Agency ‘scram­bles’ to han­dle claims in-house

The Oklahoman - - NEWS - BY MEG WINGERTER Staff Writer mwingerter@ok­la­homan.com

A back­log of re­quests to per­form med­i­cal ser­vices for Soon­erCare pa­tients is go­ing down, but the state still has work to get the process up and run­ning af­ter bud­get problems forced a quick plan B.

The Ok­la­homa Health Care Author­ity had con­tracted with a pri­vate vendor to han­dle de­ci­sions on whether it pays for some ser­vices for Soon­erCare re­cip­i­ents since 2010. Their job was to de­cide if a ser­vice was “med­i­cally nec­es­sary” for a given pa­tient, through a process known as prior au­tho­riza­tion.

The pa­tient still can re­ceive the treat­ment if an in­surer — in this case, the state — de­nies au­tho­riza­tion, but has to pay the full cost. OHCA re­views more 1,000 ser­vices that have high costs or are prone to overuse.

The plan was for OHCA to re­quest bids in late 2016 as con­tracts neared their ends, but there was a prob­lem: the agency would have to pay about $2 mil­lion to re­tain both the old and new con­trac­tors dur­ing the tran­si­tion pe­riod.

Or­di­nar­ily, that would not mat­ter, be­cause the agency could draw on re­serve funds, but the state’s fi­nan­cial sit­u­a­tion made it im­pos­si­ble to spend on any­thing that wasn’t al­ready in­cluded in the bud­get, said Garth Splin­ter, re­tir­ing deputy CEO at OHCA.

The state faces a $215 mil­lion bud­get gap. If the Leg­is­la­ture doesn’t find a so­lu­tion, OHCA will lose $70 mil­lion this year.

The re­sult is that OHCA has to take over pro­cess­ing prior au­tho­riza­tion re­quests with only 13 staff — about half as many as the con­trac­tor used. Re­quests backed up in Au­gust and Septem­ber, ap­proach­ing 3,000 at their high­est point. They’ve fallen closer to 2,000, which is roughly one day’s worth of re­quests, Splin­ter said, and most re­quests are pro­cessed within a week.

“It’s been a scram­ble to make do,” he said.

They haven’t been able to ex­am­ine re­quests as deeply as they would like be­cause of the con­straints, Splin­ter said. That likely means fewer has­sles for pa­tients and providers, but it also could in­crease the odds pa­tients will re­ceive un­nec­es­sary treat­ment, which has its own risks. So far, OHCA is on track to ap­prove about $900,000 more in ser­vices than the con­trac­tor did last year, but still will save money be­cause us­ing staff costs less than the $6 mil­lion an­nual con­tract.

Ul­ti­mately, it’s a bal­anc­ing act of try­ing not to ap­prove un­nec­es­sary ser­vices, while try­ing not to hold up care that would ben­e­fit pa­tients, Splin­ter said. And the more closely they want to re­view each re­quest, the more staff they need — staff that they can’t hire in the cur­rent bud­get cli­mate, he said.

Even­tu­ally, a soft­ware pack­age called In­terQual could ease some of the bur­den on staff, Splin­ter said. The soft­ware, de­vel­oped by health tech­nol­ogy com­pany McKes­son, has the provider en­ter in­for­ma­tion about the pa­tient and the ser­vice re­quested, and tries to de­ter­mine whether the ser­vice is med­i­cally nec­es­sary. Be­fore they can use it, OHCA ex­perts will have to de­ter­mine that the soft­ware is us­ing the same cri­te­ria their hu­man em­ploy­ees would, he said.

Once it’s up and run­ning, the soft­ware will be able to make a rec­om­men­da­tion, but a hu­man still can make the fi­nal de­ci­sion, Splin­ter said. In prac­tice, staff’s ef­forts will be fo­cused on com­plex cases and those where the soft­ware rec­om­mends deny­ing a ser­vice, he said.

“This is a tool, a very in­ter­est­ing tool, but we’re not go­ing to turn over de­ci­sion mak­ing,” he said.

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