Quick recap

This meeting focused on billing and reimbursement challenges faced by substance use disorder treatment providers. Ivonne explained that HHSC audits have identified unallowable expenses where staff salaries for maintenance and repairs weren't properly justified in the budget, leading to denied claims. The group discussed issues with United Healthcare and other managed care organizations (MCOs) not paying the correct rates after Medicaid rate changes on March 1st, with Kathy reporting that United Healthcare only paid the lower group rate instead of the higher individual rate. Providers shared concerns about declining MCO responsiveness and support, with Lucy noting that MCOs are less attentive to providers' needs compared to earlier when they had regular meetings and better communication. The discussion also covered challenges with assessment-only charges being denied due to prior authorization requirements, marketplace insurance grace periods causing authorization issues, and potential opportunities to expand billing codes for substance use disorder services.

Next steps

Kathy

• Continue tracking United Healthcare claims issues and, if/when 20 claims are reached, initiate a project with United Healthcare for review; otherwise, resubmit claims individually.

Luci.Silva

• Provide data on annual unrecouped/lost funds due to denied claims and coverage issues to Noelle, to support legislative advocacy.

Noelle

• Follow up with Duane to explore options for advocating with HHSC and legislators for improved MCO (Managed Care Organization) provider support and responsiveness, and report back to the group.

• Reach out to Yvonne for more details on the cost reimbursement and unallowable expenses issue, and clarify the nature of the holdup for the group.

• Bring up the issue of expanding billable codes and in-house service billing (e.g., nurse practitioner services) with Duane and the legislative committee, and report findings to the group.

• Share legislative committee updates and emerging priorities with the group after the next meeting.

• Investigate and report on the feasibility and requirements for organizations to bill for nurse practitioner/group services under current HHSC/MCO rules.

  
  

Summary

Budget Audit Compliance Issues

Ivonne informed the group that recent audits by HHSC and funders identified unallowable expenses related to staff work that wasn't properly categorized in the budget. She explained that when submitting budgets for state funding, expenses must be clearly justified in the salary categories to avoid future payment rejections during audits. Noelle confirmed understanding of the process and noted that detailed justification in budget narratives would help address these concerns.

United Healthcare Payment Rejection Issues

Kathy reported issues with United Healthcare rejecting higher individual rates for meetings and only paying the lower prior rates since March 1st, affecting six claims so far. Noelle asked if others experienced similar issues, and Luci Silva shared that another payer required starting a project with a spreadsheet submission, which is still pending resolution. The group discussed that filing complaints with MCOs has been the most effective approach for resolving payment issues, and Noelle noted that HHSC's failure to pay room and board for residential care remains unresolved despite previous agreements.

MCO Provider Support Decline

The group discussed declining provider support from MCOs (Managed Care Organizations), with Luci.Silva noting that provider representatives were previously more attentive to needs but now emails go unanswered and it's difficult to get assistance. Noelle agreed to investigate advocacy opportunities with Duane to address this issue, particularly given that multiple groups are reporting similar problems as more insurance companies enter the Medicaid market. The conversation then shifted to billing challenges for maintenance and repairs, though the specific details about claim denials were not completed in the transcript.

Cost Reimbursement Challenges Discussion

Noelle discussed challenges with cost reimbursement with Luci.Silva and Carrie. Luci.Silva indicated limited involvement in cost reimbursement and suggested it might be a different situation from fee-for-service. Carrie shared that they have a cost reimbursement contract with the state for residential case management without significant issues, but noted occasional challenges with BeWell invoices and discussed how they handle indirect costs for shared facilities and equipment.

Insurance Authorization Issues Discussion

Carrie and Kathy discussed insurance authorization issues, with Carrie sharing examples of United Healthcare denying claims despite proper authorization requests, while Kathy reported being denied for assessment-only charges without clear guidance on prior authorization requirements. Luci Silva explained that insurance companies have timeframes for conducting assessments and shared an experience where an appeal for denied assessment claims was unsuccessful, resulting in unrecoverable losses. Noelle suggested gathering data on financial losses from unrecouped claims to support advocacy efforts with the legislature, and mentioned that organizations like Senecor are estimated to spend $1.5-5 million annually on such losses.

Molina Insurance Authorization Issues

Luci Silva explained that Molina insurance creates issues with authorizations when clients have primary marketplace insurance and secondary Medicaid coverage, particularly during the three-month grace period when clients are still technically enrolled but may not pay. Noelle suggested investigating where the financial leakage occurs and exploring alternative billing approaches, including expanding billing codes for substance use disorder services to better recover costs rather than relying solely on rate increases.

Case Management Billing Challenges

Carrie and Noelle discussed challenges with billing for case management services, particularly noting that Medicaid does not cover case management even in residential settings, and private insurance typically uses single per-diem codes that may not fully reflect the services provided. The conversation revealed that nurse practitioners at treatment facilities face billing restrictions due to licensing requirements, with Luci Silva explaining that CDTF facilities must bill under specific group credentials to allow separate billing for nurse practitioner services. Noelle indicated plans to discuss these billing challenges with Dwayne and present legislative priorities to the committee next week for further discussion with the group.