Few providers sought emergency relief under managed care, fewer got it 

Only a fraction of providers under the newest managed care program needed to apply for emergency relief after delayed payments. Fewer got it. (Program logo)

Out of the thousands of providers participating in the state’s new Medicaid managed care program for older Hoosiers, just 223 entities have applied to a state fund for temporary emergency financial assistance — and only 11 providers got it. 

Qualifying for that relief requires that a provider went through a claims testing process prior to the July 1 rollout of managed care, a system that pays a flat rate per enrollee regardless of services rather than a piecemeal, fee-for-service approach to reimburse individual claims. The state chose three large insurance companies to serve as Managed Care Entities, or MCEs, for the PathWays for Aging program: Anthem Blue Cross and Blue Shield, Humana Healthy Horizons in Indiana and United Healthcare Community Plan. 

Of the 223 applications, 48%, or 108 providers, were denied because they hadn’t participated in claims testing. Another 40% were dismissed because providers opted to work with MCEs to get the claims paid, according to data shared by the Family and Social Services Administration. 

Of the remaining 26 applications, FSSA said that six were still open and another nine were duplicates. That leaves 11 providers that applied for relief and received assistance under the program, which is designed to offset delayed payments for specific claims. 

The agency didn’t detail how much has been paid out nor did it share the average payout. 

Program background

According to FSSA, the 11 companies that received relief were a combination of long-term care providers like nursing homes and home- and community-based providers. Nursing homes reported payment disruptions early in the transition amid confusion over billing.

Paul Peaper,  the president of the Indiana Health Care Association that represents the interests of nursing home and assisted living operators, said the work to resolve payment issues is ongoing. One of the avenues used by providers to bring forward issues is a claims workgroup, which lawmakers put into statute earlier this year.

“The work to transition to the new PathWays program continues, and thankfully, all parties remain engaged in that process. The statutorily created Claims Workgroup is still meeting on a regular cadence to identify and triage issues as they arise. Our members will continue to work with FSSA, Humana, UnitedHealthcare and Anthem throughout this transition to ensure they have the resources they need to care for their residents,” Peaper said in a statement.

Cognizant about the concerns and pushback from providers worried about the transition, lawmakers opted to create the temporary emergency relief fund in a wide-ranging bill addressing several aspects of managed care and professional services. 

The fund, as written under Senate Enrolled Act 132, is open for the first 210 days post-transition, closing on January 31, 2025. The act goes on to define what would qualify as a financial emergency for a provider, including: 

If more than 15% of claims in one billing period are denied
If an MCE doesn’t pay a provider within 21 days of appropriately submitted aggregate claims of at least $25,000 
If the claim submission system experiences a failure or overload
At the discretion of the Medicaid director 

Aside from participating in claims processing — which thousands of providers completed between April and June — the written application must provide evidence of a financial need and proof of that training alongside documentation “of a consistent effort by the provider to submit claims in accordance with the uniform billing requirements…”

Then, the Office of Medicaid Policy and Planning has seven calendar days to make a determination. The office “shall direct” the MCE “to provide a temporary emergency assistance payment to the provider” within the next seven days, according to the law.  

Nursing homes report payment disruption under managed care

That payment will be equal to 75% of the monthly average claim from the six months prior to the transition and adjusted based on the covered members. 

As noted by the agency in a July 16 bulletin, “An emergency financial assistance payment is an advance payment reconciled against future claim payments.”

Failing to do so violates the claim processing requirements for a managed care organization’s contract and an MCE could be subject to penalties.

In August, Holly Cunningham Piggot — the director of care programs overseeing the transition, shared the various ways the state tracks claims processing and payments through weekly and monthly reports. 

“I know this is a huge concern for our providers that are participating … ,” she said.

Cunningham Piggot also said the agency was still working with providers who hadn’t completed testing and wouldn’t be eligible for the emergency funding. At that time, 165 providers had applied for assistance. 

“Just because we might deny the application because they didn’t participate doesn’t mean we aren’t still reaching out to them, having the MCEs reach out to them (to) provide assistance to them to have their claims processed,” Cunningham Piggot said. 

On Sept. 20, a FSSA spokesperson added that MCEs “have chosen to advance funds to providers even if they don’t meet the legislative criteria” in some instances.