Last Friday the Health and Human Services Committee held a quarterly briefing and hearing on Heritage Health. Heritage Health oversees our three Managed Care Organizations for all Medicaid recipients in our State. These three Managed Care Organizations are Nebraska Total Care, United Healthcare, and Wellcare. Last Friday’s briefing and hearing focused on meeting the needs of our healthcare providers.

The good news coming out of Heritage Health has been that patients are being better served than they were a year ago. Clean claims continue to be processed, adjudicated, and paid at a good rate, patients can obtain services in other states and more is being done to provide for healthy pregnancies.

The bad news is that our Managed Care Organizations continue to frustrate our healthcare providers. For instance, some healthcare providers testified at the public hearing that payments on claims are inconsistent, customer service is poor, and that they lose money waiting for authorizations to come through. Some healthcare providers have complained that billing is not worth the wait. If we don’t treat our healthcare providers well, they may stop doing business with Heritage Health.

There are three key areas that Heritage Health must improve on in order for our Managed Care Organizations to provide better service to our healthcare providers. The first problem area involves overpayments to our healthcare providers. This is the most complicated of the three problem areas. When overpayments are made to healthcare providers, the overpaid amount is not necessarily returned to the Managed Care Organization; instead, some of our Managed Care Organizations insist on applying the overpaid amount to a future claim. This makes the accounting process very confusing. Even worse is the fact that the Managed Care Organizations have no way of telling when an overpayment has been made. This places the burden of catching the over-payment on the healthcare provider. In short, this presents a nightmare kind of scenario for our healthcare providers. So, going forward the HHS Committee and Heritage Health will need to find a way to place this burden back on the Managed Care Organizations, where it belongs.

Second, healthcare providers are entitled to interest on overdue claims which are not their fault. Interest payments need to be made to our healthcare providers when they are not at fault for an unpaid claim. For instance, sometimes a clean claim is erroneously denied by no fault of the healthcare provider. Other times a claim may erroneously be deemed unclean by no fault of the healthcare provider. Because these kinds of cases may drag on and on for months without a resolution, once it is determined that the claim should be paid, it ought to be paid with interest to the healthcare provider.

Third, clarification is needed to determine when the clock starts and stops on a resubmitted claim. When a healthcare provider resubmits a claim, it becomes unclear as to whether or not the clock on the new claim restarts. Should the clock continue on from the original claim, or should it restart after the claim has been resubmitted? This is an issue that frustrates our healthcare providers and which could be easily resolved through a simple policy statement.

The bottom line is that the Legislature needs to make sure that our healthcare providers get paid for their services in a timely manner, that they receive good customer service, and that their concerns get heard. I want our healthcare providers to enjoy doing business with Heritage Health.