specifically does not approve substance use disorder services at the Montana State Hospital, citing the agency’s decision in April to terminate its reimbursement agreement at the facility due to repeated failures to maintain health and safety levels there.

The state is leveraging its new Healing and Ending Addiction through Recovery Treatment (HEART) Fund, proposed by Gov. Greg Gianforte and approved by the state Legislature in 2021, which draws $7 million from new marijuana tax revenues. That money will generate federal matching dollars to bring that to a new total of $25 million in annual spending, according to the governor’s office.

“Our HEART Fund fills gaps to provide for a full continuum of substance use prevention and treatment programs for communities,” Gianforte said in a press release. “For too long, Montanans have struggled to receive timely access to treatment due in large part to the limited number of beds. With this approval, more people will have access to treatment when they need it most.”

 
 

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Department of Public Health and Human Services Director Adam Meier.

THOM BRIDGE, Independent Record

Adam Meier, director of DPHHS, said the waiver addresses the ongoing challenge of wait times for this level of care due to an insufficient number of beds available for Medicaid patients.

“Access to treatment is vital, and now hundreds more Medicaid recipients will be able to receive this critical service,” Meier said in the release.

The statewide impact will be realized over time, the governor’s office said in Wednesday’s press release. The Rimrock Foundation, meanwhile, estimates the waiver will allow the organization to scale up to serve an additional 350 Medicaid members annually.

In whole, the waiver application asked for federal approval of Medicaid coverage for additional community-based treatment and recovery services, including evidence-based stimulant use disorder treatment models, housing supports and pre-release care management for individuals in the 30 days prior to their release from a correctional setting. The state health department and CMS continue to negotiate toward the approval of these components of the waiver application, Ebelt said Wednesday.

 
 

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Clipped from: https://www.bozemandailychronicle.com/news/state_government/mt-medicaid-patients-to-see-greater-access-to-substance-use-disorder-treatment/article_5246f72a-51e6-5251-836f-50ed92f5748f.html

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Access to Urological Care for Medicaid-Insured Patients at Private Equity-Owned Urology Practices

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[MM Curator Summary]: Clinics funded by private equity do not prioritize patients whose insurance pays less and is harder to deal with.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

In light of current national trends in practice consolidation, researchers sought to define appointment availability for Medicaid-insured patients seeking care at urological practices linked with private equity companies.

They found 214 private equity-affiliated urology offices that were geographically matched with 231 non-private equity-affiliated urological offices. Investigators posed as an adult patient with either Medicaid or commercial insurance in the clinical scenario of new-onset, painless hematuria using a standardized script. The main result was whether or not the patient’s insurance was accepted for an appointment. The appointment wait time was a secondary consequence.

In 12 states, we made 815 appointment inquiry calls to 214 private equity (PE) and 231 non-PE-affiliated urology practices. Appointment availability was greater for commercially insured patients (99.0%; 95% [CI]: 98.1%-99.9%) than for Medicaid-insured patients (59.8 %; 95 % CI: 55.0%-64.6%) (P<.0001). Medicaid acceptance was greater in non-PE associated practices (66.8%; 95% CI 60.4%-73.2%) than in PE affiliated practices (52.1%; 95% CI 45.0%-59.2%) (P=.003). On multivariable logistic regression analysis, state Medicaid expansion status was independently associated with Medicaid appointment availability (odds ratio [OR] 2.20; CI 1.14-4.28; P=.020), whereas PE-affiliation was independently associated with lower Medicaid access (OR 0.55; CI 0.37-0.83; P=.004). Appointment wait times did not differ substantially between commercially and Medicaid-insured patients (19.2 vs. 20.1 days; P=.59), while PE-affiliated practices had shorter mean wait times than non-PE offices (17.5 vs. 21.4 days; P=.017).

Access discrepancies for urologic assessment were more evident in patients with Medicaid insurance at urology offices bought by private equity.

Reference: goldjournal.net/article/S0090-4295(22)00181-9/fulltext

 
 

Clipped from: https://www.physiciansweekly.com/access-to-urological-care-for-medicaid-insured-patients-at-private-equity-owned-urology-practices/

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Colorado mental health providers say they were “blindsided” again

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[MM Curator Summary]: MH services provided by interns will now need to be supervised by licensed counselors with at least 2 years licensed experience and who are not barred from the program. And providers are up in arms about this.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

New rules about the supervision of counselors working toward their licenses could worsen the workforce shortage, private practice therapists say

 
 

 
 

Carla D’Agostino-Vigil, clinical director at Ignite Counseling Colorado, speaks during an employee meeting Feb. 23, 2022, in Westminister. D’Agostino-Vigil is one of Colorado’s mental health providers who has grown frustrated with billing issues with the state Medicaid program. (Hugh Carey, The Colorado Sun)

Colorado mental health counselors in private practice say they’ve been surprised once again with new rules that will make it harder to treat the state’s most vulnerable patients: those with Medicaid insurance. 

The latest friction between behavioral health professionals and the Colorado Department of Health Care Policy and Financing centers on the supervision of post-graduate counselors working toward their state license. 

The department — which approved the policy written by the regional agencies that handle payments to mental health clinics — says the new rules are necessary to ensure Medicaid patients are receiving quality care. But counselors in private practice say the rules could mean the loss of dozens of workers and potentially hundreds of mental health appointments. 

They’re also frustrated because they said they didn’t know the new rules were coming.

The policy, which was announced at the beginning of this month, imposes stricter requirements on using interns still working toward their graduate degrees and therapists who have graduated but have yet to receive their license, a process that takes two to four years after graduation. Those pre-licensed counselors can see patients, but must have a licensed counselor sign off on their diagnoses and progress notes from each counseling session. 

With the new rules, only counselors who have been licensed for at least two years can sign off on the work of pre-licensed counselors. The rules also stipulate that any counselor sanctioned by the state licensing division, at the Department of Regulatory Agencies, must wait for two years after their sanctions have expired before supervising pre-licensed counselors. 


Colorado is divided into seven regions run by agencies that contract with the state Medicaid division. Behavioral health providers who want to take patients on Medicaid must enroll first at the state department and then with the regional agencies. (Colorado Department of Health Care Policy and Financing)

Counselors in private practice see both rules as an overreach, one that will mean fewer appointments for patients on the government insurance program for the needy, Medicaid. About 30 of them attended a virtual meeting this week with the Medicaid division, which is housed in the Department of Health Care Policy and Financing. 

“We feel like that is going too far,” Andrew Rose, a psychotherapist and director of Boulder Emotional Wellness, said in an interview. “If DORA has decided you are safe to practice, that should be good enough.”

But Cristen Bates, the state’s interim Medicaid director, said the policy is geared toward expanding the workforce — by creating standardized rules so that counselors still seeking their license have a clear path to getting experience and becoming licensed counselors. The issue is that the regional agencies that serve as the middlemen between clinics and the state Medicaid department have had inconsistent rules as they’ve allowed pre-licensed counselors to practice under supervision. The new policy, which also applies to community mental health centers, was created by those agencies to apply to counselors statewide.

“We have to make sure that our members are getting high-quality care,” Bates said. “We  were glad to see some very clear rules about when this is and is not appropriate.” 

Where the department erred, Bates said, was in not informing behavioral health care professionals about the policy changes or showing them a draft ahead of the implementation date. 

“The rollout was where we kind of had some challenges,” she said. 

The regional agencies are now considering possible changes to the policy and have said they will not deny claims or penalize clinics that are not following the new rules. After the outcry from providers, the regional agencies backtracked on the July 1 implementation date. One of them, Colorado Access, said in an email to The Sun that the policy change is not in effect and that “any changes to our current program will include additional input and advance notice.”

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Medicaid payment issues plague host of Colorado caregivers and therapists who see low-income and disabled patients


The discord is the latest in a long list of frustrations among mental health professionals who say they want to provide therapy for people on Medicaid but are fed up dealing with burdensome rules, redundant paperwork and even threats of having payments revoked. It comes as Colorado is facing unprecedented need for services, due in part to the isolation and stress of the coronavirus pandemic. 

Rose said he typically signs off on 100 to 200 notes per week for his team of pre-licensed staff at Boulder Emotional Wellness. The clinic employs 38 pre-licensed counselors and plans to bump that number to 42 next month. 

The rule changes will make this a challenge, since it’s already difficult to find licensed counselors willing to take on the liability of supervising pre-licensed therapists, he said. 

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Rose and others said they found out about the policy in a July 5 newsletter from one of the regional agencies that also laid out other policies that went into effect July 1. 

“The larger concern here is really, who sets policy and who gets to have a say in that process?” he said. “It’s hard enough right now to keep providers. We just need some relief from this. We need to be included in decisions about who we can hire.” 

The need for mental health counseling is so high right now that appointments with licensed counselors are “filled in a hot second,” said Dr. Lisa Griffiths, director of the Center for Valued Living in Aurora. Many clients rely on appointments with pre-licensed counselors under the supervision of licensed counselors. 

 
 

One of Griffiths’ seven supervisors has a doctoral degree but has not yet had her license for two years, meaning she could no longer supervise other counselors under the new rules. 

Mental health providers have been meeting regularly with the Medicaid department to smooth out their relationship after a series of issues, including rate cuts and processing problems that resulted in a regional agency trying to take back money from clinics that had already been paid for seeing Medicaid clients. 

In the past few months, providers and the department have collaborated on new policies for marriage therapists and treating patients with gender dysphoria. The latest policy changes, however, came out of nowhere, Griffiths said. 

“The providers felt blindsided,” she said. 

 
 

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Clipped from: https://coloradosun.com/2022/07/14/mental-health-medicaid-counselors/

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Federal audit forces New Hampshire to repay $7.9M Medicaid funds

MM Curator summary

[MM Curator Summary]: NH is writing a check to CMS over issues with poor quality of opioid addiction treatment services- 90% of methadone clinics did not provide required followups and other care.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

(The Center Square) – A majority of Medicaid-funded treatments for New Hampshire opioid addicts don’t meet quality standards, according to a new audit, which will require the state to pay back nearly $8 million to the federal government.

The audit, conducted for the U.S. Department of Health and Human Services, found that more than 90% of the state’s methadone treatment programs that billed the Medicaid program for services didn’t provide the required follow-up counseling or long-term recovery plans, and in many cases didn’t require follow-up with tests for illegal drugs.

Of 100 opioid treatment cases reviewed by federal auditors, only six complied with state and federal laws, according to the report.

“These deficiencies occurred because New Hampshire did not have the resources to oversee providers and enforce the opioid treatment program requirements,” the auditors wrote in the report. “Providers said high personnel turnover, difficulty attracting and retaining personnel, and difficulty keeping patients engaged in counseling services contributed to the lack of adherence to state requirements.”

Auditors also pointed out the New Hampshire officials didn’t provide enough guidance to providers on the treatment requirements.

In a response to the audit, New Hampshire officials accepted the findings and agreed to refund $7.94 million to the federal agency. That amount covers the estimated cost for more than 350,000 Medicaid claims from 2016 to 2019, according to the audit.

Overall, state officials say drug treatment programs have suffered the same staffing shortages in personnel as other health-care sectors which has impacted care.

“New Hampshire is not unique in the difficulty health-care providers experience recruiting and retaining direct workforce,” Henry Lipman, director of the state’s Medicaid program, wrote to HHS in a response to the audit.

He said the state is working on plans to expand the health care workforce and last year convened a working group of stakeholders to work on solutions to the hiring crunch.

“Over 70 health-care thought leaders from around the state convened to identify aligned priority projects and strategies that the department is uniquely positioned to help collaboratively address,” Lipman wrote. “We believe these efforts are important to ensuring care is delivered timely and with appropriate documentation.”

He wrote that the state has ordered Medicaid funded opioid treatment providers to conduct reviews of their programs and submit their findings next month.

But Lipman disagreed with claims in the audit that opioid treatment services are being rendered by “clinically unqualified personnel.”

“We are committed to working with OTP providers and Managed Care Organizations to ensure OTPs are available to provide critical treatment services which meet New Hampshire’s high standards of care,” he wrote in his response.

 
 

Clipped from: https://www.washingtonexaminer.com/news/audit-forces-new-hampshire-to-repay-medicaid-funds

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Medicaid program did not recover $292M in overpayments

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[MM Curator Summary]: NY MCOs did not run third-party liability ops like they should have.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

Lax oversight led to $292 million in overpayments from the state Medicaid program to never be recovered by New York officials, state Comptroller Tom DiNapoli’s office found in an audit released Wednesday. 

The payments were part of pharmacy claims, covering instances in which Medicaid has paid medical bills a third-party insurer should have covered, but was never clawed back. 

Both the state Department of Health as well as the Office of the Medicaid Inspector General should have done a more thorough job to ensure the payments were recovered, DiNapoli’s audit concluded. 

“Medicaid is essential for millions of New Yorkers, but the program needs to ensure that funding is only used for appropriate costs for those who need it,” DiNapoli said. “This is my office’s latest audit to uncover weaknesses in the Medicaid system’s oversight. These potentially unnecessary payments likely contributed to significant waste and a missed opportunity to recover the nearly $300 million in questionable payments. DOH should recoup any overpayments and take steps to better protect taxpayers from costly billing mistakes.”

The Medicaid program is considered a payer of “last resort.” If a recipient has third-party insurance coverage, those benefits should be exhausted first before Medicaid funds are used. 

DiNapoli’s audit covered October 2015 and May 2020, finding prescription drug claims that were paid by Medicaid managed care plans for which third party cairrers were not being billed. 

The comptroller’s office recommended state health officials review Medicaid payments made on behalf of those who have third party health insurance and assess pharmacy claims that were billed to those carriers. The audit also proposed an assessment of third-party liability recovery for managed care pharmacy services. 

 
 

Clipped from: https://www.ny1.com/nyc/all-boroughs/ny-state-of-politics/2022/07/13/audit–new-york-medicaid-program-did-not-recover–292m-in-overpayments