By Dan Matas, Founder of OutcomesBase, Inc.
On a recent episode of Last Week Tonight with John Oliver, he covered Medicaid and discussed some of the current issues recipients across the nation are experiencing. When I heard this conversation, my ears perked up, because I know just how many families are receiving ABA services through Medicaid plans. In my experience, in most states, the individuals receiving ABA treatment are funded at a higher percentage by Medicaid than commercial payers. These Medicaid issues discussed in the show don’t just impact the members of the plans, but the trickle down effects impact the provider side as well.
One of the most difficult things with Medicaid that I have experienced has to do with eligibility. Clients can lose their Medicaid benefits at pretty frequent intervals and it becomes the Provider’s problem to run eligibility checks frequently to ensure payment for services. However, as pointed out by John Oliver’s show, the State programs do not make this easy. In fact, Medicaid Unwinding is the term given to Medicaid’s return from COVID-19 operations. What it means for Medicaid members is that their coverage was no longer guaranteed (as it was during state of emergency operations), and millions of patients were dropped from their Medicaid programs nationwide, including over 5 million children. The reasons for the ineligibility often had to do with administrative/paperwork related reasons and many didn’t even know they had been dropped until a provider/pharmacy made them aware.
In working in insurance-funded services, I have seen firsthand how clunky and glitchy various payer portals can be to work with and navigate — and that’s on the provider side. I can’t even imagine some of the complexities that clients and their families are given to sort out. It can be confusing and extremely tedious. The bottom line is that it’s not easy to keep up with all of the paperwork that clients are forced to complete to remain eligible, and the States have their own bugs that further complicate the process.
Additionally, John Oliver’s program pointed out that in some states they are spending a highly disproportionate effort to track down Medicaid eligibility offenders, when the real issue is the corrupt providers. As a Compliance professional, I have seen the staggering reports weekly of providers who try to scheme the government by up-coding, over-billing, and falsifying claims. These bad actors are stealing from the government, but they are also stealing from our patients and all tax payers. With rampant healthcare fraud taking place, more pressure is put on all providers to ensure that they have a working compliance department which adds to the overhead cost of delivering quality care to patients.
Lastly, the program discussed Managed Care Organizations (MCOs) and the fact that 72% of Medicaid beneficiaries are being serviced through MCOs. I’ve worked with many, many MCOs across the nation and they can be great partners, or very poor collaborators. They make their money from what they have left over each year that isn’t spent on their patients, and so they are almost incentivized to make it difficult for their members to received medically necessary treatment, to deny claims, and to clawback reimbursements from providers. I have seen all three of these things take place, and it can be devastating for both clients and providers. In my experience, there truly is not enough regulatory oversight on MCOs by the federal government and CMS. With their often complex requirements, and confusing policies, several MCOs do not make it easy for clients or providers.
All these things together, compounded, paint a picture of the challenging landscape ABA and other healthcare providers are facing. Long gone are the days when providers can truly focus on providing quality services to their patients; all providers are also fighting the uphill battle to ensure that their patients are eligible, authorized, and that their claims are being paid. I do not have confidence that this is going to improve drastically in the next decade, but I do think it’s important for those of us working in the ABA field to be aware of these issues and to lobby for better programs and payer relationships where we can. The fact of the matter is, there are a lot of clients and families out there who need access to quality services, and providers need to be able to treat them without fear of not being paid.
If your company is experiencing issues with payer audits, clawbacks, understanding complex regulations, credentialing, or client eligibility screening, reach out to OutcomesBase to see how we can support you.
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