Clinicians frustrated by MaineCare

Clinicians frustrated by MaineCare
(March 2009 Issue)

By Ami Albernaz

Psychologists in Maine who are owed thousands of dollars in MaineCare reimbursements are cautiously optimistic as they're finally seeing long-overdue payments come in. However, some say that as a result of the problems with reimbursements, they can no longer afford to take on MaineCare clients and harbor a deep distrust of the managed care system.

Some of the MaineCare reimbursement woes can be traced back to or even predate the changeover of a computer system in 2005, during which time glitches in the system led to psychologists' and other providers' claims not being processed. Interim payments were issued by the state's Office of MaineCare Services (OMS) beginning in 2005 and as flaws in the computer system were gradually fixed, OMS began collecting the interim payments. Some psychologists, however, say their original payments had still not come in or were far less than they were supposed to have been, when the state began collecting.

"We're owed money as far back as 2002 and our claims from before 2005 got lost in the system," says a psychologist's office manager who did not wish to be identified for fear of jeopardizing what he sees as precarious recent success in getting claims paid.

When the interim payments began to be collected, the manager filled out an Alternate Repayment Recovery Form, documenting the practice's outstanding claims issues. Yet in 2007, MaineCare began withholding payments in order to "pay down" the interim payments the state maintained the practice owed. The tone grew temporarily hostile in early 2008, when an interim recovery unit began calling the practice.

"We kept saying they owe us more than we owe them," the manager says.

MaineCare was swift in collecting the funds in order to continue paying MaineCare provider claims and to ensure MaineCare could continue providing services to members, according to an online document on the Interim Payment Recovery Effort (http://www.maine.gov/bms/pdfs_doc/mecms/ipr_overview_final_022208_slides.pdf).

Norman Curtis, director of member and provider services at OMS, acknowledges that changes in the system hindered payment for psychologists and other providers, and that the office has tried to work with providers with unpaid claims on a case-by-case basis.

"We've definitely worked provider by provider by provider and said, 'tell us what are the outstanding issues," he says. "Sometimes it's the system; sometimes it's a billing error. We've been making corrections to that system and with each correction have been able to get more things resolved. We're now identifying remaining claims issues to be resolved. With that said, the issues specific to psychologists that have been problematic, to my knowledge have been resolved."

As fixes to the system were made, psychologists were in some cases asked to resubmit claims that had previously been rejected. Yet those who had already tried repeatedly and failed to get claims approved were skeptical.

"What they wanted us to do was to spend thousands of dollars writing these crossover claims, even though none were ever approved," the office manager says. "Until we can get any of them approved, we're not going to do 20, 30 of these."

Eventually, two OMS specialists visited the practice to try to submit its unpaid claims. Most were rejected. After repeated attempts, many, but not all, have been paid, the office manager says.

Fred White, Ph.D., past-president of the Maine Psychological Association who practices in Augusta, says he hired a part-time employee to try to recapture the MaineCare payments owed him since 2005. For some of his crossover claims, "Medicare paid their part and sent them on to MaineCare, where they went into a sort of black hole."

His employee "has resubmitted many, many times, followed the instructions of the people on the phone, still come up empty-handed," he says. Though a lot of his money has been recovered, White says, he is still owed around $6,000.

A meeting of the Maine Psychological Association last November brought together around 20 psychologists who met with a deputy commissioner of the Department of Health and Human Services about the reimbursement issue.

"It was darn near a coup," White says. The deputy commissioner "was able to speak to some of the concerns and was very reassuring. I don't know what's come of those reassurances; they haven't amounted in anything for me."

After a long struggle to get paid, some psychologists seemed hesitant to talk openly out of fear of turning the tide. "It might sound paranoid, but when you've been through what I've been through, you start to get paranoid," says one psychologist who says he's owed around $8,000.

He blames the problems on thick bureaucracy, rather than any person. "I don't think [the problems are] intentional," he says. "But it's a broken system. God only knows how it's going to be repaired."

Miscommunication between MaineCare and APS Healthcare, the organization contracted to handle the state's behavioral health services, might be part of the reason for delayed and seemingly lost reimbursements, says the psychologist, who began having trouble with MaineCare payments around the time APS took over the state's managed care, in late 2007.

"After APS came in, it became so formidable to try to negotiate their system," he says.

Psychologists began registering MaineCare patients online through APS. At one point, the psychologist says, problems with prior authorization numbers prevented full payment for some of these clients' services.

APS "was giving prior authorization numbers to patients with full coverage, but there was some type of code in the system that limited some patients to around $125," he says. "It was a mistake. [The patient] should have been able to go for eight sessions. This didn't happen with everyone; it was a few here and there. You'd be billing and would get paid for the first two sessions and a portion of the third, but then not after.

Eventually, that problem was fixed, though the psychologist says he received only four or five small payments over a one-year period.

"The left hand does not know what the right hand is doing," he says. "It depends who you get on the phone as to the information you'll receive. You can talk to 10 people on the phone and hear 10 different interpretations."

Eric Meyer, LCSW, executive director of APS Healthcare, acknowledges the first few months of the APS's involvement were rocky for providers and the organization alike. "In general, the idea of shifting from a system without utilization review to one with a utilization review was a big adjustment," he says. "There were a lot of places where it was tough for folks."

Meyer says employees giving different information to providers "was an area we struggled in for the first few months.

"There were many types of services we were involved in," he says. "We learned a huge amount in a short amount of time. With every problem we learned about, we said, 'we need to change this, we need to change that.' Now if you were going to call three different people, I think you'd get the same information from all three people."

As of July 2008, the most recent update reported, 87 of Maine's roughly 600 licensed psychologists had signed up for MaineCare under managed care, according to Sheila Comerford, executive director of the Maine Psychological Association.

"I do think psychologists really want to serve MaineCare clients. Money is not their primary motive," she says. (Hourly rates under MaineCare, traditionally lower than those under other insurances, were recently raised). "But when it becomes so painful to get paid, you just throw up your hands."

The office manager says his practice drastically reduced the number of MaineCare clients it sees around a year ago.

"We had to," he says. "The impact is the patients aren't getting care. It's a big, big problem," he says. "This is happening all over. We get calls from all over the state."

White is one of the psychologists who will continue seeing MaineCare clients, and credits the Maine Psychological Association's advocacy efforts in helping to improve the situation.

"MaineCare clients are a fairly large segment of populace here, and to turn away from these folks would go against my fiber," White says. "In the last year, MaineCare has been coming through more so, with reimbursements."