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As an expansion date for KanCare approaches, state officials say they are focused on making sure the billing system transitions smoothly. KanCare is Gov. Sam Brownback's managed care reform that, at the beginning of , placed most of the state's , Medicaid recipients under the administration of three private-sector insurance companies.
Two of those three "managed care organizations," or MCOs, acknowledged during a KanCare Advisory Council hearing Wednesday that there have been "bumps in the road" when it comes to claims processing and told the council they are working to smooth them out before a Jan. Rumbaugh said the company has learned from last year's roll-out and a limited pilot program that includes Kansans with developmental disabilities. She encouraged providers to go up the chain of command with claims complaints that linger.
Tim Spilker, of United HealthCare, also said "there have been bumps in the road in terms of claims payment timeliness and accuracy," adding that some claims might be filed incorrectly by providers, but some delays might be due to "configuration" issues that the MCOs themselves need to address.
Spilker said claims denials are running about 10 to 12 percent, "which is actually about right. Major hospital systems including Via Christi and Stormont-Vail HealthCare have reported increases in payment delays under KanCare and some pharmacies have reported prescription reimbursements that don't cover costs. By reaching a settlement in August that avoided any criminal or civil charges or a finding of default under the contract, the company was eligible to apply for future contracts with the state, including the upcoming Medicaid provider contract which was posted for proposals in early October.
The company recently declined to disclose to the Corrales Comment whether it would seek a renewal of its New Mexico contract it has held since It did renew Centene contracts for other parts of the state.
If the company applied, New Mexico could possibly be the first statewide program to cancel with the company. It could also be the first to renew since the latest claims were settled.
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Many will be placed in managed care. By next year, more than two dozen states are expected to have set up programs to transfer frail elderly, mentally ill or individuals with physically disabilities into managed care for home and community-based services. But in most states, those with developmental disabilities — people with impairments such as cerebral palsy, Down syndrome and autism — have been excluded from managed care for these services because their needs are so specialized.
They live with their families or in apartments, single-family homes or group homes. Some need round-the-clock supervision and many require assistance with dressing, bathing and preparing meals, as well as transportation.
Some need help finding a job or volunteer work, and many attend daytime activity centers. In Kansas, where a network of community-based nonprofit organizations and county agencies oversee these services, individuals can choose a case manager, who visits them at home and coordinates their care. In some cases, those relationships go back decades. While these organizations will continue to determine what services clients are eligible for and case managers will work with families to arrange that care, ultimately the health plans will be responsible.
Mistakes that are just inconvenient to some can be devastating to them. Only a handful of states, including Michigan and Vermont, have moved individuals with developmental disabilities into managed care for long-term services. None has turned exclusively to national managed care companies. Sam Brownback had in mind when his administration decided to transfer virtually all of the nearly , people on Medicaid into KanCare, starting in January It gives them a fixed amount per member each month.
As of Sept. The companies provide medical, pharmaceutical and mental health care to KanCare members, including those with developmental disabilities. Although the frail elderly and those with physical disabilities and mental illness are now getting long-term services through KanCare, inclusion of people with developmental disabilities was delayed until by the legislature following bitter protests from parents, advocates and providers.
Kansas State Rep. Shawn Sullivan, Secretary of the Kansas Department for Aging and Disability Services, said in an interview that providers who are fearful of change had gotten families riled up unnecessarily. The major difference, Sullivan said, is that the insurance companies will hire care coordinators who will work in conjunction with case managers and providers.
Sullivan, a former nursing home administrator, conceded that state officials should have done a better job interacting with families and providers from the start. But they will improve outcomes for clients who will receive more employment opportunities and better coordination of their medical and mental health care, he said. Ultimately, that will save money because of fewer hospitalizations and medical costs.
Jean Rumbaugh, president of Sunflower State Health Plan, said money can be saved by reducing inefficient care and better coordinating services.
Amerigroup Kansas President Laura Hopkins said her plan wants to protect the array of services for clients. The health plans say that while they may not have much experience with this particular type of program, they have been handling similar services for individuals with physical disabilities and elderly members.
They also have been hiring workers and managers with expertise in developmental disabilities in Kansas. Kay Soltz, of Wichita, said her year-old son, Zachary, was initially assigned to a pediatrician as his primary care doctor when KanCare launched.
After she complained, the health plan assigned him to a doctor located 20 miles away, and Soltz said she jumped through more hoops to get it changed. Zachary, who is in constant motion, has autism and intellectual disability. He spends much of his time watching second snippets of old TV game shows from his childhood and listening to TV theme songs on his Walkman over and over.
He attends a day program and, like Neil Carney, lives in a single-family home with a caregiver. In recent months, KanCare has also come under attack from hospitals and some providers, who have charged that the health plans have improperly denied or delayed reimbursements and created serious financial and bureaucratic obstacles for them.
The companies say they have been meeting with providers to work out the bugs and have been trying to resolve any systemic problems on their end. But they note that providers also need to become more familiar with the billing and claims process.
They say this would leave clients with fewer choices and could result in them losing their case managers and caregivers. Hulet, a cheerful year-old quadriplegic with cerebral palsy who loves watching wrestling and singing at church, lives in an apartment. He also uses a computer to type up banners and notices by pushing a button with his head. Defendant Centene Management Company is a wholly-owned subsidiary of Centene Corporation organized under the laws of the State of Wisconsin with its principal place of business at Forsyth Boulevard, St.
Louis, Missouri. This Court has jurisdiction over the subject matter pursuant to 18 U. Plaintiff has satisfied all private, administrative, and judicial prerequisites to the institution of this action. A timely Complaint was filed with the Secretary of Labor on April 24, The unlawful employment practices alleged herein were committed within this jurisdiction.
In , at the instruction and under the direction of Governor Sam Brownback, the State of Kansas undertook efforts to contract with managed care organizations to privatize the Kansas Medicaid Program. The handbook must provide information about choosing and changing providers, procedures for written notification of the termination of a contracted provider 2.
On December 7, , Governor Brownback and administration officials announced that the Centers for Medicare and Medicaid Services had approved his plan to move Kansas to the managed care Medicaid system designed at his instruction. Serious concerns regarding allegations of fraud within the KanCare program have also been raised. Leary was also in attendance. Hitchcock also explained that he did not like academic centers because the medical students order too many procedures and tests.
Beginning in March , Plaintiff began to communicate with various SSHP and Centene department leaders who would necessarily be involved in the closing of the PCP panels to auto assignment as she had been instructed by Ms. Wilms and Mr. During a meeting with Ms.
Leary was asked about the status of her efforts to close the PCP panels to auto assignment. She provided details regarding her inquiries to SSHP department leaders, then explained that she believed that Mr. In response, Ms. Wilms dismissed Ms. In the following months, Plaintiff orchestrated the closing of the member panels for KUMED as she had been instructed against her protests to Ms. Wilms regarding the propriety of those efforts. Leary was forced at the same time to determine how to alter the online and hard-copy provider directories to make these changes appear to somehow benign because KUMED administrators had not requested the closing of the member panels.
Plaintiff was then instructed by Ms. Leary explained that she was uncomfortable complying with this instruction, and Ms. In July , Ms. In August , Plaintiff informed Ms. Wilms that she was not willing to move members as she had instructed. Neither, she said, would she instruct the staff to lie in response to inquiries of this type from inquiring providers whose panels were closed to auto-assignment or SSHP members — all for reasons related exclusively to the financial performance of SSHP and its parent, Centene.
Wilms asked Ms. Leary to run a report to determine which members had actually been to see their PCP. For those that had not yet done so, Ms. Wilms proposed change in this regard would have directly affected approximately 7, members. In September , Plaintiff requested from an internal business analyst the report that Ms. Wilms sought. The analyst explained that it would take some time to generate. In the meantime, Ms. Wilms began a campaign of retaliation against Ms.
Leary which affected the dayto-day terms and conditions of her employment. Wilms canceled meetings with Ms.
Leary, explained that there was somehow no reason for the two key SSHP executives to meet for any reason, and generally refused to interact with her in the workplace. Wilms had instructed. On January 13, , Plaintiff documented in her response to her performance evaluation that she had informed Ms. Wilms that she was not comfortable moving members as she had instructed.
The following day, Ms. She noted her serious professional objection to this directive, and explained to Ms. As part of her complaint to Ms. Leary sought to discuss. Picotte asked Ms.
Leary to forward the relevant provider agreements, as Brian Deutschmann had instructed her to do, so that they could be reviewed by Centene corporate compliance representatives, along with any other information which Ms. Leary believed supported her concerns about the impropriety of the practice. Picotte explained that it was her job as VP of Compliance to confirm if Ms. She advised Ms.