Prior to the Dec. 7 meeting between the ISMA and state specialty society presidents, ISMA leaders and key staff met with representatives of Managed Health Services (MHS). A managed care organization (MCO), MHS serves patients enrolled in Hoosier Healthwise (Medicaid) and the Children’s Health Insurance Program (CHIP).
MHS’s board, which is physician-driven, has reduced rates and instituted no across-the-board cuts for physicians, according to their representatives. “Underperformers” only are experiencing reimbursement declines, said the MHS spokesmen, and the organization’s quality measures are based on HEDIS data.
Because of changes instituted earlier this year, pharmacy services are now transitioning back to the state, although some in-office pharmacy services will remain under MHS. The MCO is participating in weekly meetings to ensure things are on target and updating its Web site accordingly. A standardized drug list is in use.
Historically, the MCO has had problems with ENT prior authorization, but the representatives said MHS is now taking a softer line on these. Procedures for medical necessity reviews are changing and details will be communicated.
MHS uses Milliman criteria to determine the medical necessity on spinal surgery. An initial review shows denials are low. Joint blocks for pain management have also been an issue, and MHS is seeking to meet with pain management specialists to discuss alternative therapy.
In clarifying peer-to-peer review, MHS officials explained a physician must communicate three times by telephone about conditions of a special case. Then a formal review process can begin.
The Credentialing Committee president is an outside physician, not an employee of MHS.
Here are a few other key points from the meeting:
- Imaging – MHS requires prior authorization for an MRI, but not CT scans or X-rays.
- Hospitals – MHS is adopting the 5 percent cuts required by the state for hospital-based procedures. The 5 percent is not a change in the fee schedule but a 5 percent reduction per claim.
- Prenatal care – MHS is in the 90th percentile in prenatal care. The MCO has a pay-for-performance (bonus/withhold) system in place for physicians.
- Healthy Rewards Card – The card can be used for health-related goods, as part of MHS’s incentive program that also offers well-visits. There is a 20 percent outreach benefit to encourage physicians to contact their Medicaid patients for regular visits.
- Enrollment system modernization – Since MHS does not do enrollment, changes in the system do not affect the MCO.
- Psychological services – On average, MHS is meeting targets, though problems exist.