Every day, patients from the Wilmington area and beyond visit your center in Penny Hill. The clinic provides behavioral health and substance abuse counseling, psychiatric services, and medication management for people of all ages.
Many of the clinic’s patients rely on Medicaid to pay for their care, and about 400 of them have AmeriHealth Caritas as their primary insurance provider.
But after nearly a year of issues surrounding reimbursement and a rigorous audit process, the center plans to sever ties with the provider, meaning many patients will no longer be able to receive care at your center. It means not being able to do it.
“We don’t want to disrupt anything more for (patients’) lives, but we can’t let this continue,” said LaKeetra Josey, a psychiatric nurse and co-owner of YOUr Center.
Joshi said AmeriHealth Caritas’ problems began in January.
The insurance company notified Georgie that it was conducting a “provider integrity” audit of the center. The audit could be conducted by the company regardless of whether a complaint was filed, but that in itself was not an issue, Josey said.
Josey said the lack of transparency and more than $47,000 in missed refunds left her with no other options.
AmeriHealth Caritas Delaware acknowledged in a written statement that it is “in discussions with your center to address certain contractual issues.”
“We look forward to successfully addressing these issues and believe that these matters are best addressed directly and confidentially with our insurers,” the insurer said.
Josey said attorneys for AmeriHealth and YOUr Center have been in contact, but so far no resolution has been reached.
lack of redemption
Your center has not had any major problems with AmeriHealth Caritas in the past. The redemption process was easy. All you have to do is see the patient, submit the claim, and receive the money to pay the clinician.
Occasionally, there were mix-ups and claims rejected and required resubmission, but most of the money owed was paid to the correct payroll.
Josey said in the last cycle, YOUr Center submitted 116 claims to AmeriHealth Caritas for reimbursement. Only six were approved.
When Joshi asked for a peer-to-peer review to see why her claim was denied, the insurance company said she was denied and that her claim was not denied because of medical qualifications. , there was no other explanation.
Joshi said part of the confusion appears to stem from the fact that many of the applications are filed in the name of her husband, who also oversees many other practices. But even after trying to explain this to her insurance company, Joshi said her refund was still being held back.
As part of the audit, YOUr Center is being asked to send paper copies of patients’ medical records to AmeriHealth Caritas. Joshi said this not only presents an opportunity for privacy violations, but also requires the center’s administrative team to spend hours each week printing and mailing information.
AmeriHealth employees are also contacting patients by phone or in person to ask about treatment, and concerned calls are being made to the YOUr Center. For some patients, seemingly random contacts from insurance companies exacerbated mental health symptoms, amplified paranoia, and drowned out trauma.
Joshi said the impact could have been avoided if she had explained the situation to patients in advance – that the insurance company has the right to ask patients about treatment options and that they plan to do so. .
Joshi said she tried to raise these issues with AmeriHealth, but her emails and phone calls to AmeriHealth went unanswered or passed around for months. None of her requests to schedule a meeting to discuss the issue have been fulfilled.
“It’s very frustrating,” Josey said.
seeking support
The ongoing issue between YOUr Center and AmeriHealth Caritas is not the only issue Delaware health care providers are having with insurance companies this year.
Nurses banded together in April to demand full reimbursement after Medicaid provider Highmark Health Options began reimbursing nurses 15% less than doctors for the same services. .
High mark:Nurses say they were not informed that their Medicaid reimbursements had been reduced.now they want answers
Lt. Gov. Bethany Hall-Long, chair of the state’s Behavioral Health Consortium, was a key advocate of the movement for equal reimbursement, which ultimately led Highmark to reverse its decision.
A spokesperson said Hall Ron recently became aware of issues the YOUr Center was facing with AmeriHealth Caritas, and that she and her office were “in contact with the center as[they]investigate.” I plan on continuing to take it.”
“The lieutenant governor believes in accessing mental health care and breaking down barriers,” the spokesperson said.
The Delaware Department of Health and Human Services learned of the difficulties facing YOUr Center on Aug. 31, a spokesperson said. The Medicaid and Medical Assistance Division then contacted AmeriHealth Caritas to confirm that patients would continue to be covered at the YOUr Center for the remainder of this year.
The department will take no further action, the spokesperson said. He said it was “not appropriate” for the state to intervene as this was a matter between the provider and the company.
DHSS said it has not received any other complaints from contracted providers related to AmeriHealth Caritas.
But Josey said she has been told by other local health care providers that they have had to stop accepting insurance entirely due to similar issues.
serve vulnerable populations
The core of YOUr Center’s mission is to support the most vulnerable and traditionally underserved members of our community.
Josey explained that the diversity of the center’s staff reflects the demographics they serve. The majority of YOUr Center’s patients are people of color, and Josey said many come to the center because they “appreciate the opportunity to meet clinicians who look like them.”
Many of the approximately 50 clinicians on staff also do community service, hosting traveling outpatient clinics for children and adolescents and “seeing (patients) where help is needed.”
This is a service that YOUr Center staff continues to provide even as they wait for thousands of dollars in refunds.
But as the center informed patients on Sept. 1, unless something changes, those who rely on AmeriHealth Caritas to pay for their care will need to seek care elsewhere.
“We want to continue to do what we can for the community, but I can’t expect my clinicians to continue seeing people and get paid,” Joshi said.
Send your story tips and ideas to Hannah Edelman at [email protected]. For more reporting, follow us on Twitter. @h_edelman.
