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HMO Termination Creates Crisis For South Jersey Medicaid Patients

Courier-Post — Sunday, October 27, 2013

Written by
Kim Mulford
Courier-Post

Under their state contracts, managed care companies are allowed to end provider relationships, but must ensure there are enough doctors in the network for their patients. The state is responsible for making sure those contracts are followed.

Nicole Brossoie, spokeswoman for the state's Department of Human Services, said its division of medical assistance and health services "has engaged United on this issue and is monitoring the transition of its members to new providers to ensure network adequacy."

"There have been a few member complaints," Brossoie added. "However, United is meeting its contract requirements. The division will continue to examine the outcomes."

She could not say how many doctors accept Medicaid in New Jersey, calling it a "moving target of a number," since doctors are continually added and dropped from managed care networks.

Alice Ferreira, spokeswoman for United Healthcare Community Plan of New Jersey, would not answer specific questions about why it ended the contract with Advocare, whether there are enough doctors in its network to handle displaced patients, or how many enrollees appealed the move.

"At all times, we worked to ensure there was continuity of care for our members," Ferreira said in an emailed statement. "In addition, our clinical staff conducted individual outreach calls to members who were in a course of treatment, or required special care coordination.

"We continue to have one of the largest Medicaid networks in the state and providing coordinated health care for our members is our top priority."

Still, some impacted patients say they are paralyzed by the thought of searching for another doctor they can trust. They are waiting for Advocare to finalize a contract with one of the other three managed care companies administering Medicaid in the state.

Advocare hopes to have a contract in place by Nov. 1.

But even if patients switch managed care plans, it could affect their relationships with other specialists.

Christine Monaghan of Mount Ephraim has custody of her 10-year-old grandson, who is enrolled in the United Healthcare Community Plan. She's been taking him to an Advocare doctor since he was 2. His dentist only accepts United Healthcare.

"It's hard to find doctors that accept the Medicaid," Monaghan fumed. "When you find some that do, and you get all the other ducks in a row, to have to change is going to be a pain in the butt."

Diana Freiling of Barrington has been taking kids to Haddonfield Pediatrics for 21 years. She now has custody of her youngest grandson, who is on Medicaid.

"I'm just so fed up with United Healthcare," she said. "They just randomly assigned my grandson to a new physician."

Printed on the ID card was the physician's billing address in Haddon Heights. His physical practice? It's in Pennsauken.

Freiling went on United Healthcare's website and called one of its representatives to find a provider closer to home. As she went down the list, each doctor's name Freiling mentioned was no longer in the network, she was told.

Freiling switched her grandson to a different managed care company last week, and found a doctor she knew in Stratford.

"I cannot deal with a company whose information is so inaccurate," said the medical assistant, who processes claims and appeals for a different insurance company.

"That is totally unacceptable ... I imagine other people are having the same issue."

New Jersey Citizen Action's Dena Mottola Jaborska said her advocacy group is concerned some managed care networks don't have enough primary care providers. That's based on calls to its Health Care Helpline.

"There is no comprehensive analysis available that would provide the full picture of patient access to (primary care providers)," said Jaborska, director of organizing and strategic program development.

"The state needs to do a better job of overseeing the adequacy of provider networks, especially now that the number of patients entering these plans is expanding under the Medicaid expansion."

Josh Spielberg, a senior attorney who leads the Health Care Access Project at Legal Services of New Jersey, thinks there already aren't enough doctors in New Jersey who accept Medicaid.

To verify there are enough providers in United Healthcare's network, he said, the state should ideally contract with an outside party to survey its listed doctors.

Part of the problem, he explained, is New Jersey's low reimbursement rates for doctors who see Medicaid patients.

Although the Affordable Care Act increased the reimbursement rate for primary care providers to match the Medicare reimbursement rate for two years, it did not do the same for specialists.

"I have concerns that even the existing network is adequate," Spielberg noted.

"When you lose this many providers, it makes it more so."

Indeed, finding a primary care doctor within the network is one thing. Finding a specialist can be even harder.

Franz, the Mount Ephraim mother, also is faced with finding a doctor who can treat her bipolar disorder. The 39-year-old has seen the same Advocare primary care doctor since she was diagnosed at 18. She takes medication to control her disorder.

Franz said she appealed United Healthcare's decision, but was rejected. She then tried to argue she needed "continuity of care," another guarantee for certain patients with special health needs covered under the state contract.

That was rejected, too, she was told, because her doctor isn't a behavioral health specialist. But she can't find a psychiatrist who accepts her Medicaid.

A search through United Healthcare's physician database found no psychiatrists listed within 99 miles of Franz's home.

"I see my doctor at least once every three months," she said. "I'm able to get in with my doctor right away if I'm having a problem. He knows me. I walk in and he knows exactly what's going on.

"How do you find another primary care provider ... who knows my changes and what I need?"

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