In July of 2017, the Louisiana Department of Health enhanced its oversight of the managed care organizations and the accuracy of the available information about licensed behavioral health providers. This oversight includes desk audits, on-site reviews and targeted secret-shopper calls to behavioral health providers in order to verify provider qualifications, licensure and whether or not providers are accepting new patients. In addition, the oversight oversees technical assistance provided on-site to the managed care organizations to improve reporting, notices of non-compliance from the state to the managed care organizations, and monetary penalties (Louisiana Department of Health, October 2017).
The Department has proposed amendments to the current managed care contracts to strengthen existing oversight and monitoring, including an amendment that will require the organizations to maintain 90 percent accuracy in their provider directories and possibly face stricter monetary penalties for noncompliance (Louisiana Department of Health, October 2017).
The ability to provide oversight and monitoring is not only a requirement for all Louisiana managed care companies, but it is a necessary step to ensure that providers are being reflected properly in the managed care networks. If providers aren’t reflected properly, it impacts the managed care company, its members and its providers. Imagine being insured by one of the six managed care companies and needing to locate a behavioral health provider near your home. You would visit your health plan’s website, find a provider, schedule an appointment, show up, and they tell you that they specialize in neurology only, or better yet, they were doing behavioral health last month, but now they aren’t. Yeah, that is exactly what we are talking about.
The impact of the inaccuracies is layered. The managed care company is fined, the members are unable to obtain reliable network information in real-time and providers miss out on potential referrals and field unnecessary and inappropriate calls.
Accuracy is what the Louisiana Department of Health is asking for from the managed care companies and that is a reasonable expectation. Unfortunately, many of the managed care companies have been unable to deliver. As recent as October 2018, a few managed care companies were fined for their inaccuracies. It begs the question – why? Why can’t a managed care company, who is paid to manage the care of the state’s citizens, accurately identify who is in their network, where the provider is located, if the provider is accepting new members and verify provider qualifications?
Ever heard of the moniker “too big to fail?” Managed care companies are monoliths when viewed from the outside. However, on the inside, a managed care company is filled with hard working people that are tasked with jobs that are sometimes too small for the large expectations being levied by their contract holder, which is the state.
A simple solution would be for the managed care company to simply put systems in place to ensure that their network displays at least 90% accuracy as per the state’s requirements. However, that is much easier said than done. Like most insurance companies, managed care companies do not operate in real-time like providers do. On a daily, almost hour by hour basis, providers are interviewing, hiring, training, terminating, certifying, re-certifying and beefing up their expertise. How can a managed care company expect to keep up with the constant changes of their provider network? Is it even fair to expect them to be able to do so? The solution could be to place the responsibility on the provider and make it the provider’s responsibility to update the managed care company. Perhaps that is a reasonable expectation if the provider had a reasonable number of managed care companies to report to. Unfortunately, that isn’t the case in Louisiana. There are six different managed care companies, each with their own network platform. Is it reasonable to expect a provider to update all 6 companies every time they make a change in their practice? Reasonable, maybe; however, being feasible is an entirely different question.
The Department of Health is serious about holding the managed care companies accountable for monitoring their networks. But the managed care companies need a solution – a solution with local expertise that can be provided in real-time.
EVERSO is that local solution. Join the network of mental and behavioral health providers and outpatient clinics that are receiving real-time verification of services being rendered in the field. EVERSO offers real-time monitoring for all services, including those that are clinic-based and those that are community-based. EVERSO offers 24-7 technical assistance, daily trend analysis and daily compliance reports. What better way to get real-time confirmation that services that are being paid for have actually been provided and in the way, that they are supposed to be provided? EVERSO understands the complexity of the mental and behavioral health system in Louisiana. We are local and we are here to help. Let EVERSO’s team help!
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