The next nightmare?
Monday, Jun 6, 2016 - Posted by Rich Miller
* Managed care has been touted as a great way to control Medicaid costs. But the state budget mess and an unwieldy managed care system means things are heading for trouble…
It’s particularly tough these days to run a hospital in Illinois. Executives from hospital networks big and small say they are reeling from the state budget crisis, which is tying up crucial reimbursements.
At Downers Grove-based Advocate Health Care, the biggest hospital chain in Illinois, the stack of unpaid bills has climbed to $81 million. More than $20 million of that is due for taking care of state employees—the state isn’t paying the health care bills of its own employees or retirees, either.
Making matters worse, when the reimbursements do come, a big chunk doesn’t flow directly to hospitals. Instead, the payments filter through one of 13 managed care companies in the state. These insurers—strengthened by a 2011 law that aggressively pushed Illinois Medicaid recipients into plans—are owed at least $570 million, according to the Illinois Department of Healthcare and Family Services, which oversees Medicaid. When the managed care companies don’t get paid, hospitals don’t either. About 63 percent of the state’s 3.2 million Medicaid enrollees are now in managed care. (As for all the interest accumulating on some of those bills, both the state and managed care companies are on the hook for that.)
* And even when the managed care companies are paid, providers are apparently getting stiffed…
Michael Zenn, chief financial officer at University of Illinois Hospital & Health Sciences System, says his Near West Side flagship, one of the largest providers for low-income people in Illinois, has contracts with six of the 13 managed care companies and is waiting for $67 million in payments from them. That has created a hefty administrative burden because each has its own requirements, Zenn says. Patients might need referrals to see specialists. Others don’t understand if the state has switched them from one insurer to another and UI Health isn’t in their hospital network, yet they show up to see a doctor anyway.
There’s a “phenomenal” number of claims that companies are denying, Zenn says. To tackle the chaos, the system plans to hire 100 full-time employees by year-end, bringing to 480 the army of workers who handle such tasks as getting permission from the companies for patients to have certain procedures, like an MRI or outpatient surgery.
- Honeybear - Monday, Jun 6, 16 @ 12:00 pm:
Mark my words. Somebody is going to actually die because of this. I’m not kidding. This IS literally life and death.
- Thoughts Matter - Monday, Jun 6, 16 @ 12:04 pm:
See similar article at Sj-r.com regarding what’s owed to Springfield providers.
- Big Joe - Monday, Jun 6, 16 @ 12:21 pm:
Maybe the guv can spin this into adding 100 more jobs in the state.
- Ghost - Monday, Jun 6, 16 @ 12:21 pm:
so how is Rauner helping build a business friendly environment again? it occurs to me that none of these companies have a problem with union workers that is keeping them from doing business here…. so the turn around agenda wont influence them at all, but the holdout for a plan that does not benefit them is driving them into bankruptcy.
makes sense, push a antiunion agenda that has almost no business impact while driving those businesses into bankruptcy to get it…. yep that will build our buisness environment
- Precinct Captain - Monday, Jun 6, 16 @ 1:22 pm:
Too bad Rauner never played pro football. If his stiff arm is a good as the stiff he’s given these institutions, he’d have made the HoF.
- RIJ - Monday, Jun 6, 16 @ 2:16 pm:
The state is playing games with providers, too. My wife works in mental health and in the last year seen an huge increase in rejected claims, usually for minutia. What disturbs her most are the claims she’s sent to correct (having to do with treatment notes), then when she “corrects” them, they are returned again and she’s told to do them the original way. All to “meet state requirements.” But it’s a blatant tactic to delay payment and attempting to shift blame to the provider. Not to mention delaying the state’s interest clock.
Our own health care choices are becoming more limited because many dentists and doctors won’t take a state employee or retiree’s insurance.
It’s rough to a human support organization in Illinois these days. Heck, BruceAlmightyDollar doesn’t even support for-profit human health services. Now, that says a lot about his irrational hatred of unions.
- Liberty - Monday, Jun 6, 16 @ 2:58 pm:
Tear the state apart, pick up the pieces, default on debt, destroy the unions, outsource to politically connected and where needed pay minimum wage. That creates taxpayer value.
- Dan Johnson - Monday, Jun 6, 16 @ 3:10 pm:
This is a real opportunity for a legislative initiative to contain health care costs: mandate standardized managed care provider payments and approvals. The state ought to create one standard administrative system for health insurance payments and approvals.
- CCP Hostage - Monday, Jun 6, 16 @ 3:14 pm:
Beginning July 1, it will no longer be an option for persons who have both Medicare and Medicaid to opt out of the state’s managed care program. All will need to enroll. The current system is broken to the point that providers don’t always know which MCO to bill as the clients, MCO’s, and the state don’t always notify as they could/should. And there’s no good look up system. So, we can bill an MCO, a month later get the denial because the client is no longer a subscriber to that MCO, figure out which entity actually is the correct one to bill, bill that entity, fight the denial if it’s an MCO, or wait for the state to pay. It takes months to go through this system and will ultimately result in even more human service closures, which will result in loss of services to people, which will result in emergency room use and institutionalization. Three years from now the state is going to be organizing by work groups to figure out how we can lessen use of emergency rooms and institutions, all over again. I’m not close to retirement, I’ll be there, doing my best not to shake my head.
- typo - Monday, Jun 6, 16 @ 3:19 pm:
“when the managed care companies don’t get paid, hospitals don’t either.”
This statement is factually incorrect. The state was nearly three months behind paying those insurers before the court ordered Medicaid payments kicked in last fall. The insurers paid the hospital and doctor bills that whole time.
“Even when the managed care companies don’t get paid, hospitals still get paid” - fixed it
- union thug - Monday, Jun 6, 16 @ 5:09 pm:
A few observations from working in the system.
If providers don’t know what plan someone is on they can get it. In fact they are suppose to check each time a patient comes in. that is why they have several ways, through the internet, and phone. Heck during the week they can call a real person who would be happy to inform them the status of the patience coverage. the network system will not only tell them that the person is covered but what plan the person is on.
If a patient don’t know they probably aren’t reading the mail. Most things they get more than one letter in the mail informing them of what is going on. If they don’t read it that’s on them. However I say all the managed care stuff is contracted out (privatized) so I can not guarantee anything.
the plans paying providers has nothing to do with Medicaid paying them as they get a lump sum from the state and up to them to pay providers. Not knowing the financials I couldn’t go into the savings of it, if any.
The problem we have is more how much is privatized. so many different companies involved we have to have a book of numbers to send people to. some may or may not give truthful info or even help. it’s just one more example of why government by private company is not a good idea.