Quick recap

The meeting focused on billing and insurance challenges faced by behavioral health organizations, particularly regarding Medicaid, Medicare, and private insurance claims. Participants discussed issues with Texas Children's Hospital and other providers regarding denial codes, particularly the H0005 billing code, and difficulties in reaching dedicated insurance representatives for claims resolution. The group explored how software updates and AI automation are increasingly affecting claims processing, leading to unexpected denials and payment issues. They also discussed concerns about high insurance deductibles and coinsurance fees preventing patients from accessing necessary treatment, with participants agreeing to raise these issues at the next HHSC meeting. The conversation concluded with a discussion about tracking administrative time spent on billing activities, which could help demonstrate the operational costs associated with insurance claims processing.

Next steps

• Noelle: Consult with Dwayne about strategies and experiences related to Medicaid/Medicare billing and recoupment issues to identify potential solutions or advocacy points.

• Noelle: Raise the issue of underinsured clients (e.g., high copays, coinsurance, admission fees) and the need for HHSC to consider covering more than just deductibles at the next HHSC meeting.

• Noelle: Push for TDI and HHSC to align on acceptance of facility licensure and workforce credentials (e.g., LCDC, CI) and consider advocating for this in statute or interagency agreements.

• Noelle: Encourage organizations to track administrative time spent on billing issues (e.g., time spent resolving denials, recoupment, and insurance communication) for at least one month to build data for advocacy and rate increase discussions.

• Ivonne: Text Lucy to provide her with the new Zoom link to join the meeting (already occurred during meeting, but noted as immediate follow-up).

  
  

Summary

Texas Children's Billing Code Issues

Kathy discussed issues with the H0005 billing code for Texas Children's Hospital, where claims were being rejected due to exceeded amounts, despite an exception allowing up to one unit per day. She explained that after reaching out to customer service and following up with a liaison, she received a referral number but was still awaiting a resolution, which could take up to 30 days. Meanwhile, she mentioned that she had successfully obtained payment for an H0047 code related to residential intensive care from WellPoint. Ivonne raised concerns about the lack of designated insurance representatives, which made it difficult to resolve issues efficiently, as calls often resulted in disconnections or being redirected to different representatives who were unfamiliar with the case. LUCI confirmed that they had previously experienced similar issues with Amerigroup but noted that these had been resolved, and they did not have Texas Children's Hospital in El Paso.

Insurance Billing and AI Challenges

The group discussed insurance billing issues, particularly focusing on Medicaid and Medicare claims. Noelle and Ivonne noted that insurance representatives can be assigned to organizations, while Kathy shared a problem with UnitedHealthcare's OptumPay system, which claimed duplicate payments without providing clear information. Carrie suggested that these issues might be related to AI and software updates, predicting that AI will increasingly influence claim decisions and potentially create new challenges. The group agreed to investigate the duplicate payment claims further, as they have affected multiple members and raised concerns about the lack of transparency in the process.

Insurance Provider Challenges and Accountability

The group discussed challenges with insurance providers, including denials of medical necessity and recoupment of payments, particularly with Blue Cross Blue Shield. Luci highlighted difficulties in provider relations, noting that insurance representatives are often unfamiliar with specific issues and unresponsive to emails and calls. The team agreed that providers bear the burden of resolving these issues, which can be time-consuming, and suggested that insurance companies should be held more accountable for their actions.

Healthcare Access and Insurance Barriers

The group discussed challenges with healthcare access and insurance coverage, particularly regarding high admission fees and copayments that prevent patients from seeking necessary treatment. They noted that while HHSC covers deductibles, many private insurance plans have significant barriers like $750 admission fees and $150 copays that make care unaffordable for patients. The discussion concluded with a suggestion that HHSC might need to consider covering coinsurance and copays to improve access to care, as patients often choose not to seek treatment when faced with these financial barriers.

Behavioral Health Insurance Billing Challenges

The group discussed challenges with insurance billing and coverage for behavioral health services, particularly regarding underinsured patients and the acceptance of various professional credentials by insurance providers. They identified a need to align HHSC and TDI requirements, with Noelle suggesting this could be addressed through statute, while Ivonne emphasized the importance of expanding workforce acceptance to include lower-level licenses and certifications. The discussion concluded with a proposal to track administrative time costs associated with billing processes, which could be used to demonstrate the financial impact of current challenges when seeking rate increases.