ATLANTA — A highly critical report calls out Georgia for failing to hold its care management organizations, CMOs, accountable for how they spend billions in tax dollars.
About 1.5 million children in Georgia get access to Medicaid through a CMO, either due to income or special needs. Children in foster care are also covered by one of these programs.
But the U.S. Office of Inspector General said one of the CMOs in Georgia, Amerigroup, denied more requests for service, called pre-authorizations, in 2019 than all but two other programs it reviewed. Further compounding concern is the fact the state while receiving monthly claims processing reports, does not use that data to make sure decisions are valid or assess penalties for non-compliance.
Unlike 14 other states, Georgia also doesn’t offer a way for children denied access to care to get an external medical review to fight back.
Psychologist Shannon Mullen gets emotional when she talks about the roadblocks families face to get mental health care.
“I tell my patients all the time sometimes you have to do the hard things,” explained Mullen. “This is a hard thing I'm doing today. It's hard. But it's worth doing.”
It’s hard because Mullen worries speaking out will put a target on her practice and the employees within it. She’s not alone. 11Alive Investigates talked with nearly a dozen mental health providers the past year. They all reported similar problems and they were all afraid to talk about it.
As providers discussed their experiences, the word audit came up a lot, but really what upset them was accountability. They feel their work and requests to provide care fall under intense scrutiny, while the actions of the CMOs that deny services goes unchecked.
But Mullen said these burdensome audits and the battle to get care has pushed providers away from taking Medicaid clients. It’s just too frustrating.
She gave an example of a 10-year-old that won’t speak. She asked to run a series of tests to find out why.
“And the response back is well is not medically necessary. Let's, let’s try some medication, see how it goes. What are you medicating? Because we haven't figured out what the concern is here,” said Mullen.
According to a report by Voices for Georgia’s Children, the state has fewer than 100 child and adolescent psychiatrists. That breaks down to less than four psychiatrists for every 100,000 children. As the state works to increase its workforce, Mullen said it makes no sense to push away those who could be helping now.
11Alive made an open records request for data on CMO denials for mental health services that required a pre-authorization. It showed from 2019 to 2021 Amerigroup exceeded other CMOs in almost every category.
When looking specifically at pre-authorization for testing, as Mullen discussed, about half of the requests for low income children were denied and as much as 77-percent for children in foster care. In almost every case, Amerigroup claimed the tests were not medically necessary.
Data from Amerigroup does show in the past year, since lawmakers began focusing attention on mental health issues, the insurer has increased the number of pre-authorization requests approved in both testing and therapy.
The state pays CMOs a monthly fee to provide mental and medical care for those who qualify. That means the fewer services provided, the more the company gets to keep as profit. That’s where oversight comes in, to make sure denied services have good, legitimate reasons.
The mental health parity law passed in 2022 increased the amount of money that CMOs must spend on care. But again, oversight is required to make sure companies comply with that ratio.
Efforts to talk with Amerigroup about the data went unanswered.
MOMENTUM FOR CHANGE
"The people who need the most help are getting the least help and they're getting the least quality help,” said Mullen.
The Division of Family and Children Services, DFCS, is responsible for those in foster care. When DFCS disagrees with Amerigroup’s decision and believes the service is critical, it ends up paying for the services out of other state funds.
“So you're paying for it. You're just now paying more for it,” said Mullen. “That is a source of shame for us as Georgians, how we are managing the care of foster care kids. Unacceptable.”
Mullen said even when she gets approval to provide a services, too often, the insurance company takes back the payment afterwards.
“There’s no one to explain to you why. So you call, you know, and this takes manpower as well. So either I forego clinical time with the patient to do this work, or I have to pay somebody to make phone calls to to these companies,” said Mullen.
“You can’t run a business with, I might get paid, I might not. Just pray,” said Georgia lawmaker Shelly Hutchinson.
Representative Hutchinson is a clinical social worker with a practice in Gwinnett County. She’s tried since she won election to increase accountability for companies like Amerigroup and decrease the number of audits on those who actually provide the care.
“I am up for the audit. I am up for the intense ones and as a provider and legislator I think we need the intense ones, once a year will do it though,” said Hutchinson.
Earlier this year, Hutchinson re-introduced a bill that would assign one state agency to conduct one audit a year. It never got a vote.
“Small providers, families, families with children who have severe mental health, those are the people I’m speaking up to. That’s not who holds the power though. The people who hold the power are the people getting the contracts,” explained Hutchinson.
This week a group of lawmakers will gather to hear more about the current state of foster care and adoption in Georgia. They will hear from agencies and families affected on processes that may need to be changed, fee structures for services, and current funding barriers. Its focus is not on health care, but the issue will likely come up in testimony.
Right now, the Department of Community Health is preparing to rebid CMO contracts. Before the state started taking proposals, DFCS wrote a candid and critical letter recommending that Amerigroup’s contract not be renewed.
While that decision could take more than a year, DFCS created the Office of Health Law and Policy to review denied claims now in key areas of concern such as residential psychiatric care and behavioral health treatment for children with autism. Staffed with two full-time employees it has reviewed more than 1,200 notices, pushing back on about 12-percent by either filing an appeal or requesting a hearing.
Each month, the data shows, the number of cases under review by OHLP increases. Last July, it reviewed 11 notices from Amerigroup. Twelve months later, in June, it reviewed 350.
When OHLP pushes back, according to data from DFCS, children get care. For example, OHLP appealed more than 84-percent of the denials or discharge notices from residential psychiatric care, leading to a resolution on about half those cases.
But neither DFCS, the U.S. Office of Inspector General, or Mullen believe much will systemically change unless companies face stricter audits – just like providers – with penalties for their mistakes.