Tag Archives: Medicaid

High Medicaid Claims Denial Affecting Doc Participation: Study

Medicaid claims are denied at higher rates than are claims with Medicare and commecial insurance plans, and costs for collecting claims are higher with Medicaid than with Medicare and commercial insurance, a new study shows.

As a result, doctors in states where these barriers lead to lower Medicaid reimbursements are less likely to accept Medicaid patients than are physicians in states where they can earn more than is earned from the health insurance program for the poor, the study finds.

The working paper was written by researchers from the University of Chicago Harris School of Public Policy, Columbia University, the National Bureau of Economic Research, the Bureau of Economic Analysis, and the Federal Reserve Bank of San Francisco.

The researchers analyzed data on claims denials and computed billing costs for all types of insurance for about 90 million patient visits from 2013–2015. They found that payment was denied for 25% of Medicaid claims for at least one service after the initial claims submission. Claims denials were much less frequent for Medicare (7.3%) and for commercial insurance (4.8%).

Practices may or may not dispute the claims denials, the authors note. If they don’t, they lose revenue; if they appeal the denials and are paid later, they incur extra billing costs. The researchers called the sum of these two amounts the cost of incomplete payment (CIP).

According to the study, CIP averages 17.4% of the contractual value of a typical visit for Medicaid, 5% for Medicare, and 2.8% for commercial insurance. These are significant losses, especially for Medicaid, which pays less than other types of coverage, the authors note.

The study also shows how much less revenue physicians net from Medicaid than from other types of insurance. The average claim amount for all payers was $ 154, but it was only $ 98 for Medicaid. The total revenue collected per Medicaid claim was $ 84, vs $ 131 for Medicare and $ 175 for commercial insurance.

Effect on Medicaid Participation

On the basis of data from 2009–2015, the researchers found that physicians reported accepting Medicaid patients 72% of the time, on average, and that they accepted Medicare patients 84% of the time.

The Medscape Physician Compensation Report 2021 found that physicians remain committed to the programs. Of more than 17,000 physicians, 75% will continue taking both Medicare and Medicaid patients, the report found.

The researchers theorized that higher CIP should reduce physicians’ incentive to treat Medicaid patients. They tested this theory in two ways: they studied physicians who moved from one state to another with a different CIP, and they examined physicians in the same group who practiced in different states.

On the basis of these comparisons, they estimated that a CIP increase of 10 percentage points reduces physicians’ probability of accepting Medicaid patients by 1 percentage point if they move from one state to another. The long-term relationship between a 10-point CIP difference within groups that span multiple states reduces the probability of physicians in the state with the higher CIP accepting Medicaid patients by 2 percentage points, the authors say.

Previous research has shown the effect of Medicaid payment rates on physicians’ willingness to accept Medicaid, the authors note. “This study shows that administrative issues are just as important,” they say. They point out that other administrative challenges besides rebilling denied claims, such as preauthorization requirements, might also play a role.

Rachel Garfield, PhD, vice president and co-director of the Program on Medicaid and the Uninsured for the Kaiser Family Foundation, said this is not the first study to show the impact of administrative costs on Medicaid participation. “As the study cited, there was research many years ago showing that billing delays in Medicaid were associated with participation in the program.”

She agreed with the conclusion of the new study that administrative barriers are as important as the payment rate in the decision of doctors to take Medicaid patients or not.

Medicaid Quality “Really Comparable” to Private Insurance

She did not agree, however, that Medicaid coverage is of lower quality than other kinds of coverage. “Access to Medicaid for certain populations and certain services is really comparable to private insurance ― for example, when you look at the share of kids who are getting well visits or of adults who are getting dental care and so forth,” she said.

Where access problems exist, she added, they may be limited to certain kinds of specialty care or specialists in general, or they may be localized. For example, residents of low-income areas may have difficulty traveling to medical offices. “So it’s not just about the participation rate for providers nationally but whether there are providers in your neighborhood who take Medicaid,” she said.

The study didn’t provide enough data, Garfield said, to explain the reasons for Medicaid claim denials. Denials because of patients’ lack of eligibility were higher for Medicaid than for other payers, which could be part of the explanation, she added.

The study does not allow a comparison of claims denials by traditional Medicaid programs with denials by Medicaid managed care plans, she said. But it’s unlikely that the managed care plans rejected a higher percentage of claims or that they paid rock-bottom rates.

“Certainly, in managed care plans, there’s an incentive to manage care efficiently, but it’s not open-ended in terms of what plans can do to capture a profit. The rates have to be approved, and there are requirements on how those rates are set, and they have to be realistic so people can access services,” she said.

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House Democrats from Texas push local Medicaid expansion

Local governments would be able to bypass conservative state leaders and implement their own Medicaid expansion programs for working poor Texans with federal funds, under federal legislation introduced Monday by U.S. Rep. Lloyd Doggett, D-Austin.

Dubbed the “Cover Outstanding Vulnerable Expansion-Eligible Residents Now Act,” the legislation is a “homegrown solution” to a decade of resistance by a handful of red states to allowing more people who are struggling financially to access the federal health care program, said Doggett, chairman of the House Ways and Means Health Subcommittee and lead sponsor of the bill, which has 40 cosponsors.

SEE RELATED STORY: Republican state House speaker backs expanding Medicaid to cover mothers for a year after they give birth

In Texas, that could be as many as 1 million newly eligible residents – most of them people of color – who currently fall into that gap because they can’t afford private health insurance and can’t qualify for subsidies, but make too much to qualify for Medicaid.

The bill sponsors include all of the Texas congressional Democrats and most Democrats from 12 other states that have refused to expand Medicaid through the Affordable Care Act. It is the first time local governments have been able to directly contract with the federal government for Medicaid funds.

“For many of our most disadvantaged citizens, this bill offers a pathway to access a family physician, necessary medicine, and other essential coverage that thirteen States continue to deny,” Doggett said in a statement. “The COVER Now Act empowers local leaders to assure that the obstructionists at the top can no longer harm the most at-risk living at the bottom.”

The bill allows counties, cities and other political subdivisions to apply directly to the U.S. Centers for Medicare and Medicaid Services for funds that were declined by their states, including Texas. States would be required to cooperate and authorize access to state Medicaid systems for those entities, with incentives for cooperation and potential penalties otherwise.

That amounts to 100% federal funding for three years and tapering to 90% federal funding by year seven and beyond, Doggett said.

The bill will be filed later Monday, he said.

An effort by a bipartisan coalition of state lawmakers to expand Medicaid during the most recent session of the Texas Legislature became mired in conservative opposition and never got a hearing.

Opponents of expanding Medicaid to an estimated 1 million Texans who would qualify under the Affordable Care Act of 2010 argue that the program is poorly managed and financially unsustainable, and that expansion encourages government dependence, delivers poor health outcomes, and crowds out children and people with disabilities who need it the most.

RELATED: Supreme Court upholds Affordable Care Act for 3rd time, preserving coverage for millions

The death of the state legislation left on the table billions of dollars in federal incentives that supporters said would not only have paid for the expansion but added money to state coffers and lowered costs for hospitals that care for large numbers of uninsured patients.

Under Doggett’s proposed COVER Now Act, that money would be directly available to local governments through pilot programs approved by CMS without the state’s involvement.

“Health care coverage is as vital to a community as education, roads, or reliable power,” said Tom Banning, CEO of Texas Academy of Family Physicians, which supports the proposed legislation. “Sadly Texas has stubbornly refused federal assistance to expand Medicaid, leaving millions of our fellow Texans to get their health care by waiting in a long line at a free clinic, ignoring a treatable problem, or using the ER when that treatable problem worsens. That isn’t just morally wrong, its economically dumb.”

With more than 5 million of its residents without coverage, Texas has the largest number of uninsured residents in the nation, many of them working adults who can’t afford private or subsidized insurance but don’t qualify for Medicaid because they earn too much.

Roughly 20% of the state’s population lacks health insurance – a number health officials say has grown since more than a million Texans lost jobs and, in many cases, health coverage because of the COVID-19 pandemic.

Some 4.2 million people are on Medicaid in Texas – including more than 3 million children. The rest of the recipients are people with disabilities, pregnant women and parents living below 14% of the federal poverty level, or about $ 300 per month for a family of four.

Adults with no disabilities or dependent children don’t qualify for Medicaid, and the vast majority of children on Medicaid have parents who do not qualify.

The ACA allows states to expand that threshold to 138% of the poverty level, or $ 3,000 per month for a family of four.

Two recent polls show that 70% of Texans support Medicaid expansion.

The prospect of Texas leaders pushing for expansion any time soon is dim. None of the state’s top three Republicans has professed support, and their conservative base has been resisting it since the U.S. Supreme Court made it optional for states in 2012; it had been mandatory under the ACA until that provision was challenged in court.

It is unclear how long the federal incentives will be available, supporters of Medicaid expansion say, and there is also the uncertain future of the 1115 waiver, a temporary agreement to reimburse hospitals for uncompensated health care costs. It was meant to help Texas transition to Medicaid expansion before the state chose not to do it.

That waiver is set to expire in 18 months if Texas can’t persuade federal health officials to extend it.

The video above is from a previous story.

The Texas Tribune is a nonprofit, nonpartisan media organization that informs Texans – and engages with them – about public policy, politics, government and statewide issues.

This post originally appeared on ABC13 RSS Feed

TribCast: Weighing whether the Legislature will expand Medicaid and if voters would elect Matthew McConaughey

Author: Matthew Watkins and Justin Dehn
This post originally appeared on The Texas Tribune: Main Feed

Medicaid expansion picks up bipartisan support in the Texas House, but hurdles remain

Author Karen Brooks Harper
This post originally appeared on The Texas Tribune: Main Feed

Medicaid expansion in Texas

“We exist, and we matter”

Republican state House speaker backs expanding Medicaid to cover mothers for a year after they give birth

The Republican House Speaker threw his weight Wednesday behind a bill that would extend Medicaid coverage to mothers for a year postpartum, as part of a broad package of proposals meant to increase access to affordable healthcare in Texas.

The number of reported maternal deaths has increased nationwide in recent decades[2], and Texas data shows Black women in the state die disproportionately while pregnant or after delivery, from causes like infections, heart problems and mental disorders.

But health experts and advocates point to a fix they say would avert some postpartum deaths: Give low-income moms government-sponsored insurance for a year after delivery. They are kicked off after two months in Texas — though about a third of deaths[3] happen 43 days or more postpartum.

“Childbirth, while a wonderful and almost magical milestone in a woman’s life, can lead to postpartum depression. It can lead to medical crises, premature death, including suicide,” said state Rep. Toni Rose[4], D-Dallas. “While access to medical resources and counseling can save the lives of mothers, the safety net for those needing assistance disappears 60 days after delivery.”

Rose has proposed a bill, included in the House healthcare package unveiled Wednesday, that would extend Medicaid to a year postpartum. Lawmakers failed to pass a similar measure in 2019, when the cost of extending coverage was estimated to cost more than $ 70 million a year.

The announcement comes after Congress passed a pandemic relief bill that incentivizes states to extend it by waiving a lengthy and cumbersome process they would normally have to go through. The federal government has also sweetened the pot for the dozen states, including Texas, that have not more broadly expanded Medicaid to adults who can’t afford insurance but don’t currently qualify for the public program.

Legislation to do that is pending in both chambers, though it was left out of the House’s plan.

Texas has the highest rate of uninsured residents in the country with nearly one in five Texans lacking health coverage. While women can qualify for Medicaid if they are pregnant, a mother with one child would have to make less than $ 196 a month[5] to be eligible as a parent in Texas, which has the strictest income limits of any state, according to the Kaiser Family Foundation. Medicaid pays for about half of births in Texas.

Texas’ maternal mortality rate is slightly higher[6] than the national average, though that’s based on deaths that happen during pregnancy or within 42 days of delivery. More than 600 women died nationwide in that time frame in 2018 and 277 died 43 days to a year after the end of their pregnancy, according to federal statistics. More than 90 women died in Texas that year — 22 after the 42 day marker used by the government.

Dr. Lisa Hollier, chair of the state’s Maternal Mortality and Morbidity Review committee, said there are complications like heart disease and mental health conditions that are more likely to happen two months or more after delivery.

“It’s really important that women have access to the full range of services… like emergency room visits, like hospitalizations, that can really help them recover from their heart conditions, for example, or recover from their postpartum depression,” Hollier said.

There is a Texas program that gives mothers one year of coverage for mood or substance use disorders, diabetes, asthma and cardiovascular disease. Hollier said it is a “package of outpatient services” that are helpful but limited; Medicaid provides the same services and additional medications, testing and hospitalizations not covered by the state program, she said.

Advocates have said the state program has almost no network of specialty or mental health providers to deliver those services right now.

The rate of maternal deaths has gained attention nationwide. Experts and studies have found many of the deaths are preventable and that the maternal mortality rate is higher in the U.S. than other high-income countries. The risk is particularly acute for Black and indigenous women, who are two to three times[7] as likely to die than white women.

The past year has been something of an experiment in extending Medicaid coverage for new moms. Because of the pandemic, the federal government temporarily stopped states from kicking new moms off Medicaid — women like Claudia Nungaray.

Nungaray, 30, had used a state women’s health program for her annual checkups, but tried to avoid hospitals or doctors’ visits whenever possible because of the potential cost. When she did need to get glasses or go to the dentist, she paid out of pocket.

“Insurance is very expensive and I couldn’t really afford it,” said Nungaray, who lives in El Paso.

It was a “big relief” to learn Medicaid would cover her prenatal appointments, she said, where her doctors tested her for gestational diabetes and monitored her blood sugar. She was also able to see a counselor and get medication for anxiety and depression that she was diagnosed with during her pregnancy.

In November, she gave birth to a boy she named Kael and spent the next few months in the sleepless haze of new parenthood. She worried what she would do when she lost insurance and is grateful she hasn’t. She’s been able to keep seeing her counselor and going to doctor’s appointments to check on her elevated blood pressure levels.

“I don’t know what I would have done without that help,” she said.

Through a separate Nurse-Family Partnership program, Nungaray was paired with a nurse who checked on her regularly during her pregnancy and will continue to work with her and Kael for two years.

Doctors and advocates told lawmakers at a March hearing that losing insurance two months after delivery can affect new moms, especially those with limited means. Uninsured women who forego healthcare because of the high costs might find out they have underlying health problems at their prenatal appointments but can’t address them before their insurance coverage ends, doctors said.

Dr. Amelia Averyt, a primary care physician at a Houston health center, said she cared for a young mother who had pregnancy-related cardiomyopathy — a heart muscle disease. She was unable to follow up with cardiologists after her Medicaid expired, Averyt said, and instead visited emergency rooms with severe shortness of breath and hypertension.

“Continued care with specialist services could have helped preserve her heart’s functioning. But instead interrupted care contributed to a slow decline to the point where she could not keep up with her baby,” she said.

Adriana Kohler, policy director for Texans Care for Children, said at a legislative hearing this spring that there is a “human toll” if the state does not extend Medicaid coverage to a year postpartum.

Texas moms face complications like cardiac arrest, infection, postpartum depression and extreme blood loss in the year after pregnancy. That can lead to “scary and expensive hospital stays,” more procedures, and long-term health issues. Left unaddressed, they can affect an entire family, she said.

“There’s a greater risk of babies dying of SIDS, sudden infant death syndrome. If postpartum depression is untreated, kids are more likely to have ADHD, develop depression or anxiety in themselves, or have behavioral or conduct disorders,” Kohler said.


  1. ^ Sign up for The Brief (www.texastribune.org)
  2. ^ recent decades (www.cdc.gov)
  3. ^ third of deaths (www.dshs.texas.gov)
  4. ^ Toni Rose (www.texastribune.org)
  5. ^ 196 a month (hhs.texas.gov)
  6. ^ slightly higher (www.cdc.gov)
  7. ^ two to three times (www.cdc.gov)

Shannon Najmabadi