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CCC Plus or Minus?

March 15, 2018

Beginning December 1, 2017, most Medicaid beneficiaries in Virginia were assigned to private insurance companies tasked to manage their Medicaid long-term care benefits. The six companies that were awarded by Virginia Medicaid to become managers were Anthem HealthKeepers Plus, Aetna Better Health of Virginia, Magellan Complete Care of Virginia, Optima Health Community Care, United Healthcare Community Plan, and Virginia Premier CompleteCare. Despite the massive information campaign about the transition, some home care agencies, especially those that were newly established, were ill-prepared. Some Medicaid beneficiaries were also caught by surprise, not clearly understanding the letters and ID cards that they received. It created a mass confusion among the elderly and disabled individuals who have been receiving home-based community services for a long time.

Premium Home Health Care was one of the home care organizations that experienced and continues to experience extreme hardship because of the transition. Dealing with the CCC Plus insurance companies is like dealing with six “Medicaids” – each with its own processes and ways of handling things.

I’m not certain how these insurance companies developed their own method and operational mechanism, but I can say that some of them are out to make our lives difficult and miserable. There is one whose “care coordinator” spent weeks trying to investigate why we provide 16 hours of care a day to a client. She told the primary caregiver of the client that agencies have been “overcharging” Medicaid with this practice pattern. Well, this particular care coordinator already seemed to have some bias against home care agencies.

Anyone familiar with the traditional Medicaid program in Virginia knows that getting authorization for services is no easy task. You need to have the UAI, or Uniform Assessment Instrument, completed by the County social worker and/or nurse. Then the agency nurse performs his/her assessment, completes the necessary paperwork and submits all the required documentation to KePRO. Everything is then reviewed by a dedicated nurse reviewer and medical reviewer who may ask for additional documentation or even deny requests if the supporting documents are deemed insufficient. With this process alone, one can conclude that it is not easy to get service authorization at all.

So, I’m wondering, do some of these CCC Plus companies follow a different set of criteria? How can a client with an approved authorization of 16 hours/day from Medicaid be denied those hours and be approved only for 8 hours/day based on the care coordinator’s “assessment?” Is the care coordinator’s assessment the only basis for service authorization? Isn’t it an insult to the judgment and determination of the original reviewers who issued the initial approval?

I haven’t heard of any uproars yet from other agencies, maybe because some of them are franchise companies and do not worry much if their revenue cycle is disrupted. But what about small, local agencies like Premium Home Health Care who depend on timely reimbursement in order to pay its workers to ensure there is no interruption in services? What about the Medicaid recipients with prior approval who depend on the authorized hours to ensure their safety, health, and welfare in the home through personal care assistance? Should the insurance companies simply reduce their hours without a thorough assessment of their needs?

I understand the importance of cost-cutting. But if it means denying the hours of care that the recipient needs, even if there is substantial documentation, then there is absolutely no value to the CCC Plus program. I am hoping that the Virginia government will look further into this and revert to the traditional Medicaid program.

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