Important Issues

The Medical Society of DC joined six other DC health associations in a letter to the Department of Health Care Finance (DHCF). The letter asked DHCF to place common-sense reporting requirements on the Managed Care Organizations (MCOs) now that the new contract for the DC Medicaid program is being implemented.

The letter asks for more publicly shared data from the department and MCOs to ensure the public knows if the entities are meeting guidelines for transparency and clarity. Of particular interest to the entire physician community is the request to report on the number and type of prior authorizations issued by the MCOs.

The letter in its entirety is below.

To: Melisa Byrd, Senior Deputy Director and Medicaid Director, Department of Health Care Finance

From: Patricia Quinn, VP of Policy and Partnerships, DC Primary Care Association
Justin Palmer, VP, Public Policy & External Affairs, DC Hospital Association
Mark LeVota, Executive Director, District of Columbia Behavioral Health Association
Robert Hay Jr., Executive Vice President, Medical Society of DC
Veronica Sharpe, President, District of Columbia Health Care Association
Kurt Gallagher, Executive Director, DC Dental Society
Ian Paregol, Executive Director, DC Coalition of Disability Service Providers

Re: MCO Reporting on Billing and Credentialing

Date: January 30, 2023

cc: Angelique Martin, Deputy Director, Finance, Department of Health Care Finance
Lisa Truitt, Director, Health Care Delivery Management Administration
Katherine Rogers, Director, Long-Term Care Administration

The DC Primary Care Association, the DC Hospital Association, the DC Behavioral Health Association, the Medical Society of DC, the DC Health Care Association, the DC Dental Society, and the DC Coalition of Disability Service Providers are grateful for the work of the Department of Health Care Finance (DHCF) to support health system sustainability throughout the COVID-19 pandemic and beyond. A key factor in sustainability is efficient and effective billing and payment from the District’s Medicaid MCOs.

As the District further invests in a Medicaid MCO approach, and as the carve-in of new behavioral health services brings new providers into MCO billing systems, the need for DHCF oversight of MCOs grows. Additionally, consistency of billing and credentialing practices across all contracted MCOs is essential. DHCF has the power to hold MCOs accountable in these areas and improve the functioning and sustainability of a comprehensive, coordinated system prepared to meet the needs of high priority District residents.

In an effort to maintain consistent standards regarding claims, we urge DHCF to clearly define for MCOs what constitutes a clean claim for each provider type. This will provide transparency and clarity for all parties, and minimize one-off set up requirements for billers.

In order to have a clearer picture of actual MCO performance, our associations jointly request that DHCF require the following reports from the Medicaid MCOs on a quarterly basis:

• Number and Percent of claims paid; approved and pending payment; pending a determination and denied within 30/60/90/120 days of initial submission
  o Total dollar value of paid/denied claims
• Top 10 denial codes inpatient/outpatient/emergency/pharmacy
  o Medical, Dental, and Behavioral Health
• Number and Percent of denied claims resubmitted for payment
  o Percent of resubmitted claims redenied within 30/60/90/120 days of resubmission
• Percent of claims paid at an incorrect amount

Credentialing

• Total number credentialing applications submitted
• Number and percent of credentialing applications approved and denied within 30/60/90/120 days
  o Sort the above by top 10 license categories
• Time between approval of credentialing application and upload into MCO payment systems, including
  o Percentage of total approved credentialing applications uploaded in 10/15/30 days
  o Number and percentage of approved credentialing applications pending upload

Prior Authorization

• Average number of days from initial request to approval of prior authorizations broken down by hospitalization / specialty care / behavioral health / dental / pharmacy / skilled nursing.

MCOs must fix billing issues at the systems level, and cease the practice of requiring providers to work every individual claim impacted by MCO systems problems. Some issues are global problems, and others are MCO-specific. All result in significant loss of revenue from valid claims; significant burden on billing teams to track down, document, and communicate; significant stress on health care providers already struggling with staffing shortages and burnout across all aspects of their enterprise.

Additionally, provider credentialing must be standardized and streamlined. Workforce shortages have plagued the healthcare landscape due to provider burnout challenges that preceded the COVID pandemic, and have since worsened.

Our associations and District government partners are actively working to improve the healthcare employee pipeline in the District. We must address credentialing problems that exacerbate a crisis situation. With additional data collected about the MCO credentialing process, as described above, DHCF will need to consider what steps need to be taken to improve timeliness of credentialing.

Our associations commit to a roll-up-our-sleeves problem-solving approach with DHCF and our MCO partners on all of the above challenges. But we need transparency about the magnitude of the problems, and that can only come from the accurate reporting we request. We welcome the opportunity to discuss our recommendations with DHCF leaders, and to work together to improve payment and credentialing systems so we can all fully focus on ending persistent, pervasive inequities that drive disparate health and well-being in the District.