Gov. Mike DeWine has announced that the Ohio Department of Medicaid (ODM) will select new Medicaid managed care partners to provide healthcare insurance for approximately 2.8 million Ohioans. The process is underway and is expected to conclude in 2020.
ODM earlier this summer invited providers and other groups to offer comments on how the state’s Medicaid process is currently working and how it might be improved. The OOS sent the following letter to ODM Director Maureen Corcoran on July 31:
To: Maureen Corcoran, Director
Ohio Department of Medicaid
From: Reginald Fields, Director
Ohio Ophthalmological Society
Re: Ohio Medicaid Managed Care Program Feedback from Individuals and Providers
Date: July 31, 2019
As Ohio’s most comprehensive and experienced group of eye doctors and surgeons dedicated to preserving vision and advocating for eye safety, we appreciate this opportunity to share feedback from Ohio’s ophthalmologists. Our members provide patient care to Ohio’s Medicaid population and thus are uniquely qualified to provide meaningful information to assist the Ohio Department of Medicaid in its upcoming competitive Medicaid managed care procurement process.
The comments we received from our members generally centered on areas where improvement is most desired, including plan accountability, grievances and appeals, provider support, benefits and delivery, and care coordination and management. The following is for your consideration:
There must be more transparency as to the performance of the plans that can assist with assuring patients are gaining access to quality medical care and best practices are being followed. Furthermore, plan contracts should have clear, standardized guidelines for how providers are to file claims and stipulate the process for how claims will be processed. Network adequacy should also be bolstered to assure that the level of patient care needed is available within a reasonable distance.
Grievances and Appeals
When claims are denied, plans should be made to provide prompt explanations for the denial, including specific codes, descriptions and rationale for the denial and outline a reasonable remedy process and period. While the claim is pending, the provider should still be paid from 14 days of the claims submission. The claims appeal process should be clarified and standardized across all plans and an appropriate response should be delivered to the provider within 30 days.
Each plan should employ a dedicated ombudsman department to help providers fully understand and navigate their plan contracts as it relates to coverages, adjustments, claims submission, appeals process, prompt payments, and prior authorization issues. The plans should also allow for a dedicated provider representative available to each physician who is easily accessible and knowledgeable to answer questions pertaining the plan the provider’s contract. And while has a prior authorization law, many providers say that the process remains inefficient. Full enforcement of Ohio’s prior authorization law is necessary and stiffer penalties for the plans who do not adhere to the law should be enforced.
Patient Care Coordination and Management
To make medical services more efficient, managed care plans should be required to provide interpreting services to help meet the needs of a growing multi-cultural Medicaid patient-base. With more patients requiring these services and the expense providers incur in delivering the service, there needs to be a requirement in the contract that interpreting services are provided by the plan for any scheduled patient appointment. Similarly, the plans currently provide transportation services for patients who otherwise are unable to travel to their medical appointments. This service should remain part of the plan contracts.
Thank you for allowing the Ohio Ophthalmological Society to provide valuable input into this process. We hope this information will benefit your procurement process. For additional information you may contact Reginald Fields, OOS Director, at RFields@ohioeye.org or 614-527-6726.