Advocates for low-income patients have long insisted that medical care is harder to find than it looks on paper. A recent state audit seems to have proved them right, identifying numerous inaccuracies on lists of Medicaid providers that insurance companies have submitted to regulators and posted online for policy holders.
In reviewing filings from recent years, State Auditor Stephen Eells — whose office is part of the nonpartisan Office of Legislative Services — discovered hundreds of situations where doctors, dentists and other specialists were not practicing at the locations listed in insurance materials provided to the state or available to patients. Of those that were, some no longer accepted Medicaid. Dozens of facilities that claimed to be acute-care hospitals were actually specialty care operations, Eells found. As a result, Medicaid patients may be having trouble finding appropriate care near home or work.
Regulators in the wrong
While the audit, released in late January, found quarterly reports from the insurance companies involved with the program often contained inaccuracies, it placed the responsibility for these problems on regulators at the Department of Human Services charged with overseeing these managed care contracts. “We found the division (of Medical Assistance and Health Services (DMHAS)) does not effectively monitor the adequacy of the Managed Care Organization (MCO) provider networks regarding access to care and provider availability,” Eells wrote.
While some of these deficiencies violated contract rules designed to ensure patients can access treatment within a reasonable distance from their homes, the audit did not measure if or how these failings actually affected the health of the 1.6 million Medicaid patients covered by these managed-care plans — the vast majority of those in the state’s FamilyCare, or Medicaid program. (Another 7 percent are covered by fee-for-service plans, which reimburse doctors for each treatment, instead of with a flat fee designed to cover all “managed care.”) The state spent $8.1 billion on the Medicaid MCO program in 2015.
But Medicaid patients have complained for years about the challenge involved in finding conveniently located providers — especially dentists and other specialists. Physicians often blame the low reimbursement rates associated with the program, which they have said make it a financial challenge for them to participate. The problem is particularly acute in urban areas, where — according to reports — there are less likely to be other options, like urgent-care outpatient clinics.
In the report, DMAHS defended its efforts to manage these contracts. The division “rigorously” monitors these networks with the resources available and assigns extra staff and technology to the job when possible, the state said. The state is also in the process of upgrading a database system so that, starting in the summer of 2018, DMAHS will be able to directly track provider involvement in these MCO networks — avoiding the reliance on insurance company reporting. In the meantime, DMAHS has instituted new measures internally to improve the accuracy of network listings and it has formed a workgroup to help insurance providers ensure their online physician directories are up-to-date.
Protecting the patients
In addition, DHS said patients are protected against these inaccuracies because the networks already provide “sufficient redundancy” by including multiple provider options, in most regions. Plus, the plans are required to provide certain levels of care — even if it means paying for a physician that is not in their network — and the audit doesn’t reflect these exemptions. “This provision acts as a fail-safe to ensure that periodic access issues do not lead to gaps in care,” wrote Meghan Davey, the DMAHS director.
The report, based on documents filed from July 2013 through May 2016, also noted several dozen physicians were caring for more 3,000 Medicaid patients, even though patient panels are limited to 2,000 under the state contract. Research has shown that when physicians are responsible for too many patients they are unable to provide the attention each one needs to be effectively treated.
The audit did not name all five insurance carriers on its FamilyCare website: Aetna, Amerigroup, Horizon Blue Cross Blue Shield, UnitedHealthcare, and WellCare. According to the state, Horizon and UnitedHealthcare operate in all 21 counties, and Amerigroup has providers in all but Salem county.
According to the audit, most of these providers have at least 3,000 physicians in their Medicaid networks. Insurance officials insist it is hard to maintain up-to-date provider networks given the changing nature of the healthcare landscape, and thus some inaccuracies are inevitable. The vast majority of patients report being satisfied with their physicians, they note. FamilyCare covers doctors’ visits — including mental health services and other specialists — hospitalization, dental care, diagnostic procedures, prescriptions, eyeglasses, and more, at no or low cost to the patient.
Among the problems uncovered in the audit:
+ Online physician directories maintained by the three largest insurance plans for patient use revealed problems with certain specialist listings] in Camden, Atlantic, Passaic, Essex, and Monmouth counties. Of the 251 providers checked, one-quarter of them were not at the location listed; of those with accurate locations, 11 percent no longer accepted Medicaid.