Hospitals report delays in payments, treatment from KanCare companies

Some hospitals say paperwork delays are slowing care for some patients and payments for them as KanCare nears the end of its first year.

Carrie Saia, chief executive officer of Holton Community Hospital, said one of their patients had to wait a week for a cardiac “stress test” because of delays authorizing tests, which she said has been a problem with the three companies administering KanCare. The patient didn’t suffer any complications during the wait, she said.

KanCare, which rolled out in January, moved most of the state’s 350,000 Medicaid recipients into plans administered by three private companies: Sunflower State Health Plan, Amerigroup and United Healthcare. Gov. Sam Brownback pitched KanCare as a way to achieve substantial savings on medical costs while improving care. Earlier this month, he announced $37 million had been saved so far, which he said would allow 650 more people with physical or developmental disabilities to get off the waiting list for in-home services.

Saia said she was skeptical of the savings. When Saia was interviewed Thursday, she said some of the hospital’s staff members still were working on getting paid correctly for services performed in March, though rural health clinics affiliated with the hospital haven’t had the same difficulties.

“We expected there to be some bumps, but not 10 months into it, so many bumps,” she said. “The reason they’re saving so much money is we’re not getting paid correctly.”

Cindy Samuelson, Kansas Hospital Association vice president for member services and public relations, said hospitals around the state have reported problems getting reimbursed for services they perform and getting “prior authorizations” — permission from an insurance company to provide a certain treatment — quickly. Some hospitals and clinics haven’t reported problems, she said, while others say problems are frequent.

“It’s not just happening at one hospital. It’s not just happening with one of the MCOs,” she said.

The MCOs, or managed care organizations, don’t have to follow the “prompt payment” law that other insurers do, Samuelson said, which requires insurers to pay most claims within 30 days provided it was a “clean claim” that provided all necessary information. Companies who failed to pay on time would be charged 1 percent interest on the claim each month.

Robert Moser, secretary of the Kansas Department of Health and Environment, said the MCOs also have an incentive to meet quality standards, because a percentage of their payments will be withheld if they don’t meet goals set by the state.

Hospitals estimate it is taking three to 10 days to authorize treatment, Samuelson said. The state has attempted to deal with the issues, but the insurers haven’t been as cooperative so far, she said.

“Really, KDHE has been very responsive,” she said. “We’re hoping to get that same kind of response from the MCOs.”

Moser, who was a family practice physician for 22 years, acknowledged there have been some issues with the change in running Medicaid. KDHE, the Kansas Department for Aging and Disability Services, KHA, the Kansas Medical Society and the three MCOs have been meeting to discuss issues and come up with solutions, he said.

The MCOs are compiling a weekly summary of the top three to five issues they are dealing with and developing plans to address them within a specific time frame, Moser said, and they have pledged to hire more staff and improve staff training. He said service has improved, and 97 percent of clean claims are being processed in 20 days.

“There has to be more customer service to the providers, as well as the consumers,” he said. “I understand the frustration from the providers.”

Some of the confusion arises from one of KanCare’s strengths, Moser said: It allows more flexibility to meet patients’ needs. Some services, like home-based care after a person leaves the hospital, used to be denied out of hand, but the MCOs now can allow it if they believe it would help the patient more than moving to a rehabilitation unit, he said.

Another goal, getting patients care that is within medical guidelines, can cause some difficulties if doctors aren’t used to those standards, Moser said. For example, an insurance company won’t automatically approve an X-ray or MRI for a person complaining of lower back pain, because those tests often don’t yield much useful information, and the insurers want to “make sure we’re not jumping to the most expensive test first,” he said.

Representatives of the three MCOs said they are improving their service and that building relationships with providers is their priority.

Monica Stoneking, spokeswoman for Sunflower State Health Plan, said the company’s average time for processing a clean claim is about six days. Prior authorizations are being processed in an average of two days, she said.

Sunflower is holding daily “workgroups” to solve issues and has weekly calls where providers can share their concerns, Stoneking said. It also will host meetings for providers around Kansas this fall, she said.

Maureen McDonnell, spokeswoman for Amerigroup, said 99 percent of prior authorizations for hospitalized patients are completed in one day and 79 percent of outpatient prior authorizations are completed within three days. Prior authorization isn’t required for emergency room procedures, she said, and clean claims are paid in an average of five days.

Molly McMillen, spokeswoman for United Healthcare, said the company is offering weekly meetings for providers and other communication tools, and welcomes feedback.

Jerry Slaughter, executive director of the Kansas Medical Society, said members reported some issues with prior authorization and prompt payments, but difficulties are to be expected in any large-scale undertaking, he said.

“It’s never going to be as smooth as everyone might like,” he said. “I would expect by year’s end they will have some of those problems resolved.”