Advocates of state appeals for Medicaid managed-care claims make last-ditch effort to get it passed, by hijacking another bill

By Melissa Patrick
Kentucky Health News

FRANKFORT, Ky. — Advocates of a bill to create a state appeals process for health-care providers to appeal decisions of Medicaid managed-care companies are trying to jam it through at the end this short legislative session on the coattails of an unrelated bill that appears to be uncontroversial.

Rep. Joni Jenkins

Senate Bill 120, sponsored by Sen. Ralph Alvarado, a Republican physician from Winchester, would create an administrative appeals process in the Cabinet for Health and Family Services, which opposes the idea. A Senate committee has attached Alvarado’s language as an amendment to House Bill 71, sponsored by Rep. Joni Jenkins, D-Louisville, that would allow judges to order a person who is “incapacitated by alcohol and other drug abuse” into treatment.

“I think it has the potential of killing this bill,” Jenkins said in an interview. “I heard there was a really large price tag put on [Senate Bill 120], a large fiscal load. So this late in a non-budget year, it is probably going to kill it.”

Sen. Julie Raque Adams, chairperson of the Senate Health and Welfare Committee, disagreed. “Everybody in the Senate [is] very supportive of Rep. Jenkins’ bill, and we have also passed out Senate Bill 120 from this chamber,” she said in an interview.

SB 120 passed the Senate 35-0 on March 2. HB 71 passed the House 90-1 on Feb. 26.

Rep. Robert Benvenuti of Lexington, Republican co-chair of the Democrat-controlled House Health and Welfare Committee, said he thought SB 120 “has a lot of support” on the House floor if leaders of the House’s Democratic majority allowed it to come up for a vote.

But to get a floor vote it must first come out of the committee, and that appears unlikely. The legislature can still pass bills on March 23 and March 24, after the 10-day recess for Democratic Gov. Steve Beshear to veto bills, but if he vetoes bills passed then there is no opportunity to override vetoes.

“I think it is a bill that properly sets up a process for providers who believe they have not been properly reimbursed to have some redress,” Benvenuti said in an interview. “Our health care providers who serve this commonwealth need to have an avenue of redress so that they can be properly paid for medically necessary services that they provide.”

Alvarado has said an administrative appeals process is necessary because managed-care organizations are denying claims for medically necessary treatments and then denying the providers’ appeals, which means providers are not getting paid for their work.

The cabinet says it should not be responsible for an appeals process for MCOs because they do not have any legal authority between a contract made between a provider and the MCO. They have also said it would cost the state money. MCOs are paid a flat fee for each person whose care they manage, but an increase in approval of initially denied claims could give them leverage in negoiations for the next annual contract.

The fiscal note for this bill says the cabinet estimates its administrative cost for an appeals process would be at least $1 million a year, which would increase in later years. Alvarado maintains that the added cost to the state should be minimal.

Jenkins, whose nephew, Wesley, died of a heroin overdose two years ago, said that this is the fourth year she has tried to pass this bill, with a lack of funding to pay for the program its main obstacle, “but with the passage of the ACA, it has opened up private insurers and Medicaid to pay.”

Jenkins said if the House didn’t concur with the changes made by the Senate, she hoped the Senate would withdraw its amendment.

Adams said if the House didn’t concur, she would be “very receptive” to going into conference committee to resolve their differences because Rep. Jenkins “has got a very important bill that we need to pass.”

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