Notes and Opinions from Georgia Medicaid Fair Dec 1st

I went to the Georgia Medicaid Fair in Macon today on a mission to solve two issues: Prior

authorizations and Credentialing process for CMOs. I left feeling very frustrated instead.

Here are some points/highlights that might be of importance to those in our community:

Prior Authorizations (PA)

If you are working on a Prior Auth via the Medicaid web portal and the patient shows not

eligible/wrong CMO per eligibility, you can contact GMCF at centralizedpa@gmcf.org to

inform them of the issue.

If you receive a tech denial for any PA, you have 3 days to make the corrections.

Amerigroup only allows 2 days

If you receive a warning during any part of the PA process while entering a request

(Provider is not affiliated with CMO, patient is not member of CMO) continue with request.

System will allow you to still submit and they will review, forwarding information.

If you are having issues with being credentialed into a CMO, you have the option to contact

the CMO a patient that needs to be seen and request an authorization directly. The CMOs

know at this time that the providers are having major issues with credentialing, therefore

they are being more lenient at this time with auths.

Be as descriptive as possible when asking for PAs in the comment secꬅon so it is clear as to

what you are requesting.

Make sure your diagnosis code is a billable code before submitting the PA. There is not

anything in place at this time to catch the error, therefore you will receive a tech denial for

the PA later.

Supposedly you can correct any tech errors for a PA that was for a CMO request. I have had

many that were not reviewed after a correction was submitted on the web portal and

complained about such today. I was told they are looking into it.

I asked Amerigroup how long their turn around time was a韀�er we contact them with

questions about a PA or Peer to Peer reviews. Dr. William Alexander (Chief Medical Director

of Amerigroup) said there wasn't a specific time, however a general rule of 48 hours is

suppose to be followed once they receive the email. I have more complaints about

Amerigroup and Dr. Alexander to follow...

Credentialing:

Supposedly any approved applications for CMOs currently are being reported every Friday

to the CMOs. If the CMO doesn't contact you within a week of receiving the letter in the

mail that your contract has been approved, contact the CMOs listed on the letter. They have

30 days to add you to a Tax ID group if already existing in the system. They have 45 days if

the provider/Tax ID is new to their system.

Currently there is not a solution for applying to an additional CMO without terminating your contract. To explain this further: Provider was enrolled with Peachstate prior to August. Provider decides in Oct 2015 they want to join Wellcare as well. If an application is submitted online to the web portal for Provider, the application will deny or reject for duplicate application. Medicaid/CVO credentialing is going by the Provider's NPI, so if they reflect in the system that they are participating with any CMO, they can't apply.

Medicaid is aware of the issue, however their solution is as follows... Provider must file any claims with currently enrolled CMO. Once processed, Provider must submit a letter to enrollment on letterhead to ask for a termination date for any current CMO they participate with. Once the termination date is set, the provider will then submit an application on the web portal. THIS, I argued, was a huge problem. For example: Provider terminates contract, which means they would have to stop seeing patients for 3‐4 months while their current CMO patients wait for the application to complete. The discussion led to thoughts on how to obtain Prior authorizations during this "non‐networked" time. Opinion: It won't work. I asked why we can't simply submit an application not logged into the web portal as if it was a new application, but the response was the system is based on the provider's NPI.

Any application that is submitted for either regular Medicaid or CMO is contracted to the 1st of the month. This would mean that every CMO group would begin their contracts the 1st of that particular month.

There is a possible update in January to the CMO credentialing system to fix some current issues.

I did speak to Debra Bailey with Peachstate about concerns with some claims processing

out of network. She said the problem should be fixed in their system by the end of next week and all claims will be reprocessed. Any claims after this reprocessing that still deny should be brought to her attention at that time. Opinion: I haven't had as many issues with Peachstate as I have compared to Wellcare or Amerigroup. Anyone have an opinion on Peachstate as of recently?

I attended the Amerigroup meeting to inquire about hearing screens for rural areas and prior auths. The main presenter, Dr. William Alexander commented that "he couldn't understand why a speech therapist would want to request 48 to 52 visits of therapy without having a hearing screen". I argued that a bell test is often performed for IFSPs, but AG is the only CMO that requires hearing screens, and only allows a hearing screen with hertz levels. He also commented later while speaking to him after the meeting "Part of the problem is there are no standard rules for therapists to follow". Which I followed a response stating "Yes they do, National Boards, such as ASHA". He didn't respond to my comment. I did mention towards the end of our conversation that he should take in more concern with their policies for therapists practices due to the fact that therapists see their members much more often than a pediatrician would. Therefore therapists are encouraging parents which particular CMO to choose that works best for therapists. It seems to me that these CMOs are only interested in making sure their numbers are met (documentation is present with audits, CMOs are reaching out to a certain number of members for certain programs they offer to show benefits to their program, how the Georgia Families 360 program is working with a certain percentage of members attending health screens, dental checks, etc). The concern is not with how providers are treated, claims or related questions are responded to, and how authorization delays should be improved. When will these insurance companies realize that without providers, they do not have a job?

Something's gotta give soon....

I'm having to "bite my tongue" in a lot of this blog and try to keep my opinions down, but it's very difficult. I've been quite frustrated with the system as of lately, wishing I could figure out some type of lobbyist position I could help therapists. If anyone has suggestions, feel free to comment as usual.