State reviews Medicaid-network denials

Jul 31, 2008

Officials say computer system responsible for errors in unprocessed claims

By Jim Ash
Tallahassee Democrat--July 31, 2008

A state review of nearly 300 children that the Tallahassee Pediatric Foundation claims were denied access to its physician network shows that only 14 cases could possibly be linked to problems with Florida’s new, $300 million Medicaid computer system.

Officials with the Agency for Health Care Administration stress that all but two of the 267 children were enrolled in Medicaid and had access to a doctor.

"At no time were the children who were on this list ever restricted from receiving the medical care that they need," said agency spokesman Doc Kokol.

AHCA’s sister agency, the Department of Children and Families, determines Medicaid eligibility. AHCA records showed that two of the patients on the TPF list were not eligible for Medicaid and two more are scheduled to lose their eligibility at the end of the month.

The Pediatric Foundation list is misleading, Kokol said, because all of the Medicaid eligible patients on it could still see a doctor in the TPF network if that doctor is willing to accept them on a fee-for-service basis.

Begun as a Medicaid experiment by the Legislature in 1984, the Tallahassee Pediatric Foundation is a nonprofit network of about 20 area family and pediatric physicians and the first of its kind in the state.

The idea was to improve state-subsidized health care by giving Medicaid recipients a "medical home" where they could obtain routine and preventative care. Another goal was to cut costs by steering patients away from emergency rooms, where care is far more expensive. A follow-up study by the University of Florida four years later showed that the network was reducing emergency room visits by two-thirds.

TPF case managers help guide indigent parents through the Medicaid system and help them choose a physician for their children from birth to 18, either with physicians in the 7,000-patient TPF network, or through other provider networks, including three HMOs that serve North Florida’s poor children.

TPF case managers were shocked two weeks ago when 267 patients who wanted to join the TPF network in July were listed as ineligible. Usually, about 90 percent of patients are accepted by Medicaid managers, TPF administrator say.

The problem cropped up at the same time that the state acknowledged struggling with a transition to a new computer system run by Texas-based EDS that manages some 2.3 million Medicaid patients.

AHCA administrators pored over the list provided by TPF and found that 51 of the patients were not eligible for the TPF network for a variety of reasons. Many of those patients were still locked in to a previous provider network. Others didn’t follow the right procedures, Kokol said.

AHCA said it had no record that 197 of the patients on the TPF list ever contacted Medicaid Options, an EDS-run gatekeeper that screens the applications.

However, they blamed a "system error," for the rejection of 14 patients who contacted Medicaid Options but never received the proper follow-up notification. AHCA is attempting to reach them to tell them that they are eligible for TPF, Kokol said.

Dr. Louis St. Petery, a pediatrician and one of the founders of TPF, disputes some of the AHCA findings.

TPF physicians see Medicaid patients through the network, but some won’t see Medicaid patients on a fee-for-service basis, he said.

He’s also skeptical that as many as 197 TPF applicants failed to contact Medicaid Options. St. Petery said it’s likely that they were unable to get through swamped phone lines. EDS beefed up its call centers after receiving complaints.

"I don’t believe we ever had 197 patients who didn’t call Medicaid Options," St. Petery said. "That’s crazy."