Managed Care, N.C.: Providers use break to address concerns

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Monday, January 6, 2020

RALEIGH, N.C. – HME providers here got a reprieve in November when North Carolina suspended its transition to Medicaid managed care after Gov. Roy Cooper vetoed a $502 million bill to fund it.

The program was slated to begin Feb. 1, with many providers already enrolled with one of the five managed care plans.

“At this point, they are not cancelling the contracts, but they are suspending related activities,” said David Chandler, director of payer relations for AAHomecare. “They are not going to announce a new timeline until a budget is approved and they evaluate what steps need to be taken. Some (steps) will have to be repeated.”

The General Assembly in 2015 passed legislation directing the Department of Health and Human Services to move from a fee-for-service to a managed care model.

Although the program was just over two months from starting, there were still a lot of unknowns for providers faced with a new system and five managed care companies.

“We understand each entity is going to have its own rules and regulations that we need to learn their medical policies and prior authorization policies,” said Lisa Feierstein, president of Active Healthcare in Raleigh.  “And, for the first year, we are guaranteed the rates are staying stable but after that, we don’t know where the rates will go.”

The delay will give stakeholders the opportunity to work with the plans to address concerns, says Kim Lynn, state Medicaid chair for ACMESA.

“This will give us a chance to get in there and try to help with concerns about the prior authorizations and rentals,” said Lynn, who is also operations manager for Carolina Apothecary in Reidsville. “We have done our best to tell them the lessons learned from problems (in other states).”

A properly functioning managed care program boils down to proper oversight, says Chandler.

“States need to ensure they have the tools that enable them to properly oversee the managed care plans and ensure patients continue to have access to quality equipment and supplies,” he said.

It also comes down to reimbursement and coverage criteria, says Chandler.

“They need to ensure its consistent with what the state has in place—all the way down to the prior authorization requirements and the quantity of supplies allowed,” he said. “There needs to be some consistency there.”