Texas Insider Report: AUSTIN Texas -- Texas Medicaid system is an ailing patient in dire need of healing according to many physicians but the Texas Health and Human Services Commission (HHSC) is using the input of Texas doctors to fix the system many say is filled with bureaucratic red-tape and road blocks to patient care.
Hang-ups with enrollment and credentialing confusion with claims submissions and problems obtaining prescription drugs for patients
are just a few of the issues topping physicians fix-it list on top of nearly unbearably low pay according to Texas Medical Associations (TMAs)
Texas Medicine magazine.
The time physicians spend on claims processing prior authorizations and other red-tape rules that vary among the states 20 Medicaid HMOs also cuts into the perpetually low payment rates Medicaid offers and further discourages physicians from entering the program" said McAllen ophthalmologist Victor H. Gonzalez MD a TMA physician leader. He is a part of TMAs Physicians Medicaid Congress comprising TMA physicians from various specialties and committees. The congress asked new HHSC Executive Commissioner Chris Traylor for Medicaid improvements.
The expansion of Medicaid managed care in Texas has exacerbated problems preventing doctors from enrolling in Medicaid and treating patients. Only 37 percent of Texas physicians currently accept all new Medicaid patients according to the
TMAs 2014 physician survey.
Physicians want HHSC to make regulatory Medicaid improvements before the new Medicaid enrollment/reenrollment deadline which was extended from March 24 to Sept. 25. The physicians wishlist includes simplifying the process for doctors just to enroll in the program.
For example Athens family physician and TMA Board Trustee Douglas Curran MD said he recently hired two new physician partners saying it took almost a year for Medicaid HMOs to fully credential them to care for Medicaid patients. Without credentialing Medicaid cannot pay physicians. The doctors took call during that time for zero money" he said. How am I supposed to recruit?"
San Antonio neonatologist Alex Kenton MD said an application error can disrupt the entire process delaying physicians ability to practice for months. How are we supposed to encourage doctors to participate when they cant even enroll?" he asked.
At the Texas Legislatures direction HHSC reached out to TMA as well as hospitals home health facilities health plans and consumers as part of a broad initiative to simplify Medicaid and improve physicians and patients experiences in the program.
The Physicians Medicaid Congress recommendations include a variety of reforms and encourages adoption of best practices and care delivery improvements across the Medicaid program and participating HMOs. The fix-it recommendations include:
- Simultaneously processing physician credentialing once the enrollment process starts;
- Simplifying the Medicaid Vendor Drug Program;
- Eliminating payment recoupments for services physicians already provide to Medicaid-eligible patients;
- Waiving prior authorization for simple in-office procedures and for physicians with a history of providing high-quality low-cost care;
- Promoting adoption of new care delivery and payment models and care coordination benefits and payments; and
- Improving data sharing among health plans and physicians.
Some problems include:
- Processing claims and obtaining payment. Austin pediatrician Maria Scranton MD said her staff spends at least 10 percent of its time getting Medicaid claims paid. In one instance Medicaid denied her claims for certain lab tests and asked for additional procedure codes that did not exist.
- Medicaid HMO payment recoupment also called a claw-back." HMOs recoup payment for care doctors already provided as much as two years after treatment because of patient enrollment errors on Medicaids end.
- Outdated state network adequacy standards for Medicaid HMOs that contribute to known shortages in specialty care which has concerned TMA over time.
Some 4 million low-income Texans currently rely on Medicaid for their health care coverage. The vast majority of these patients live in families earning less than 100 percent of poverty or roughly $20000 a year for a family of three. Most Medicaid beneficiaries do not have access to employer-based health insurance or cannot afford it if they do.
Texas lawmakers have not expanded Medicaid like some states have done. But they are using managed care to try to reduce costs and improve care delivery now that Medicaid consumes more than a quarter of the state budget.
Commissioner Traylor acknowledged that simplifying the Medicaid program is like untangling a bowl of spaghetti" but he also said the state is committed to improving the program for patients and the physicians who care for them. The goal at the end of the day is to have a much more beneficial provider experience and participation in the Medicaid program" he said.
TMA is the largest state medical society in the nation representing more than 48000 physician and medical student members. It is located in Austin and has 110 component county medical societies around the state. TMAs key objective since 1853 is to improve the health of all Texans.
