Health

Months after AmeriHealth exit from Iowa system, work still to be done, state says

Some providers say they still are owed payment

Cindy Smothers, a para-educator and parent of an adult son with a disability, shares thoughts with Democratic candidate for lieutenant governor Rita Hart during a roundtable to meet with care providers to discuss the impact of Medicaid privatization at the Arc of East Central Iowa in Cedar Rapids on Wednesday, Sept. 5, 2018. (Liz Martin/The Gazette) (Liz Martin/The Gazette)
Cindy Smothers, a para-educator and parent of an adult son with a disability, shares thoughts with Democratic candidate for lieutenant governor Rita Hart during a roundtable to meet with care providers to discuss the impact of Medicaid privatization at the Arc of East Central Iowa in Cedar Rapids on Wednesday, Sept. 5, 2018. (Liz Martin/The Gazette) (Liz Martin/The Gazette)
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Although it’s been nearly a year since AmeriHealth Caritas left Iowa’s Medicaid program, a Department of Human Services spokesman said “AmeriHealth Caritas’ work is not 100 percent complete.”

In light of the insurer’s abrupt exit last year, some Iowa health care providers feel abandoned by the managed care organization.

Pat Giorgio, president and chief executive officer of a Cedar Rapids-based residential care facility, while unable to cite a precise dollar amount — noting unpaid claims were “substantial” — said, “Certainly, I can say without any hesitation I have lost much more on those Medicaid clients than I ever anticipated I would.”

Giorgio founded Evergreen Estates more than 30 years ago as comprehensive care facilities for seniors. The organization cares for about 60 clients, including Medicaid enrollees, offering senior living and other residential services across three facilities in Cedar Rapids.

But now that AmeriHealth pulled out, the Cedar Rapids provider said it’s rare to interact with the company.

“If that was UnitedHealthcare or Amerigroup, I still have interactions with them, I can work with them, we try to work through it. I’m not getting paid entirely as promised, but they are at least responsive to my questions and concerns,” she said.

“The last three times I tried to get hold of somebody at AmeriHealth about outstanding claims, I didn’t even get returned phone calls or emails back.”

That $14.6 million figure

The state’s Medicaid program provides health insurance for more than 608,000 low income and dependent Iowans. When AmeriHealth was in the state’s program, it served about one in four of Iowa’s Medicaid population.

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However, in October 2017, the company announced it would leave at the end of November after it couldn’t reach an agreement with the state on future rates and terms.

According to a June 30 report to the Iowa Insurance Division, AmeriHealth reported $14,624,276 in unpaid claims from its time as a managed care organization in Iowa. Some concluded it to mean the company owed that amount to various providers.

But AmeriHealth officials told The Gazette that dollar amount wasn’t necessarily what it owed.

The $14.6 million figure “is an estimate of the amount of claims that may need to be paid based upon historical information, in accordance with actuarial standards and principles as required by Insurance Department rules and regulations. Meaning, we have to forecast on an ongoing basis what our potential total claims and other medical liabilities could be in the future,” according to a statement from AmeriHealth to The Gazette on Friday.

“This figure, called a claims reserve estimate, is meant to ensure that we have enough cash on hand to pay all potential claims.”

“AmeriHealth Caritas’ work is not 100 percent complete. AmeriHealth Caritas continues to pay and adjust claims,” Matt Highland, Department of Human Services spokesman, said in an email to The Gazette.

“This continues to wind down considerably but could continue into 2020 due to timely filing standards for claims where another commercial payer is primary or in instances where the provider would like to submit an adjustment to a claim originally submitted within the 180 day timely filing.”

AmeriHealth, along with the remaining managed care organizations Amerigroup Iowa and UnitedHealthcare of the River Valley, were contracted to pay for claims submitted by providers of health care services given to a Medicaid enrollee. Contracts between the state and the managed care organizations require these to be done in a “timely manner.”

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But a number of providers throughout the state have said their claims are wrongly denied, or don’t receive a response for some time.

However, managed care organizations have pushed back on those statements in the past, saying that provider reimbursements are accurate and that some claims are denied for legitimate reasons.

“The department continues to work closely with providers and with AmeriHealth Caritas,” Department of Human Services’ Highland said. “We continue to monitor their progress as they wind down operations and are committed to ensuring claims are paid as appropriate.”

‘Really been a challenge’

Kyle Schramp, senior operations director for the Arc of East Central Iowa, expressed a similar concern to The Gazette earlier this past week. She said although her organization appealed about $10,000 in unpaid claims, AmeriHealth officials have been unresponsive.

“When we lost our (AmeriHealth) representative in December, we lost our voice for getting claims collected,” Schramp said. “That’s really been a challenge without them because there’s very little staffing to support that for us now because they moved out of this area.”

She said a large portion of the unpaid claims that is due to a misunderstanding on AmeriHealth’s part on different forms of respite services — temporary relief from caregiving — that occurred on the same day.

The Arc offers one-on-one respite care in the home, as well as group respite through activities at the organization.

Although those services didn’t overlap for clients and were not in violation of the contract, the managed care organization denied reimbursement.

To recoup the loss, Giorgio is forgoing certain expenses. For example, she is putting off repaving a parking lot for another year, and doesn’t plan to replace the carpet or buy new furniture for her facilities.

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“There’s any number of ongoing expenses in keeping it up to date, and it’s very difficult to do some of those things that a few years ago would have been an automatic,” Giorgio said. “When you’re carpet needs to be replaced, you replace it. Now we wait longer to do those kind of things.”

Giorgio said it’s important to her that her employees’ wages don’t suffer, and that her clients — at least the ones she hasn’t turned away — receive the best care possible. She is even retaining some clients at a reduced rate.

“I will close my building before I reduce the quality of care,” Giorgio said.

Schramp, at the Arc of East Central Iowa, said the roughly $10,000 loss will affect the Arc’s bottom line. But she doesn’t expect her clients will see a change in services.

However, she added, “I think the greatest frustration for many of us is not the (managed care organizations) as much as the state telling us everything is working, people are being better served. It’s simply not true. That’s not what we see.”

In its email to The Gazette, AmeriHealth said its staff members continue to work with providers “to ensure that they are paid accurately and according to our contracts with them.”

Getting the care they need

The Arc of East Central Iowa hosted a roundtable discussion with Sen. Rita Hart in Cedar Rapids this past Wednesday with a handful of area long-term services and supports providers who shared their frustrations on privatized Medicaid with the lieutenant governor-hopeful.

The stop at the Arc of East Central Iowa earlier this week was a part of a campaign tour Hart and her running mate, gubernatorial candidate Fred Hubbell, are doing leading up to the governor’s race in November.

“In light of AmeriHealth not paying their bills, it just adds up more insult to the whole process that truly its clear how much of a disaster this Medicaid privatization has been,” Hart said after the roundtable.

“In the end, our focus should be the best care we can provide with the best system that makes sense for Iowa,” she said to The Gazette.

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“That’s why it makes so much more sense I believe to have Iowans taking care of Iowans rather than have these out-of-state corporations, which don’t even understand their own system and are making these decisions to provide care to these Iowans. The rest of us want to make sure they are getting the care that they need.”

This disagreement on the effectiveness of the current Medicaid program has become part of the gubernatorial race in part because Gov. Kim Reynolds was lieutenant governor when the system privatized under then-Gov. Terry Branstad. She has stated the previous fee-for-service model was not sustainable long-term.

“It was important to me that we were able to look Iowans in the eye and assure them that we’ll have a system in place that will help take care of their loved ones and vulnerable Iowans,” Reynolds told reporters this past week.

She added concerns raised about the program have been addressed.

“We recognized that we needed to do things differently, and in a year we’ve made a lot of significant changes so that we can have a sustainable system,” she said. “... Payments weren’t being made in timely manner and so we’ve addressed that in the new contract that we’ve signed.

“We want to make sure that members’ voices are being heard, and so that’s incorporated in the new contracts that were signed.”

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

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