PHA Pediatric Cabinet Discusses Medicaid Managed Care Expansion, Appeals
More than 30 representatives from providers serving pediatric patients gathered at the new PHA office last week for a Pediatric Cabinet meeting to discuss several major issues affecting them, including the expansion of Medicaid managed care in Pennsylvania and a reduction of service hours.
"The agenda was so relevant to what our program is currently facing," said Wendi Nagle, Home Nursing Agency & VNA. "It was great to get many of my questions answered and meet the presenters, some of which I have personally spoken to on the phone."
Darlene DeMore, DPW Bureau of Medicaid Managed Care, listened as providers expressed their concerns about the expansion. She listened to concerns from agencies on issues including how rates are negotiated with MCOs and limits to benefits. DeMore confirmed that current open authorizations will be honored by MCOs for 60 days after the expansion takes effect in counties.
David Gates, Esq., Pennsylvania Health Law Project, discussed the process for Medicaid appeals so agencies can help to advocate for their patients. Click here to download his presentation.
Michael Baer, MD, and Kristy Bailey, DPW, discussed the determination of medical necessity and how claims are reviewed. Bailey noted that approximately 50% of claims from providers come in with missing documentation, and she urged agencies to double and triple check their information before sending it.
"It was wonderful to be a part of this dynamic PHA cabinet with over 30 pediatric homecare stakeholders," said Darien Zimmerman, Pediatric Services of America. "PHA makes sure it is in tune with our issues, bringing key people from DPW and the pediatric homecare industry to help us address issues, learn about initiatives and ultimately provide the best care possible for our clients."
"It was great to see such a large group of providers come together and discuss topics that affect us all on a day-to-day basis," said Lyndsay Coleman, Maxim Healthcare Services. "I'm appreciative to the speakers for taking time out of their busy days to listen to our concerns and most importantly, help us find solutions."