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Doctors, patients fume over HMO delays

CareSource, Ohio’s largest Medicaid HMO, says it exceeds state requirements

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By Jim DeBrosse, Staff Writer Updated 9:20 PM Saturday, March 13, 2010

Tonya Slusher of Dayton said a side benefit about landing a job with health care benefits a month ago was that she was able to quit CareSource, the largest Medicaid HMO in Ohio.

She said her doctor “had to go through all kinds of authorizations just to get simple things like birth control” prescribed for her. “You have to be persistent if you want to get through to them,” she said.

Doctors say CareSource and other Medicaid HMOs, the private insurance firms that manage care for Medicaid patients in Ohio, disrupt patient care and pay too little to cover their costs. Since 2007, the state has mandated Medicaid patients enroll in an HMO as long as more than one serves their region.

The Miami Valley is largely served by Dayton-based CareSource, which enrolls more than half of the 1.5 million family members covered by Medicaid managed care in Ohio, and Molina, the second largest Medicaid HMO at 15 percent.

CareSource not only dwarfs its competitors in size, it also logs more complaints, with the vast majority coming from health care providers. Of 717 provider complaints last year, 371 were lodged against CareSource and 46 against Molina, according to the Ohio Department of Job and Family Services. In nine of the months between January 2009 and January 2010, CareSource was at or above the state average for provider complaints.

Pam Morris, chief executive of CareSource, said the vast majority of its 23,000 providers have no complaints and that the number is remarkably low “when you consider that we paid out approximately 12 million claims in 2009,” up from 10 million in 2008.

But Dr. Lynn Grace of Springfield said many doctors know it’s useless to complain because “CareSource systematically declines to pay for services we deem necessary.”

Treatment denials are a common physician complaint. Grace said that before the state took over the Medicaid prescription drug program in February, CareSource refused to pay for more expensive medications for treating high blood pressure until patients first tried ACE inhibitors — a class of drugs that she says has proven ineffective in African-Americans. CareSource officials say they never had such a requirement.

Dr. Edward Cutler, a pediatrician in Columbus who specializes in treating patients with mental health issues, said he can spend as much as 90 minutes on the phone trying to get a pre-authorization for a patient’s treatment from CareSource. “You can go through four or five different people. And if you get cut off, you have to start all over again. That’s an hour and a half wasted that I could be spending with patients.”

Cutler says he doesn’t want to abandon his patients because many would have no choice but to go to hospital emergency rooms for care. But he said he’s had to borrow thousands of dollars from friends to keep his doors open, in part because of low reimbursement. CareSource covers about 40 percent of his patients, he said.

Two weeks ago, Cutler said, his utility company “came over to turn off my electricity. I had to give them a bad check for $450, and then scrape and beg to get the money together to cover it.”

Cutler says CareSource uses a variety of technical reasons for delaying and denying claims.

“I’ve gone as long as seven weeks without a check from CareSource,” he said.

In a statement, CareSource said its automated claims system “can feel more arduous ... for smaller, less technology-savvy physicians’ practices” such as Cutler’s.

The statement also said CareSource pays 97 percent of its claims within 30 days — well above the state requirement of 90 percent — and that the majority are paid in 17 days.

Morris pointed out that all HMOs must pre-authorize treatments that are not standard practice in order to remain financially viable and provide quality care to patients. However, she said CareSource is working on a system that would eliminate pre-authorization for doctors who “have pristine track records — where there are never any questions” about their treatment approach.

“That will allow us more time to spend with other (physicians) where there are questions,” she said.

Medicaid rolls swell

With the number of jobless people in Ohio at their highest levels in decades, Medicaid rolls have grown at a time when the state also is cash-strapped. The average monthly number of Medicaid clients grew from 1.31 million in 2007 to 1.57 million in January of this year, a 20 percent increase. In just 2010 alone, the rolls have climbed 11 percent over last year, according to state data.

But as their ranks swell, Medicaid patients say their choice of doctors is limited, especially for specialists.

Doctors say that’s because they can’t cover the costs of their staffing and other overhead on what Medicaid HMOs pay for their services.

Most doctors want to serve the poor in their communities, said Mark Jarvis, senior director of practice economics for the Ohio State Medical Association. “But when you take the low reimbursement and you add the administrative burden, the state, in effect, makes it impractical to take on more than a small percentage of Medicaid patients” in their practices, he said.

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