Thursday, December 22, 2011

Medicaid Briefing

Secretary Miller briefed the full House earlier this week on the implementation of Medicaid Managed Care.  She had Carrie Banahan and Commissioner Neville Wise with her to answer questions, but she handled the majority of the briefing and many of the questions.

She started with a statement that she knew legislators had been receiving calls, because she was receiving calls.  She said they would still receive calls as they move into each phase of the implementation.  They anticipated the first month would involve calls relating to the change in process and an education process on billing claims and pre-authorization under the new system.  They also anticipated the second month to be calls from providers on non-payment of claims.

She believes, and I think had the members believing, that for such a massive change in process, it had gone pretty well considering they had enrolled or registered 560,000 lives.  She thinks many of the original problems are getting resolved and the communication system has improved.  She had Neville address the Independent Pharmacy issues and Carrie address the claims payments issue.

The independent pharmacy issues relate mostly to the cuts in reimbursement and aren't going away.  Medicaid reimburses more than Medicare and more than commercial carriers.  The MCO's have moved very quickly to reduce the amounts.  The Cabinet has met with many of the independent pharmacists and the MCO's.  Their message to the pharmacies is they are working with the MCO's to see if they can improve the situation and in some areas they have been able to up the levels some.  Their message to the MCO's is these independents are vital to the communities, especially rural areas and if they are forced out of business will certainly impact access that is required under the contract.  As the Secretary put it, they are working with both groups to balance the access with the costs.

Carrie is leading the effort to handle the claims issues and is working with the MCO's directly on any calls she receives.  Initially the problem was with achieving clean claims to process.  That is getting better and where there have been problems, the MCO's have done some "gap" payments to alleviate pressure while they resolve the claims.  The Secretary believes the providers are getting better at billing and the MCO's better at reviewing.

The Secretary addressed the prior authorization issues.  She said that early in the transition it was taking an hour or so to get prior authorization and it was basically a communications problem.  Providers could not get through, but when they finally did, they were pre-authorizing 8-10 in one call.  She believes that is getting better.

The Commissioner stated he would be working at putting the state P and T committee with the P and T committees of the individual MCO's to see if they can normalize the formulary issues that have come up. Secretary Miller stressed that every drug for which a rebate agreement exist with the feds is covered under state Medicaid, if it is medically necessary.  She tried to refer to the formulary as a mechanism to get to whatever drug was medically necessary.

Specialty drugs have been a problem as the MCO's are apparently requiring they be obtained through their providers and that involves mail order.  That has created some confusion over whether or not the MCO's were trying to drive everyone to mail order.  The Secretary explained that the MCO's are not pushing anyone to mail order, and don't necessarily want it, but they do accept it.

There were several questions by legislators and nearly all were related to independent pharmacies and payments.  The Cabinet was staying over to get what information the individual legislators had.  They stressed it was important to get as much information together from their constituents on specific problems so they could track back to get to the problem.

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