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By Clarissa Donnelly-DeRoven

Three months into North Carolina’s Medicaid transition, some small health providers say they’re struggling to navigate the new system. They describe spending hours more on new administrative tasks, trying to ensure their patients don’t experience lapses in care and that they get paid for the services they provide.

“I want to help everybody, and this is preventing me from doing that,” said Rebecca Rowe, a speech language pathologist who runs her own practice in Charlotte. Rowe and other small medical practice owners worry that the added administrative costs may make it untenable for them to serve as many Medicaid patients in the future. 

“When you’re talking about a small business, you have to maximize the time, right? Maximize the time spent one-on-one with clients,” Rowe said. “It’s hurting children first and foremost, but it’s also hurting small businesses and I don’t think that’s something that the North Carolina government understood.”

Dave Richard, the deputy secretary for North Carolina’s Medicaid system, said the agency is aware of these problems and working to address them through weekly conversations with the CEOs of each of the managed care organizations. Still, he said, some of the issues are just a function of the new system. 

“Managed care is managed care and there’ll be some of these changes that just are inevitable because of the way that managed care organizations have to work,” he said.

From public to private

On July 1, North Carolina’s Medicaid program transitioned from a system run and managed primarily by the state, to a system run and managed by five different private insurance companies, called managed care organizations or MCOs. About 1.6 million low-income North Carolinians had their coverage switched from state managed to MCO managed. Three quarters of those people — 1.2 million — are under 21 years old. 

Some 900,000 people who have more intense health care needs, ranging from developmental disabilities to chronic mental health issues, remain on state-run Medicaid and will see their plans turned over to the MCOs in 2022. 

Nationwide, about 70 percent of people on Medicaid receive coverage from a managed care entity, according to the Kaiser Family Foundation. Before the transition, North Carolina was the largest state in the country without a significant presence of corporate managed care organizations in its Medicaid system. 

In 2019, 40 states used managed care entities within their Medicaid system. As of July 2021, North Carolina joined the majority. Map courtesy of the Kaiser Family Foundation.

The transition from state run to MCO run occurred by and large to save money and provide more budget predictability. 

When North Carolina ran its own Medicaid program, state employees were responsible for authorizing claims and allocating the funds to pay doctor bills. The cost of the program came in at $14.8 billion in 2019 and $16.8 billion in 2020. The federal government pays for the majority of Medicaid costs; over that two year period, North Carolina’s share came out to about $3.8 billion. 

The cost savings is expected to come from the shifting payment structure. The state-run Medicaid program operated using a fee-for-service model, where the state reimbursed health care providers for each visit, test and service. The model used by managed care organizations pays providers a set payment per patient. Under the new model, patient health outcomes will be one of the key benchmarks for measuring how well providers are doing.

The MCOs are for-profit entities. In the past, they made money by denying services and cutting reimbursement rates. Richard said there are accountability measures in place to prevent this kind of nefarious behavior, specifically through something called a Medical Loss Ratio.

The Affordable Care Act requires private health insurance companies to submit data on how they spend their money. The standard under the Medical Loss Ratio requires the companies to spend between 80 and 85 percent of the money they take in from premiums on actual health care services. If they don’t do that, and instead spend customer payments on things like executive compensation and advertising, they have to issue rebates. 

The rule extends to the MCOs working with North Carolina’s Medicaid program.

Division of Mental Health director Dave Richard speaks to reporters at the WakeBrook event Thursday. Photo credit: Rose Hoban

“They have to spend 88 percent of what we pay them on services,” Richard said. “It can’t be that they’re spending 80 percent, then they’re pocketing the rest. So there’s this real tight part in our managed care plan that I think holds them accountable at that level.”

With managed care, more logistics to deal with

Before the transition, service providers submitted requests for authorizations and claims directly to the state’s Medicaid program through the NCTracks online portal. Now they have to navigate the systems of multiple managed care companies. This, they say, is one of the most time consuming parts of the transition. 

Stacy Kozlowski, an occupational therapist, works with a client.

Lakajai Harris, a speech language pathologist, runs her own practice and works with children in rural Beaufort County. About 95 percent of her patients are now on managed care plans. She is in-network with four of the five managed care plans and said navigating them has presented huge logistical burdens.

“It seems like all of these insurance companies, they have one site that you need to go on to submit claims and one site to submit payments,” she said. “That means that we’ve gone from NCTracks to eight different sites.”

Stacy Kozlowski, an occupational therapist who also runs her own practice, said the same. She operates primarily in Johnston County and is in-network with all of the managed care companies.

“Small businesses like myself that provide services in the more rural areas, rural areas that big hospital systems don’t go to.” she said. “We don’t have the overhead or the administrative ability to manage seven or eight different entities with different systems.”

Providers say the MCOs are allotting them shorter authorization periods for service than the state-run Medicaid program did, which adds to their administrative work. 

Rowe, the Charlotte speech therapist, said Carolina Complete Healthcare recently authorized her to see an existing patient for just one month. 

Rebecca Rowe is a speech language pathologist who runs her own therapy practice in Charlotte. She’s struggled to handle the added administrative burdens of the new Medicaid system. Photo courtesy of Rebecca Rowe.

“That was down from six months that this child was receiving before, so that equates into extra manpower for our staff, for our front desk to continually do these authorizations,” she said. “Let’s say your practice sees 50 to 100 kids under these managed care companies. So you think about an hour every month getting a new authorization, right? That’s a lot of time and a lot of money.”

Harris said the time it takes the MCOs to authorize claims is slower than it was under the state-run system. In the past, she said it took about two weeks for her to receive a signature from their doctor and authorization from Medicaid before she could start services. Now, that timeline has doubled.

Since Harris knows when an existing client’s authorization will run out, she tries to submit the paperwork early enough that their new authorization for services will start immediately after their old one runs out, meaning the new waiting period primarily impacts new clients. 

Sometimes, though, existing patients get sucked in. She told the story of one boy whose authorization expired and his mother couldn’t make an appointment for a few days. By the time the boy’s doctor sent back the signed form to Harris and she submitted it to the child’s insurance, two weeks had passed. 

Six health insurance companies run the majority of managed care plans nationwide. In North Carolina, the health care entities running managed care include AmeriHealth Caritas, Blue Cross Blue Shield, UnitedHealthcare, WellCare, and Carolina Complete Health. Graph courtesy of the Kaiser Family Foundation.

Harris said Blue Cross Blue and Shield of North Carolina, which runs HealthyBlue, requires 15 days to approve services. She said she called to see if they might be able to expedite the approval, but she had no luck. 

“This child has gone almost a month without services because I had to wait those 15 days to get approval,” Harris said. “I basically feel that I will have to start all over with him.”

Harris said BCBS of NC’s timeline for authorization feels especially arbitrary because some of the other entities, like AmeriHealth, approve authorizations in as little as two to three days.

More paperwork

Kozlowski said one MCO plan is asking her to send updated care plans every 30 days, which she said in her professional opinion is not necessary. 

“This is not like adult outpatient therapy where they’re progressing within six to eight weeks,” she said. “These are kids with chronic conditions that take greater periods of time to make progress.”

Sending an updated plan of care every 30 days means the therapist working with a child has to take daily notes, write up the new plan, and then Kozlowski’s office will fax it to the child’s pediatrician, wait for the pediatrician to sign and return it, and then submit it for authorization to the insurer. 

“We have to allow at least a month so that there’s no lapse in service,” she said. Kozlowski has hired additional staff to deal with the added administrative work that’s come from juggling five new insurance programs. 

Harris, who does her own billing, said she doesn’t know how sustainable a system like this is for a one-woman business. She only just received payment for services she provided in July, after a long hassle with one of the MCOs. The entity kept denying her claims, saying she wasn’t in-network, which she said wasn’t true. Eventually, she learned it was because the MCO entered her biographical information incorrectly into their system. But, it wasn’t easy to figure out.

“They kept just giving me the runaround, like, ‘Well, submit a claim, see what happens, and then we can go from there.’ And it would take a week or two before I get some type of response back,” she said. “I finally told the rep, if I wasn’t going to get paid soon — by the month of October — I would have to close down because I was not receiving payments. I’m still seeing these children, and I’m not getting paid for these children.”

Harris said her issue was only resolved after she submitted a complaint to the North Carolina Medical Society, an organization that serves as an intermediary between the MCOs and health care providers. 

“This managed care,” she said, “I don’t know how small businesses like me are going to survive.”

State expected some bumps

Richard, the head of North Carolina’s Medicaid program, said the agency was “preparing for the worst” during the first few days of the transition, such as a total crash of the program’s online systems. 

“But honestly, the big stuff went well. We’ve had what I call serious issues for people, but not the catastrophic problems that I think people were concerned would happen,” Richard told a virtual audience gathered during an October conference for the state chapter of the National Alliance on Mental Illness.

Some of the serious, but not catastrophic, issues included problems with non-emergency medical transport, a program that is supposed to help people get transportation to and from their medical appointments.

Kelly Zyablov, a mom with two children on the new managed care plans, told her children’s speech therapist — Rowe — that she couldn’t afford gas for the 45-minute trips back and forth between her house in Union County and the office in Charlotte. 

Rowe looked at a brochure, created by the N.C. Department of Health and Human Services, that describes the different services available to those on the new managed care plans. The services are designed to address social determinants of health. 

When North Carolina transitioned to a Medicaid system run by five managed care organizations, the contracts required the companies include services to help those receiving coverage address social determinants of health, like access to transportation and healthy food. Many states include similar provisions in their contracts with MCOs. Graph courtesy of the Kaiser Family Foundation.

Under the “Other” section, Rowe noted the bullet point: “$20 in Uber or Lyft gift cards for college students for grocery stores, local events.” She told Zyablov to call the insurance company and see if they could give her that benefit, or something similar, so she could drive her son to therapy. 

That sounded like great news for Zyablov. She called the number and said: “My kids have therapy, we need to get back and forth. Do you offer gas cards? They said no, but if your children are obese, we can give you a food card.” No thanks, she said and hung up. 

Without the extra gas money, Zyablov can only take her son, who has a brain disorder called apraxia, to speech therapy once a week — and sometimes even that is a stretch. 

Richard said there must’ve been a miscommunication. Though non-emergency medical transport is not exactly the system designed to help someone in Zyablov’s situation, there are a handful of “value-added services” attached to each managed care plan that are designed to address social determinants of health, such as not being able to afford gas to and from appointments. 

What might managed care look like in years to come?

“We know that there’ll be some disruption right? Because as you make this change, managed care principles take place,” Richard said, “And we’ll see a few rocky moments.”

Providers are worried about what those “managed care principles” might look like in practice. Many look to states that have recently switched over to managed care plans. Iowa, for example, moved from state-run Medicaid to a system operated by managed care organizations in April 2016. 

Over the last five years, providers have complained about declining reimbursements for care, while patients say they’ve been denied critical coverage. Two of the managed care companies, UnitedHealthcare and AmeriHealth Caritas, abruptly left the program just a few years in. UnitedHealthcare said it left because Iowa underfunded its Medicaid program, but Iowa officials said the insurance company left because it didn’t want to comply with oversight mechanisms. 

The possibility that the MCOs will cut reimbursement rates is what worries many providers the most, including Rowe. 

“These plans typically cut rates and cut services, right? That’s what they do to try to save money,” she said. “What will happen is, it’s all downstream. So these kids will go without services, they will get to their public school, they will be behind.”

Richard said that, hopefully, won’t be the case.

“If the health plans do their job, and if our community based care management does its job, the way health plans are going to make money is by people being healthier,” he said. “And that’s really the goal that we have, is that healthier people will use less of the more intensive services, which then allows for those health plans to make their margins.”

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Clarissa Donnelly-DeRoven

Clarissa Donnelly-DeRoven covers rural health and Medicaid. She previously worked at the Asheville Citizen Times where she reported on the police, courts, and other aspects of the criminal justice system....

7 replies on “Three months into Medicaid transformation, providers say the new administrative burdens are crushing”

  1. There is no way on this earth or any other that Managed Medicaid is going to “save money” That is a siren song from the companies who support the politicians who vote for this. And North Carolina’s Legislature has a history of voting for Big Health at the expense of its citizens and taxpayers.

    1. Totally agree.
      It’s delusional to believe that managed care would save money or benefit patients.
      Dave Richard has sold out.

  2. Finally someone has brought to light our problems with serving our children in our community. Big companies stopped providing services because it was no longer cost effective to run therapy programs like home health. We needed to become small businesses to keep our children from falling through the cracks without support and now it feels like we are falling through the cracks.

  3. I take issue with the statement that Dave Richard has “sold out.” Richard is doing his job and his statements quoted in this article show that he is not sugar-coating the reality that managed care is very different than fee-for-service. Beyond that, it is NC legislators that made the decision to shift to managed care that should be held accountable for the down sides that providers and patients are experiencing. These could be ameliorated to a great extent if those same legislators would approve Medicaid expansion in NC. Why? Because that would bring in substantial more funding to NC via the Federal portion of Medicaid, which would improve economies of scale for the 5 Prepaid Health Plans, would create more customers for all healthcare providers, would be especially helpful to hospitals that foot the bill for many uninsured individuals through their emergency departments; AND would be extremely helpful to the health and wellbeing of those individuals who would become Medicaid recipients if expanded in NC.

  4. MCOs can’t make people with developmental disabilities or brain injuries healthier by delaying or denying services. Corporations and remote care coordinators on a phone can’t build all the relationships that small business providers bring to individuals in communities. We will pay for MCO cost savings of OUR tax dollars with our lives. This system makes families and the professionals devoting their skills sick with worry, frustration and despair. Long ago someone called NC the “vale of humility between two mountains of conceit”; now we are the Valley of Deaths of Despair.

  5. Why would the Director for Medicaid expect some hurdles? This program is not new! The problems that small health practices are experiencing should not have happened beginning July 1st! North Carolina is the 46th state to go from fee for service to managed care! This is not a new thing and the big health companies should have all the startup issues worked out by now. I run a small private practice in Western NC and I’ve never seen large organizations operating the way these MCO’s operate. There are two to three different login portals for each MCO. One for the provider portal, one for the claim portal and one for the authorization portal. The thing that gets me most is when the MCO instructs the provider to contact their sub-contractor to resolve an issue. That’s your sub-contractor! One subsidiary of one of the MCO’s informed our office that it would take 60 to 90 days to review medical documentation before a claim could be paid! Who can wait that long! NC Legislature dropped the ball on this one. I can imagine that several small private practices will be closing their doors and the rural communities of North Carolina will suffer. This is not about cost savings. If it ain’t broke, don’t fix it! Five to ten years from now, someone will report on the lack of savings from this transition. Who will pull out of North Carolina like Iowa? Why do this in the middle of a pandemic? Shortages in staff due to Covid and now you add additional paperwork to meet the needs of big health Insurance companies that don’t know anything about day to day operations inside of health providers offices. Really, who do our State Government work for? Exactly how much are you going to save the state, in comparison to the hurt you will cause to the people of North Carolina when a private practice tells their client that they will no longer take patients for X Insurance due to the heavy burdens X Insurance company placed upon their day to day operation. In Rural areas that means that the client may have to travel a distance to get care or the skip the care all together. Time will tell.

  6. Insurance companies and management companies are in business to make money and they certainly get more than a lion’s share. Where corners are cut is at the point where people in need meet providers who can help and a third party steps in and says, “it can’t be done”. Went through this working for a provider and the management got caught with huge piles of money, executive staff making mega-salaries while consumers were given limited services or denied altogether. Provider operated on a bear bones budget, staff working for less than liveable wage, but determined to serve those seeking care. Now retired, but still have a heart for all involved.

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