Senators press Nebraska’s Medicaid director about ongoing problems with managed care system

LINCOLN — Nebraska lawmakers raised concerns Monday about continuing problems with the state’s nearly year-old system for managing Medicaid services.

Members of the Health and Human Services Committee quizzed the state’s interim Medicaid director about unpaid claims and balky authorization processes that have frustrated health care providers and delayed care for patients.

State Sen. Matt Williams of Gothenburg disputed statements by Director Thomas “Rocky” Thompson that the majority of providers have experienced business as usual under the new system.

“My five critical access hospitals and my rural health clinics would disagree completely with that statement,” he said.

Williams said the facilities have struggled to get paid and get care authorized, including at least one case in which care was authorized for a mother but not for her newborn baby and another case in which surgery was authorized but not the services of an anesthesiologist.

But Thompson argued that the system has successfully provided about 230,000 Medicaid patients with more consistent, all-inclusive health coverage.

Under the system, called Heritage Health, the state has contracted with three private companies to manage and pay for the bulk of Medicaid services.

The contractors — United HealthCare Community Plan, Nebraska Total Care and WellCare of Nebraska — are responsible for administering $1.2 billion worth of physical health, behavioral health and pharmacy services for almost all Medicaid recipients.

While Thompson acknowledged that there have been some issues during implementation, he said the three contractors have worked hard to make improvements.

“I think they’re doing remarkably better than they were in the first half of the year,” he said.

Among system accomplishments, Thompson cited the 5.9 million claims worth $743.5 million that the contractors paid during the first nine months of the year.

He said the contractors provided care managers to work with 13,433 Medicaid patients with the most complex and potentially costly health care needs.

Thompson also pointed out that contractors must reach certain performance levels to earn incentive payments from the Department of Health and Human Services.

[More: Nebraska’s new Medicaid system got off to a rocky start, but state says ‘growing pains’ are healing]

One performance measurement looks at the percentage of claims paid within 15 days. In September, United HealthCare met the standard for 94 percent of claims, while the other two met it for 99 percent of claims.

But Sen. Sue Crawford of Bellevue questioned that figure.

She noted that the requirement applies only to what are called “clean claims,” meaning they have all the information required by the contractors in the correct computer fields.

Thompson offered information showing that, in September, Nebraska Total Care had 97 percent clean claims.

The other two contractors reported that 82 percent and 80 percent of claims were clean, with the rest being rejected. In July, WellCare had only 70 percent clean claims.

Thompson said it is the provider’s job to submit clean claims.

But Crawford said the differences in clean claims levels suggest the problems are with the contractors.

She called for HHS to set a new performance requirement to push contractors to work more closely with providers on bringing down the number of rejected claims.

Sen. Merv Riepe of Ralston, the committee chairman, expressed concern that the state only requires annual surveys of patients and health care providers. He said more frequent surveys are needed to do proper oversight.

Thompson said he expects the department will have the results of its surveys by March or April.

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