Tag: State News

MM Curator summary

A recent state audit claims that MCOs deny services at a much higher rate than FFS.

 
 

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.

 
 

DES MOINES, Iowa — Iowa’s privatized Medicaid system has illegally denied services or care to program recipients, and both private insurance companies managing the system have violated terms of their contracts with the state, according to a state audit released Wednesday.

Auditor Rob Sand released a report from his investigation that examined a six-year period from 2013 through 2019. He said his investigators found a massive increase in illegal denials of care by managed care organizations, or MCOs, under privatized Medicaid.

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“What this means is that privatized Medicaid is less likely to treat Iowans in accordance with the law. It means that the Medicaid MCO’s that we have contracted with are not upholding their end of the bargain,” Sand said.

The head of Iowa’s Medicaid program responded within minutes of the audit’s release, rejecting its conclusions and arguing Sand was making an “apples to oranges comparison” that mischaracterized the current program.

Former Republican Gov. Terry Branstad in 2016 abruptly shifted Iowa’s Medicaid program from management by the Iowa Department of Human Services to private insurers. His successor, current GOP Gov. Kim Reynolds, has continued to support privatization amid complaints that service has suffered, payments to service providers have been delayed at times and promised savings never materialized.

Such privatization became a popular idea among GOP politicians, who argued private companies would more efficiently manage Medicaid than a state government agency. Currently, the private Medicaid managers provide health care for more than 781,000 poor and disabled Iowans.

Sand said after privatization, there was an 891% increase in the number of cases in which a judge restored services to a Medicaid participant, concluding services were unlawfully denied by the private insurers managing the program.

He promised after being elected in 2018 that he would do a compliance report on Medicaid after service providers and recipients complained about the new system failing to provide comparable care and payment.

“This has been a long-time coming. It has taken a lot of work. We’ve reviewed tens of thousands of documents and at the end of the day what this is, is a statement of facts,” Sand said. “It’s telling Iowans what’s going on in the state. We’re doing our job. It’s about the people.”

Sand also reported that the two companies managing the Medicaid program, Amerigroup and Centene Corp., operating as Iowa Total Care, violated provisions of the contract established with the DHS.

He said Amerigroup failed to comply with one provision of the contract, and Iowa Total Care failed to comply with numerous provisions of the contract. For example, in multiple documented instances, both companies failed to comply with the contract clause requiring Home and Community Based Services providers to continue providing services to a member switching from one provider to another.

“This has resulted in members going without services, such as bathing and wound care, thus violating the contract and state and federal law, while the company still receives payment for their care,” Sand said in the report.

In her statement responding to the report, Medicaid Director Elizabeth Matney called the audit “an incorrect and flawed report.”

Matney said the report inaccurately compares the previous “fee-for-service” system with a managed care approach in which appeals can be resolved without going before an administrative law judge. Such judges then can focus on more complex cases.

“We worked with the Auditor of State’s team to explain why this was an apples to oranges comparison,” Matney said. “The process is not the same, so making a comparison without factoring in the improvements we built into the MCO appeals process prior to ever seeing an administrative law judge is just wrong.”

She said much more information would be needed to substantiate the claims in the auditor report.

She said the department is reviewing the allegations of contract violations and offered to meet with Sand to discuss in further detail agreeing that “contract compliance is something that requires diligent oversight.”

 
 

Clipped from: https://www.nwaonline.com/news/2021/oct/25/auditor-iowas-privatized-medicaid-illegally/

 
 

 
 

 
 

MM Curator summary

 
 

More details released from the PA court case against Aetna suggest an extensive issue of assigning kids to PCPs known to not be in network.

 
 

 
 

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 following article was originally published in the Ohio Capital Journal and published on News5Cleveland.com under a content-sharing agreement.

COLUMBUS, Ohio—In a case that could have implications for Ohio, a Pennsylvania whistleblower is accusing Aetna of making it impossible for the parents of some kids on Medicaid to find doctors. The insurer then pocketed money from the state for services not rendered, the suit alleges.

Aetna denies the charges.

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The case is relevant here because the Ohio Department of Medicaid in April awarded a $1 billion contract to Aetna to implement OhioRISE, an ambitious new program meant to coordinate care for 60,000 children with complex behavioral needs.

The Pennsylvania allegations, which were unsealed last month in federal court in Pittsburgh, might cast doubt on whether the company will live up to its promises in the OhioRISE program.

The allegations also add to questions of conflict and bias concerning Ohio’s procurement this year of the OhioRISE contract and six others for $22 billion worth of Medicaid managed care. Together, the contracts are meant to reshape the way the Ohio Medicaid department delivers care to 3 million people.

The Ohio Department of Medicaid was asked to comment on the Pennsylvania suit a week ago. As of Tuesday, it hadn’t responded other than to acknowledge that it had been asked for comment.

For its part, Aetna parent company CVS Health denies the accusations.

“Aetna places the highest priority on the health and wellbeing of its members, and we provide access to quality care through a comprehensive provider network, including in Pennsylvania,” spokesman Bob Joyce said in an email. “Plaintiff’s allegation that Aetna has network adequacy deficiencies across the country is irresponsible and unrelated to the (U.S. Justice Department’s) investigation.

“Aetna denies the allegations in the complaint, and intends to vigorously defend itself should (the whistleblower) choose to move forward with her non-intervened complaint. Aetna is pleased that after reviewing all of the evidence, the government chose not to participate in the lawsuit.”

The case was filed under the False Claims Act, which encourages people with knowledge of government rip-offs to blow the whistle by giving them a portion of the money recovered.

While it’s accurate that the federal government declined to intervene in the suit, the federal government is said to intervene — or take over — in only about 20% of such cases.

And in an Aug. 25 filing, the Justice Department notified the court that the federal government would continue to be listed as a plaintiff and pointed out that the case can only be dismissed if Attorney General Merrick Garland consents to it. The filing also asked U.S. Magistrate Judge Cynthia Reed Eddy to unseal the complaint, which she did the following month.

Serious claims

The Pennsylvania whistleblower, Carol Wessner, accused Aetna Better Health of Pennsylvania of shrinking its network of doctors for kids on Medicaid and then lying to the Pennsylvania Department of Health about it.

Aetna hired Wessner as a “quality management nurse consultant” in 2013. Her primary task was to investigate why such a high percentage of Aetna’s child patients were missing their Early and Periodic Screening, Diagnostic and Treatment appointments. The doctor visits, required by Medicaid since 1967, are intended to catch developmental and other health issues as early as possible.

Wessner claims that she discerned a pattern. Aetna officials contended that kids were missing appointments because providers were discriminating against them, but she found that time and again, those providers weren’t in Aetna’s network.

Wessner “never encountered an (Aetna pediatric doctor) who discriminated against children on (Aetna) Medicaid,” the suit says. “Rather, many of the (doctors) to whom children were assigned (i) were not contracted with (Aetna); (ii) were dead; (iii) were out of state; or (iv) did not see children at all.”

Many of the physicians to whom Aetna claimed to assign children wouldn’t be likely to pass even superficial scrutiny, Wessner said.

“… children, including two-year-old boys, were assigned to gynecologists, hospitalists and vascular surgeons,” the lawsuit says, referring to a provider group that Aetna listed as in its pediatric network. Aetna “also had wrong addresses, phone numbers and affiliations for the (primary care providers) at this site.”

Wessner also provided possible evidence that Aetna was deliberately shrinking its network while telling a different story to Pennsylvania Medicaid officials.

She said that on May 7, 2014, she was in a meeting with a Philadelphia public health official when the official was handed a note from Aetna. The company was notifying the city’s department of health that it was terminating its contracts with all eight of the agency’s City Health Centers, the suit says.

Yet by “February 2015 — almost a year later — (Aetna) still had 491 children enrolled with the department,” the lawsuit says. “Some were enrolled as recently as Feb. 1, 2015.”

Wessner claims that Philadelphia was far from the only agency in which Aetna terminated contracts with providers while continuing to tell state Medicaid officials that its child clients were enrolled with the agencies’ doctors. Her lawsuit says Aetna took similar actions with at least six other health systems, in some cases assigning children to doctors within the systems even after terminating their contracts.

In the case of the Reading Health Physicians Network, the lawsuit claims that in September 2016 — almost two years after Aetna had terminated its contract — the company still assigned 1,127 of its child clients to doctors there. Seven hundred thirty six of them hadn’t had their federally required diagnostic exams in at least a year, it said.

The lawsuit says money was the motive for all this.

Aetna “misrepresented its network adequacy by including providers (Aetna) knew were inaccessible in order to gain new Medicaid enrollees that would increase (Aetna’s) per-member/per-month payment from Medicaid.”

Payback?

Wessner claims she was retaliated against for repeatedly flagging problems to her superiors, including Aetna Better Health of Pennsylvania CEO Jason Rottman.

She said her supervisor, Alice Jefferson, in 2015 told her to stop sending written reports and make them verbally instead. In 2016, Wessner was removed from her job investigating kids’ missed checkups. Then in 2018, she was terminated.

Regardless of the outcome of the case, it adds to questions about the companies hired as part of Ohio’s Medicaid reforms this year.

Aetna’s parent company, CVS, has long been accused of gouging Ohio Medicaid for prescription drugs — a charge the corporation denies. UnitedHealth has faced similar accusations and is being sued over fraud claims by Attorney General Dave Yost. Yet it was one of six giant corporations to be awarded huge managed-care contracts in this year’s procurement.

Yost in March sued another of those corporations, Centene, and it paid out $88 million in June to settle them.

When the Ohio Medicaid department undertook its procurement process, it set it up in a way that didn’t allow evaluators to consider previous bad acts by the companies applying. Now Mercer, the consultant that facilitated the process, won’t say whether any of the successful bidders are also its clients.
 

 
 

Clipped from: https://www.news5cleveland.com/news/state/aetna-an-ohio-medicaid-contractor-accused-of-denying-kids-care-in-pennsylvania