Providers still face challenges over Medicaid payments

Nearly 21 months after Iowa switched most of its Medicaid enrollees to private managed care, some health care providers say they still struggle with billing issues and rejected payment requests.

'It's not even enjoyable to take care of (my patients) because at night I'm worried about how I'm going to pay for my employees,” said Julie Knake Tow, owner and operator of Comfort Care, a Cedar Rapids home health care provider. 'Before, it was such a tremendous thing, and I had a passion for my company.”

Since the state's Medicaid system transferred the majority of its beneficiaries to private insurers, health care providers - including hospitals, clinics and not-for-profit agencies - report they have run into billing issues and late or inaccurate payments.

Pat Giorgio, president and chief executive officer of Evergreen Estates, a Cedar Rapids residential care and assisted living facilities, said her company is losing money with each Medicaid resident.

Evergreen Estates is approved for home and community-based service (HCBS) waivers through Medicaid. About 50 percent of 115 residents, housed throughout three facilities, are on Medicaid.

'I have had to refinance my major bank loans since the inception of Medicaid managed care and have had to make a significant infusion of my personal savings to make up for Medicaid shortfalls,” Giorgio said in an email to The Gazette. 'I consider what we do a vocation, not just a job or a business. Otherwise, I would have already pulled out of the HCBS program.”

Other providers, such as Knake Tow have been denied reimbursement for certain services. Comfort Care provides home health care services for 700 patients in Eastern Iowa, about 75 percent of whom on Medicaid.

The state's managed-care organizations require prior authorization of services for Medicaid recipients, but Knake Tow said insurers have denied services for which Comfort Care previously had been paid when Medicaid was state-run - services she said are imperative for individual health.

She has appealed to the insurers and continues to provide for the patient. She is not being paid during an appeals process while continuing care.

By Knake Tow's estimation, the three managed-care organizations - including AmeriHealth Caritas, which left the state this year - owes her company $69,000 from services between January and July 2017.

'I am on my last money from the bank,” Knake Tow said. 'My husband and I took our retirement money out and our pension money out to make payroll.”

Rose Kladivo, 84, is one of the residents at Irving Point who receives services from Comfort Care. Twice a day, home care aides check on her, give Kladivo her daily pills and take out her trash.

Kladivo said she is able to live independently, but the daily visits are a reassurance for her family.

'I can take care of myself, but help is there if I need it,” Kladivo said.

LOOKING AHEAD

Three managed-care organizations took on the state's Medicaid population when Iowa privatized its system back in April 2016 - AmeriHealth Caritas Iowa, Amerigroup Iowa and UnitedHealthcare of the River Valley. Only Amerigroup and UnitedHealthcare remain after AmeriHealth withdrew from the state's Medicaid system in December.

However, about 213,000 Iowans from AmeriHealth were left without a choice in their managed-care provider and had to remain with UnitedHealthcare when Amerigroup told the state it no longer had 'capacity to take any new members.”

As a result, 10,121 Iowans who had chosen Amerigroup as their insurer were moved to a fee-for-service system maintained by the state.

Jerry Foxhoven, the Iowa Department of Human Services director, told state legislators earlier this month that officials hope Amerigroup will be able to take on new members by March of 2018.

Gov. Kim Reynolds has remained firm that the state will remain on this course, despite criticism from Democratic legislators and health care providers.

Knake Tow and Giorgio both said they voiced their concerns to Reynolds on Dec. 12 at Iowa Health Care Association conference in Des Moines.

'Gov. Reynolds was sympathetic to our concerns, but clearly stated she would not allow our Medicaid system to return to the way it was before managed care,” Giorgio said in an email to The Gazette. 'She did not offer any solutions to our concerns, except to say that she would look into our concerns and that the current situation was unacceptable.”

State officials have request-for-proposals for a new managed-care organization to replace AmeriHealth, to be available for enrollees beginning July 1, 2019.

As of Nov. 22, two agencies submitted to their intent to bid - Iowa Total Care Inc. and Medica Health Plans.

Iowa Total Care is a subsidiary of Centene Corp., a Missouri-based insurer that became the nation's largest provider of Medicaid health care plans in 2015, according to the St. Louis Post-Dispatch. Its profits reached $355 million, with revenue of $22.8 billion, that year, according to the newspaper.

Medica Health Plans is a subsidiary of Medica, the Minnesota-based company that currently is the only insurer selling individual health policies throughout most of Iowa.

Medica officials announced in June it would continue selling plans for the 2018 coverage year. However, for all products, the average proposed rate increase is 43.5 percent.

l Comments: (319) 368-8536; michaela.ramm@thegazette.com