Print 🖨

The Senate Committee on Health & human Services met on September 12 to consider interim charges related to mental health capacity, maternal mortality, CPS and community-based care, and abortion reporting requirements, as well as to hear about certain payment issues with rural hospitals.

This report is intended to give you an overview and highlight of the discussions on the various topics the committee took up. It is not a verbatim transcript of the hearing, but is based upon what was audible or understandable to the observer and the desire to get details out as quickly as possible with few errors or omissions.

 

Initiatives to increase capacity and reduce waitlists in the mental health system, including the construction of state hospitals and new community grant programs

Sonja Gaines, Health and Human Services Commission

  • SB 292 used $37.5 million appropriated in budget to reduce recidivism & develop mental health supports, couple with another $30 million from HB 13 supporting community services around mental health
  • These grants required a match from local communities, scaled for urban and rural
  • Identified gaps in statewide health plan & asked groups to identify how they were addressing gaps
  • Out of 80 grants, have seen a number of innovative projects across the state; were able to focus on unique aspect in communities like partnerships with jail programs, follow-ups on referrals, etc.
  • Provides map of the grants distributed across the state
  • HB 13 programs were focused on leveraging existing partnerships and identifying gaps, selection committee included personnel to ensure there was no duplication of effort within communities; addressed gaps in behavioral health needs in public school students & access to timely treatment
  • Also developed metrics to measure success in these programs
  • Kolkhorst – Were the HB 13 grants issued later because of the contracting issue?
    • Yes, HHSC needed to pause to look at procurement and scoring, set the agency back a little bit
    • However, HB 13 & SB 292 grants are in process but moving forward
  • Kolkhorst – Could communities get both SB 292 and HB 13 money, or was it one or the other?
    • No, evaluation looked at all aspects & some communities did receive both grants
  • Kolkhorst – Where are we on monitoring the effort to achieve efficiencies in these services? Where are we on looking on how much money reaches patients or constituents?
    • HHSC probably has the most robust oversight over services provided to LMHAs; i.e. $60 million was issued last session to address wait lists & wait lists have gone done significantly due to the investment
    • HHSC tracks all data related to these efforts, there are sanctions and penalties for problems
  • Kolkhorst – And there is an overall coordination for all these government dollars?
    • Contracts with LMHAs fall under my leadership, one of our goal areas is financial alignment
    • Compared to 2 years ago, we are in a far better place for coordination of behavioral health services
  • Kolkhorst – One of the contractual limitations is that the grants are late & feedback will be hard to gauge next session as programs are just beginning
    • Many LMHA grants have been executed & will have some feedback to share; will ensure we have impact info available to share

 

Mike Maples, Health and Human Services Commission

  • Oversees SSLCs and state hospitals
  • Population is shifting, system is serving fewer civil patients and serving more forensic population
  • This includes patients who are not guilty by reason of insanity and numbers of these patients have risen dramatically; length of stay for these patients is very long
  • In 2017, number able to be served by the system dropped to 7,200, so patients increase and space is decreasing; this leads to the waiting list issue
  • More so than needing beds, an important focus is how beds are used, e.g. space for IDD patients vs. space for not guilty by reason of insanity patients
  • Also struggling with retention and staffing, looking at telemedicine, salary increases to offset contracting, as needed staffing pools, etc.
  • Shares experience with trying to attract new employees, launched campaign efforts to present the facilities as modern medical care & seeing some results from this
  • 34% of patients in state hospital have been there for 1 year+, needs to be addressed
  • Preparing for expansion of resources to be able to present info to legislature next session, partnering with Dell Medical to prepare info; construction is not funded, only preliminary effort
  • Plan is also focusing on patient flow and possible partnerships with the system
  • Part of plan initially was a new 100 bed unit at Rusk & is in procurement, which currently has 40 beds; also included planning for a second 100 bed building which will be part of the next legislative session
  • San Antonio State Hospital is partnering with San Antonio Health Science Center to develop a rebuild of the campus
  • Working with UT Houston for facility adjacent to Harris County Hospital to expand capacity, ~228 beds; needed to enter into lease with Texas Medical Center to negotiate this
  • These initiatives are 328 beds funded already, will be speaking on funding with legislature for additional expansion aspects; have an exceptional item for this, but no solid number yet
  • However, without addressing how beds are used, these new beds will fill very quickly
  • Schwertner – We really need judicial reform, couples with discussion on how to use the beds; need to explore options like intensive respite care, diversions, etc.
  • Schwertner – Will be an ongoing effort for at least 2 more sessions
  • Perry – What are your plans for the Panhandle region?
    • Has been part of the ongoing plan, part of this is getting together with communities and exploring what could be there; have been working with Texas Tech
    • Also examined building a facility in Dallas, the only major city without one & Terrell is the closest
    • Preliminary effort to examine feasibility
  • Perry – Would strongly encourage discussions with community/district, agrees that tech/higher education is a good anchor for these efforts, would also encourage looking at civil commitment resources and possible repurposing of existing resources
    • Point of pre-planning group is to look at what resources are available in the area
  • Watson – Asks Sonja Gaines, regarding work with LMHAs, what role are you playing in system redesign around the state, including at Ash
    • Gaines, HHSC – Worked closely with Maples, explored community services and community bed purchases; looking at all options to ensure proper coverage
    • Maples, HHSC – Discusses collaboration needed to make the most of efficient use of beds existing today & importance of shortening stays, need to work down the 365 day list & could improve wait times dramatically if this is down
    • Also have a large number of patients on misdemeanors, community & hospitals need to work together on these issues
  • Watson – Have been very impressed with what has been done, if we could turn beds over a little more could see significant improvements not only in waits, but also likely in patient care
  • Watson – Asks Gaines after communication efforts and participation in planning, if HHSC has been fully involved
    • Gaines, HHSC – Personally attends or has staff attend planning meetings regularly
  • Watson – Using the specific need to do something with Austin as a catalyst for a full system redesign will give us better results
  • Schwertner – This is not just about building new beds, this is about changing how we care for mental health patients; needs to be rethought at the regional level by interested parties & design regional systems to best affect patient population
  • Schwertner- Will be looking at plans next session on how much the community was engaged, how closely LMHAs were worked with, etc.
  • Kolkhorst – Have often heard from county officials about unfunded mandates and interference, Texas Association of Counties states in 1964 we had 15k beds while we had a much lower overall population, in 2016 we had 3k beds and a much higher overall population, with the accusation that state has abandoned responsibility for mental health care and pushed it to counties
  • Kolkhorst – Wondering what the answer is, have heard there is a new model to avoid institutionalizing patients, but there is another story being told to our constituents
    • Maples, HHSC – There have been evolutions in mental health care since 1964, institutions were largely the only places for these individuals at the time
    • Over time, the view has shifted to look at these facilities as places to recover rather than places to put these individuals away
    • More dollars are being invested in community resources as not everyone needs hospitalization, need to find out where inpatient capacity lies in the system & if it is being applied appropriately
    • Not sure of the right number of beds, likely somewhere between what we have today –
  • Kolkhorst – What do we have today?
    • I have 2,240 funded in operation beds and about 600 community beds, so 3,000 total is about right; but there are also local community resources
    • Have read that we need 1,100 to accommodate need over the next few years
  • Kolkhorst – So this first phase is rebuilding, modernizing, and planning issue; we will get to more capacity in phase 2?
    • Phase 1 had 328 beds paid for in Kerrville, Rusk, and Harris County
  • Kolkhorst – I’m dealing with frustration in the rural areas due to transport time, long time to take local law enforcement resources out of play; severe lack of resources in my counties at least
  • Kolkhorst – there is capacity out there that we could change, I want to encourage us to look at possibly repurposing resources available; unsure which side to believe on this issue
    • Idea is, that even with allocated beds we also try to figure out the need for each community; refers to Gulf Bend numbers to illustrate
  • Kolkhorst – You said we had how many in Gulf Bend and how many on the wait list?
    • 16 beds, 5 on the waitlist
  • Kolkhorst – There are 21 who need services in this large area with a small population, I think there is a way we can do this better
    • Gaines, HHSC – There is more to hospital than just the state hospital, legislature is also funding community beds
    • Last session we had an exceptional item for more community beds & received roughly half of what was asked, beds were allocated to areas with little to no resources
    • Will be asking for more beds in the upcoming session, particularly for those rural areas, doesn’t make sense to build more hospitals in these areas
  • Kolkhorst – My data says we have 42.9 new private psychiatric beds in FY18, so it’s headed in the right direction, but we do need to look at this
    • Continued focus, funding, and attention in this area is good, also understands that we need to look towards local resources available
    • Also important to consider the new generations of medications in changing functionality and quality of life of individuals, also have robust crisis services
    • Not enough, but we are moving in the right direction, $60 million was dedicated to capacity and waitlists & we largely don’t have waitlists today
  • Kolkhorst – Appreciate that, but Gulf Bend has 2 beds, Texana has 2 beds; I look at this as scalable and it can’t make sense to have a practitioner with 2 beds, could be combined
  • Perry – Suggested to some of my counties that they google for available bed space, actually took some patients to Oklahoma recently

 

Initiatives to better understand the causes of maternal mortality and morbidity, including the impact of legislation passed during the first special session of the 85th Legislature. Recommend ways to improve health outcomes for pregnant women and methods to better collect data related to maternal mortality and morbidity

John Hellerstedt, Department of State Health services

  • SB 17 renewed the Maternal Morbidity and Mortality Task Force, allowed us to look closely at these areas
  • Attention was brought to Texas originally due to calculation of maternal mortality rate, e.g. number of mothers who die within 42 days after delivery
  • Calculations driving attention were using pregnancy status as a basis & led to errors, DSHS revamped the method for calculating maternal death rates
  • Gives overview of DSHS process in developing new analysis method, verified 56 deaths in the first 42 days following delivery as a result of new process leading to a much lower rate of maternal mortality
  • DSHS will use the new method for calculating maternal mortality, but CDC will likely continue to use the old method; although, improvements in data collection from death certificates would mean more accurate data is sent to CDC
  • Task Force also found that causes of death were not recorded accurately on death certificates, DSHS tasked with reviewing death certificate accuracy by Rider 36
  • Schwertner – So we can boil this down to our death certificates not being good, identifying pregnant women that died who were not actually pregnant
    • Yes
  • Schwertner – So the study took 147 deaths down to 56
    • Yes, using the enhanced methodology
  • Schwertner – You can call it enhanced, but I would call it correct as it tracks those who were actually pregnant
    • Correct
  • Schwertner – And this is consistent with the CDC?
    • Consistent with the way the CDC calculates, yes
  • Schwertner – So we’re getting better with vital statistics?
    • We know we need to do better & some things are being put into place
  • Schwertner – Can you hit the high points on causes of death
    • Looked at 7 days after delivery, 42 days after delivery, and 365 days after delivery
    • 7 days was primarily inpatient care, 20% of deaths were found to occur in this time period, Texas AIM is targeting causes like hemorrhage that present in this period
    • Opioid use AIM bundle will be unique and have inpatient and outpatient elements
    • Hope to follow up with bundle on hypertension
  • Schwertner – So causes of death include hemorrhage, emboli, etc., and then after 7 days there is a somewhat different death profile & we are also doing work to ensure causes of death are being accurately reported
  • Kolkhorst – We made this bill a lot better during special session and digging into the bundles
  • Kolkhorst – The erroneous study really brought a spotlight to this, but grateful as it made us focus; we’re doing better, but can still do better & hospitals are doing a great job with the bundles
  • Kolkhorst – Regarding causes, it looks like much of it is opioids, some of it is sedative, look forward to hearing information on this portion

 

Lisa Hollier, Maternal Mortality and Morbidity Task Force

  • Basis of Task Force finding are from the initial reviews of 89 deaths in 2012 & also the DSHS analysis of multiple years
  • New components of 2018 report were driven by legislative requirements
  • Of 89 cases reviewed by Task Force, 34 were determined to be pregnancy-related, Task Force also identified contributing factors ranging from underlying medical conditions, delays in diagnosis, poor coordination, etc.
  • Average of 5.2 contributing factors in each death, not one single cause
  • For each cause of death, the majority are preventable; underscores importance of safety bundle and efforts by agency to reduce maternal hemorrhage
  • Many finding are similar to 2016 report, including increase incident of death among black women
  • Recommendations
    • Increase access to services in year after delivery
    • Screening and appropriate referrals leading to proper assessment of risk
    • Better communication/care coordination throughout treatment
    • Safety and reliability of care, continued need to identify solutions to leading cause of death – cardiovascular conditions
    • Comprehensive and individualized postpartum planning
    • Increase awareness in high risk population and community as a whole
    • Encourage strategies to improve review from Task Force
  • Schwertner – Article that came out identified an extremely high rate, is the accurate rate of 14.6/100k similar to other states?
    • In our best estimate it puts us in the middle of the pack, but unsure of data analysis methods from other states
  • Schwertner – so 40% of maternal deaths studied were related to pregnancy, the rest primarily being suicide, homicide, and drug abuse?
    • Correct
  • Watson – You recommend increasing access to health services, how?
    • There are a number of different ways, one is Healthy Texas Women program giving us an opportunity to address high risk conditions
    • Other opportunities may come up, e.g. legislation was introduced last session to increase time period for benefits
  • Watson – Can you identify best practices you looked at from other states
    • One of these was the AIM safety bundles, California saw a 20% reduction in severe morbidity due to hemorrhage in implementing hemorrhage bundle
  • Watson – Are we looking at any alternative protocols with pain management and how we determine pain? Have heard of efforts at Dell Medical
    • Hellerstedt, DSHS – Opioid dependency bundle is just getting started, it is different as it incorporates outpatient care as well
    • Dell Medical work was very good, maintained patient satisfaction & these efforts are contributing to ours
  • Watson – Does Texas AIM address specific issues with providers, facilities, etc.?
    • AIM bundles have been developed at a national level, we are providing hospitals and staff tools to implement these bundles; they will be tracking their own data and improving quality
  • Watson – Our state C-Section rate is higher than national average, will this be addressed in the bundles?
    • Hollier – C-Section is associated with higher risk, there is a bundle for reducing the C-Section delivery rate, but we are first focusing on hemorrhage, hypertension, and opioid bundles
  • Watson – Will there be a time we try to address things like C-Sections?
    • Hellerstedt, DSHS – Would think that as we move forward we will use data to drive were resources are allocated, after current bundles we will look to others
  • Watson – What do you see as the time frame?
    • Our look into confirmed deaths goes all the way up to 2015, Task Force just completed review of 2012
  • Watson – What do you see us doing in processing this information?
    • Experience with Texas AIM will inform our future approach to improvements
  • Watson – Trying to figure out when you will come back and present results and next recommendations
    • Will certain have data to offer in the next biennium over hemorrhage, and hopefully will have data to share with opioids; much will depend on resources we have
  • Watson – Regarding AIM plus, do you know why some facilities aren’t willing to do the plus?
    • May be that smaller facilities cannot spare the time/resources, one of our exceptional items is to offer hospitals stipends to implement
  • Watson – We were talking about the bulk of the causes being 61+ days, and you recommend extending benefits; were you able to identify whether women who died had health care coverage?
    • Hollier – We were able to identify coverage at delivery, majority of deaths occurred for women in Medicaid at the time of delivery
  • Watson – And we don’t have data to show if the women had coverage at the time of death to inform whether this might have impacted these women seeking health care?
    • We do not, though the agency is looking into this; no time frame
  • Kolkhorst – In 2010, early elective deliveries were @~35%, bill was passed and dropped to 22% in 2014 & is associated with positive infant health; important to avoid C-Sections
  • Kolkhorst – Black women across all socioeconomic categories have a higher mortality rate, recalls that Sen. Miles wanted to study this trend; on average, these patients enter care later, have higher rates of obesity, hypertension, etc.
  • Kolkhorst – We have a lot of work to do & we are getting good enough to look at certain regions; next leading causes are marital status, education, and insurance, need to partner with medical communities on outreach and improving access
  • Kolkhorst – Are there any other highlights from the report I missed?
    • I think you covered it well, important to look at medical crossover with social issues
  • V Taylor – If I looked at similar issues for 2013, 2014, etc. would it look similar to the 2012 analysis?
    • Looking at data in terms of preventability, will look very similar year over year; would anticipate it looks similar going forward

 

Lesley French, Health and Human Services Commission

  • Texas has highest birth rate and one of the highest teenage pregnancy rates
  • In working with DSHS, we have found that around 35% of women today are pregnant, but not intending to be pregnant
  • Have also seen increases in obesity, hypertension, diabetes, etc. that contribute to risky pregnancy; important to educate mothers about available care
  • Only 65% access care within first trimester, a crucial time period
  • Better Birth Outcomes Initiative is a workgroup made of multiple agencies that looks at initiatives across the system, approx. 30 different initiatives in maternal health based on discoveries since 2010; one example is changed C-Section policy to require medical reason
  • Also run collaborative with Healthy Texas Moms and Babies, work closely with DSHS and stakeholders
  • Healthy Texas Women has been very successful
  • Also run infant mortality initiatives
  • Have ensured benefits are paid in Medicaid and other services for long-acting reversible contraceptives, have seen increased in usage & data is very promising
  • Have seen an increase in disparity with African American women regarding infant and mother care, partnered with UT Health Northeast to examine access issues in the region

 

Stephanie Stephens, Health and Human Services Commission

  • Both Medicaid and CHIP programs provide coverage for pregnant women, both provide prenatal care, delivery services, and some postpartum care
  • Medicaid also provides substance abuse, mental health, screening services, etc.
  • Recently added coverage for postpartum depression screening, occurs as part of covered child’s medical visit; built around existing CHIP service
  • Have had data sharing arrangement with DSHS since 2015, they provide data on women enrolled of pregnancy age, shared with health plan to provide outreach, i.e. with treatments for pre-term birth
  • HHSC runs a pay for quality program, also looking at how to incorporate AIM bundles into quality program
  • Watson – Only 65% of mothers enter prenatal care in first trimester, do you know what percentage continue receiving care in second and third?
    • French, HHSC – We see an increase in second and third trimester, but first trimester is the best time to address issues
  • Watson – On Medicaid, does HHSC track number of women who use short term Medicaid
    • If by short-term you mean presumptive eligibility, then yes; smaller percentage of pregnant women use this; ~2,700 women
  • Watson – Do you know what percentage of those were eventually granted coverage under Medicaid?
    • Around 1,600; they get coverage during presumptive period and then ~1,680 were determined eligible for Medicaid for pregnant women
  • Watson – Trying to figure out what percentage who are eligible and able to receive benefits are actually enrolled
    • Can look into this and get data to you
  • Watson – You said there was continuation of coverage for maternal depression screenings, but what happens if they are depressed
    • Coverage through Medicaid ends roughly after 60 days, have worked with partners to identify other treatment options @LMHAs or other providers
    • Also an automatic process for transitioning to Healthy Texas Women
  • Watson – As of July 1, 2018 Medicaid covered screenings, but if a woman is determined to be depressed, right now we do not have seamless mechanism to give coverage for depression
    • Not a seamless process within Medicaid, would need to go to another service provider unless eligible for Healthy Texas Women
  • Watson – Then we may have women who are screened and determined to be depressed, but then they fall out of coverage
    • It’s possible
    • French, HHSC – I think the benefit is so new (~2 months) that we don’t have the data yet, mother could be eligible or auto enrolled for other services
  • Watson – Do you have a program to educate providers to make sure we don’t have them fall off?
    • We have been working on this, just released postpartum depression toolkit as a training guide launched with the screening benefit

 

Initiatives intended to improve child safety, Child Protective Services workforce retention, and development of additional capacity in the foster care system. Make additional recommendations to ensure children with high levels of medical or mental health needs receive timely access to services in the least restrictive setting

Kristene Blackstone, Department of Family and Protective Services

  • 85th Expanded community-based care, created 3 day medical exam, provided funds to stabilize children, revamped legal practices, and other efforts; ~90 bills passed regarding CPS last session
  • FTEs efforts allowed stabilization of workforce
  • SB 11 codified the annual capacity needs assessment in the legacy system, highlights differences between licensed capacity and homes sometimes accepting fewer kids that licensed for; assessment helps identify actual capacity and identify needs based on location
  • Latest capacity assessment has been published & distributed
  • Have lost >500 beds since 2016, due to a variety of factors like contract terminations, some providers impose limitations on their own capacity
  • Also saw a 50% reduction in DFPS home & community waiver slots for population aging out & 100% reduction in general residential diversion slots
  • However, have ~300 new slots due to new providers, etc.; providers are hesitant to grow programs due to legislation however
  • 85th also supported capacity through the Intense Plus rate which support intensive needs care, signed first contract with a provider to provide this type of care recently
  • Due to needs of children coming into foster care, sometimes need to sign child-specific contracts; expecting a significant decrease in costs in this area due to several factors
  • Also added a new provision in residential contracts, now requires RTCs to provide longer notice when child needs psychiatric care
  • Have seen an 8% increase in overall foster care capacity from July 2017 to July 2018
  • 3 in 30 initiative has been built out with the SB 11 3-day medical exam, expecting to hit every region this year before law goes into full effect in December
  • House added language to have 3-day exam for children removed for sexual abuse, or who have complex medical issues; though DFPS personnel are not medical professionals & all incoming children are receiving an exam
  • Have seen initial very positive results due to the 3-day exams, catching many difficult conditions and injuries
  • Monetary penalties for GROs and others will go into effect on March 1
  • Family First Prevention Services Act, essentially Title IV(e) for congregate care, but new funds could be used for front end services; also contains provisions related to substance abuse and mental health funding, licensing standards, etc.; cost estimate is underway & expecting to provide an array of options
  • Schwertner – Touch on faith-based partnerships and high acuity children
    • We continue to grow faith-based partnerships, have visited individually with members; these partnerships are very important to support foster placements
    • A portion of children who enter foster care have a high level of need, including emotional disturbances, diabetes, autism, IDD, etc.;
    • Intensive Psychiatric Transition Program provides stabilization services
    • Treatment Foster Care looks to serve children 8-10 years old and provide preventative care
  • Schwertner – What is your overall assessment on where we are and building capacity that Texas needs; the work done last session
    • We have come a long way in knowing who is being served and who is not, have come a long way in providing rate increases that providers need,
  • Schwertner – What percentage of the population is in congregate care that would be affected by family-first legislation?
    • Residential treatment centers do not meet the standard set in FFPSA
  • Schwertner – There is a large number of child specific contracts. A disturbing trend is the increase in out of state psychiatric populations.
    • Have 1,300 in residential treatment and 3,000 in congregate care, some portion would be covered under FFPSA, but longer than that would be
    • We don’t currently have placements that meet standards of FFPSA, could be delayed to 2021 to allow providers to get up to speed
  • Schwertner – Some disturbing trends with children languishing in psychiatric hospitals, out of state placements have grown from 3 to 11 in FY18, state RTCs from 24 to 71, can you explain these?
    • When we are unable to find placements for children we do source out of state placements, in some cases it is locating children with families out of state
    • I do think we will see a change in children going back to RTC
  • Kolkhorst – Do you intend to ask for a waiver from the FFPSA?
    • What’s due by Nov. 6 is whether Texas will take a delay on the start date
    • We are still finishing our analysis of the bill so we can seek guidance
  • Kolkhorst – How many RTCs do we have in the state?
    • Around 70
  • Kolkhorst – and that’s the 1,300 children you referenced?
    • Correct
  • Kolkhorst – How many of those qualify today under the FFPSA?
    • I don’t believe any would as we have it today, Act requires a qualified individual who will determine placement is appropriate & we do not have this currently
  • Kolkhorst – Where are we on capacity for RTCs or congregated care?
    • We have developed new residential treatment capacity in the last year
    • Now we are in a holding pattern to develop new capacity while everyone waits to see how the state moves forward on FFPSA
  • Kolkhorst – You don’t do licensing of new ones, you just oversee it?
    • That is a result of HB 5 which split licensing to HHSC, contract monitoring remained
  • Kolkhorst – How many RTCs are in the pipeline; is there communication between DFPS and HHSC?
    • There is regular communication between the agencies, also community/contractor outreach
  • Kolkhorst – As I understand it, you build it first and get licensed, why?
    • I’m not sure how that came to pass
  • Kolkhorst – This needs to be looked at, you can’t be licensing facilities before they are built
  • Kolkhorst – very difficult in that if you have a poor RTC operator, we don’t close them, just hope they get better; Sen. Schwertner had a harsh nursing home bill & this population is similarly sensitive; if we aren’t ready for FFPSA, a similar 3 strike model should be looked at
  • Schwertner – We had a large push to re-engage faith-based communities, do we track capacity added through that initiative?
    • With these numbers, we can’t track that back to a specific congregation
  • Schwertner – We don’t ask families where they heard of this from?
    • Some placements do, but we can’t tie it to specific events in the community
    • For CPAs who do ask, they do hear that people heard through faith-based entities
  • Watson – If the agency indicated that it wants to delay becoming a part of the FFPSA by Nov 6, that is not an indication that it we will not do that
    • That is correct, merely an indication we will not implement by October 2018; we can pick any time between then and September 2021
  • Watson – What is the process between now and then to get to a decision?
    • We have done a thorough analysis concerning where we are and what needs to happen, many things in the bill we don’t have in place yet
    • We want to figure out what the costs are
  • Watson – So you’re not ready on cost; there is work that needs to be done to get there
  • Watson – Will you bring us things you need the legislature to handle?
    • Yes
  • Rep. Frank – We have increased capacity and investigators, but increasing investigators leads to more removals; one question I’m stuck on is if we lowered the bar for removing kids
    • Family Code lays out reasons for removal and judges lay out reasons for removal; I don’t believe reasons or standards for removal have changed & judicial review has not
  • Rep. Frank – As we put more resources in, we might create bottlenecks; as we move forward we need to look at this as FFPSA focuses on keeping kids in the home
  • Perry – As we ratchet up resources, we will create bottlenecks; need to look at Family Code that does not match our current CPS practice, rural judges in my area have decreased budgets due to increased CPS workload
  • Perry – Need to look at funding next session & it’s time to have an honest discussion about the Family Code

 

David Harmon, Superior Health Plan

  • Gave an update on participation in the STAR Health Program
  • Data shows over 50% completion of Texas health Steps
  • Schwertner – Why is it not 100%?
    • Variety of reasons, mostly that children are not getting in for appointments
    • Encountered difficulties with Arrow where the placement agency did not understand requirements; Superior also discovered that it needs to improve communication, also tried to work with providers in the area to improve
    • Goal now is to take lessons learned and apply statewide, introducing a $100/visit 3 in 30 incentive to coordinate getting children in for Texas Health Steps & CANS assessment
  • Schwertner – This looks to be an issue going back years, is there a performance metric in your contract with the state?
    • There is in the sense of getting it done, but nothing on the dashboard
  • Schwertner – Has there been any corrective action placed on you?
    • Have not had any so far
  • Pregnant women in STAR Health have the same Medicaid benefit as other STAR members, additionally participate in care management program for women
  • Recently added a communications app to connect with care manager, have seen a lot of excitement and uptake for this
  • Regarding Turning Point program for crisis residential services and preventing placement disruption, program sees significant reductions in readmissions compared to inpatient facilities
  • Turning Port started in Fort Worth, replicated now in San Antonio, Houston, & Abilene with similar results
  • Foster Care Centers of Excellence – required to meet 60 requirements and designed to highlight excellent care centers, developing more around the state
  • Regarding Health Passport, internet-based records to help reduce duplication of services
  • Buckingham – What are some of the different pieces of info on the health passport? Is it everything on the EMR?
    • No, more of a summary, several modules cover factors like recent Health Steps checkup, PCP assigned, Supervisor, etc.
  • Buckingham – So it’s definitely not an EMR?
    • It’s not an EMR
  • Buckingham – Is the hospital obligated to share medical info with the child’s primary care doctor?
    • We ask that they do, but no specific requirement
  • Buckingham – Are you aware of complaints that hospitals are starting to consider medical info proprietary?
    • Have not heard this
  • Buckingham – How often do you update the provider network online?
    • Not my area, can get back to you
  • Buckingham – I’m wondering if some of the reason kids aren’t meeting metrics is that they can’t find a provider
  • Buckingham – Did you want to address the Dallas article saying only 90% of listed psychiatrists were taking new patients
    • We asked for the survey methods & they would not provide this; Superior conducted its own survey with different, better results
    • HHSC also surveys foster parents on access, Superior meets the higher threshold for this
  • Buckingham – So your list doesn’t differentiate between those accepting new patients and not?
    • Providers can decide mix of patients from month-to-month or day-to-day, we have always been able to find providers when we get called by those with need
  • Buckingham – I think some in the articles and other members might disagree, there are doctors who have retired or passed away on the listings; you need to do a better job with this
  • Schwertner – The Centers of Excellence seem to coordinate services for these children, how many do you have?
    • 3 today
  • Schwertner – Are they institutions or individuals?
    • South Texas Center for Pediatric Care in San Antonio, Harris County CPS Clinic, Health Assistance Ministry in Harris County
    • We have had academic programs show interest, TX Tech in Lubbock
  • Schwertner – Do they have a differential reimbursement model?
    • 3 in 30 is geared towards these practices with high volume, gives them up to $100 extra per child where they are coordinating care
  • Watson – Regarding the contract, how are you paid under the terms?
    • Payment is outside of my area of expertise, can get staff in to speak to this
  • Watson – Your materials say by 60 days 10% of children have not seen a doctor for any reason, how many is this?
    • This would be about 150/170 kids

 

Efforts to transfer case management of foster children and families to Single Source Continuum Contractors (SSCCs). Monitor the progress of this transition and make recommendations to ensure the process provides continuity of services for children and families and ongoing community engagement

Kristene Blackstone, Department of Family and Protective Services

  • Community-based care (CBC) focuses on SSCC, SSCC is responsible for various DFPS duties in three tiered stages
  • SB 11 created CBC, currently running in Region 3B in Fort Worth, readiness activities in Region 2 and Region 8
  • RFAs are in work for Amarillo and counties around Bexar
  • Region 3B was renewed effective Sept 2018, allows placements and new options for case management and remedies
  • Timing and process into more extensive management by SSCC is still under discussion
  • Schwertner – 3B is up now, 4 total in the budget, and DFPS has another 4 in the LAR? So 9 regions serving 74% of the children
    • Yes, could be up to 74% depending on the regions
  • Schwertner – And there will be a review commissioned by Texas Tech?
    • Correct, have been evaluating performance over time and will continue to do so as new areas are rolled out
    • Texas Tech is also working on process evaluation of rollout process
    • Also working on study to inform blended rate development and startup cost

 

Wayne Carson, ACH Child & Family Services

  • On improvements being made, Rider 21 shows we are continuing ability to keep children in community, maintain safety, and reduce placement disruption
  • Continuing to be successful in increasing capacity of foster care, showing 31% increase in homes in Region 3B; CBC can maintain this well
  • Also building capacity for higher needs kids, started Professional Home-Based Care to place these children with families with intensive care services integrated into the home
  • Provides sample list of community & gives overview of how community partnerships have improved foster care in the region incl. hospitals, other placement agencies, specialty providers
  • Seeing increased numbers of kids coming into care with higher levels of needs, capacity continually needs to be built
  • Have a 13 bed RTC in Tarrant, ACH opening an additional 16 beds
  • Also focused on sibling group placements, can be difficult for large sibling groups, those with differing levels of needs, or those coming in at different times
  • ACH has developed system improvement tools like data sharing, performance metrics, communications networks, etc.
  • Met with both other recent SSCCs to share lessons learned, hoping to create efficiencies by coordinating work; there are some entities that will be working with multiple SSCCs & important to have data parity
  • Working together to create a common data gateway for SSCCs, ready by Nov 1
  • Also looking to coordinate monitoring and contract oversight

 

Initiatives to strengthen oversight of long-term care facilities to ensure safety and improve quality for residents and clients of these entities

David Kostroun, Health and Human Services Commission

  • Presenting on implementation of HB 2025, HB 2590, & SB 304 related to long-term care
  • HB 2025 – Relating to the regulation of certain long-term care facilities, including facilities that provide care to persons with Alzheimer’s disease or related disorders; authorizing an administrative penalty.
    • Divided into licensure, survey frequency, and training
    • Will allow HHSC to assess admin penalties and take other actions
    • Will result in stronger training reqs for facilities staff caring for residents with Alzheimer’s disease & related conditions
    • Rules should be effective in October
  • HB 2590 – Relating to the administrative penalty, amelioration, and informal dispute resolution processes for providers participating in certain Medicaid waiver programs.
    • Provides for use of amelioration plans in place of admin penalties, essentially allows money that would’ve been lost in penalties to be used to improve care; plans to do so must be approved by HHSC
    • Also provides for alternative dispute resolution
  • SB 304 – Relating to the continuation and functions of the Texas Board of Chiropractic Examiners; authorizing a reduction in fees.
    • Reqs HHSC to revoke license of nurse facility with 3 or more violations related to abuse & neglect
    • Issued 131 strikes since implementation, 103 still active; change of ownership results in new license and eliminates strike cited under previous license
    • HHSC looked into these changes, mostly related to QIPP
    • Have preliminary data showing SB 304 is contributing to decrease in facilities receiving the most severe violations
    • Strike deletions also due to settlements with CMS or through IDR process
  • Perry – I think nursing homes see the common sense you’re trying to employ

 

Abortion complications and other reporting legislation that was passed by the 85th Legislature

David Kostroun, Health and Human Services Commission

  • Three bills: SB 8, HB 13, and HB 215
    • SB 8 – Requires dignified disposition of embryonic fetal remains, requires reporting of abortions performed and of certain tissues donations
    • HB 13 – Expanded abortion complications reporting to include certain facilities and practitioners
    • HB 215 – Expanded reporting requirements for abortions performed on minors
  • Rules passed for SB 8 in February 2018, currently enjoined in Women’s Health v. Smith
  • Rules to update definition & expanded reporting were adopted in May, reporting requirements for donations are expected at the end of September 2018
  • General rules for HB 13 were adopted in May 2018, in effect currently; currently adding same requirements to rulesets for each provider type
  • HB 215 rules were adopted in May 2018

 

Calvin Green, Health and Human Services Commission

  • Presenting on assumption of abortion reporting duties previously at DSHS & development of electronic system, assumed responsibilities on June 1, 2018
  • Tried to do as little as possible to disrupt reporting functions, modified forms to meet new requirements & these went out in June
  • Electronic system development has been worked on with all partners, will ensure efficient reporting and access from providers and HHSC
  • Identified basic system reqs needed regarding ensuring security of info, ability to confirm reporting info/accuracy information, & ability to monitor in accordance with deadlines
  • Schwertner – Concern first is that it is complete, accurate, and secure; also easy for individuals to report; always worry that transition from paper to electronic reports causes frustrations
  • Schwertner – How are you reaching out to providers and practitioners?
    • Trying to communicate through paths they are used to & work through DSHS distribution lists, etc.
  • Schwertner – Are Texas Association of OBGYNs, Texas Association of Hospitals, etc. participating in spreading the word?
    • Not yet, we have not built out the systems for them to be able to know what they would be looking at
  • Schwertner – If we put a significant reporting obligation on providers, important to have a way for them to easily report

 

General Counsel Division, Attorney General’s Office

  • Update on SB 8 legislation re: disposition of fetal remains
    • Challenged as undue burden on woman’s access to abortion, federal district court has enjoined enactment of these laws
    • Appealed to 5th Circuit with a high degree of confidence that they will uphold this law
  • HB 13 requires certain practitioners to report complications, legislature may want to consider two main areas to build on this legislation
  • Likely that complications are underreported, e.g. when patients do not return for treatment or do not inform the practitioner after a complication, follow up treatment has no reporting requirement under HB 13
  • Schwertner – So if a patient presents with uterine sepsis at emergency provider & is diagnosed as such, not a complication, there’s no mandate on the ER or facility to report?
    • Correct
  • Schwertner – If it is retained placental material, would be pretty difficult to say its not an abortion complication & this would need to be reported
    • Probably so
  • Schwertner – And hemorrhage would be a grey area as well, patient would have to disclose or have the complication be obvious
    • Correct
  • Adopting a requirement for practitioner to follow up after the procedure to ensure no complications have arisen and require reporting would protect health of patient
  • Could also looking at strengthening reporting requirements itself, info is confidential and not subject to PIRs, can be released for statistical purposes if data is de-identified; without possible release of info patients cannot determine if a particular provider has history of abortion complications, could also aid in enforcement
  • Legislature may also want to consider concurrent jurisdiction to enforce criminal abortion laws, AG’s Office currently does not have statewide jurisdiction
  • Lack of statewide jurisdiction can lead to unbalanced enforcement of laws across the state

 

Discussion of issues affecting rural hospitals

  • Schwertner – Rural hospital struggling have attempted to increase revenues with untested business practices, plans are withholding payments due to these methods; can cause hospitals to close, even with temporary hold of payments & has impact on rural community

 

John Henderson, Texas Organization of Rural & Community Hospitals

  • Recent trend in rural hospitals is to partner with outside lab services and marketing and bill through the hospital, billing through hospitals often results in higher payment rates
  • TORCH does not have a position on these agreements
  • Texas is #1 two statistics you do not want to lead in: percent of uninsured patients and hospital closures
  • Lab management is a national issue, have seen a trend of private lab management firms reaching out to struggling hospitals, can introduce revenue stream for hospital; lab work can be done in the hospital or out of the hospital, occasionally samples never enter the hospital
  • Hospital rates are typically higher than what insurance would typically pay to outside non-hospital labs, some insurance companies are now declining to pay these rates, though nothing prohibits these agreements
  • Some insurance companies and some hospitals are now in a dispute over payments, insurance carriers contend they are overcharge and hospitals contend that the arrangements are within the bounds of the contract
  • Agreements are not illegal or fraudulent, health plans are addressing issue in new contracts, but existing contracts are still in place
  • Perry – Aware of what brought us to this discussion, don’t want to hear if contractual rates are bad or good
  • Perry – Want to make sure committee is aware of the way MCOs and insurance have responded and the remedies available
  • Perry – Want to ensure that when contracting disputes come up, you don’t starve out your contractors, that new terms aren’t drafted just be because an entity has more lawyers available, that settlements discussion is not ongoing for 6+ months after one is announced
  • Perry – Don’t want to hear that some are offended to have to come to the legislature to talk about these issues; legislature writes the checks & shouldn’t put people out of business by dealing unfairly
  • Perry – Have seen MCO scope used as a veiled threat to entice providers to renegotiate under unfair terms; e.g. that providers will not get paid or get business without negotiations, that there would be no health care provided
  • Perry – But, if things are not getting paid anyways, I’m not sure there is a loss to the state; don’t want to get into legal discussion as it’s not our purview, but want to focus on timeline, how contract are paid, etc.

 

Kelly Dawson, Knox County Hospital District

  • Hospital have expanded laboratory capabilities within the parameters of the contract and code
  • Described timeline of the issue
    • May of 2017 all payments ceased – Knox attempted communication that was not returned from Blue Cross
    • October 2017 received notification that payment was forthcoming from blue cross
    • December 2017 still had not received additional information
    • Filed with TDI in late December
    • January 2018 heard that Knox is under pre-payment review by Blue Cross and all payments are being withheld
  • Knox has not yet received payment
  • Have been told by TDI that Knox is committing fraud – without minimal due-diligence
    • Have worked through the issue with Blue Cross – but they want a contract that is more favorable to them
    • Submitted 20% reduction on the contract
  • We are leading in hospital closures – there needs to be a mechanism and enforcement from TDI

 

Jamie Dudensing, Texas Association of Health Plans

  • Related to commercial contracts – if it was happening in the Medicaid program it would be considered as fraud
  • Concerned with revenue generating schemes in healthcare that are driving up costs
  • Same type of scheme has been a growing type of problem
  • Remote billing is controversial and legally murky
  • There is usually an aspect of nontransparent billing that make it difficult to see what service were actually provided
  • The duty of health insurance companies is to protect their customers from fraudulent billing and fraudulent practices
  • It is likely that many of these practices are fraud
  • There is concern about other rural hospitals being approached with same type of schemes
    • The risk is associated with high paying contracts to keep rural hospital afloat

 

Lee Spangler, Blue Cross Blue Shield of Texas

  • Described Blue Cross Blue Shield
  • Became aware of the situation through members
  • 318 members and counting contacted about services that were run through hospital lab services that they were unaware
    • The initial concern was identity fraud
  • Received complaints from patients that they had never stepped in the reported facility
  • The problem is that middlemen have emerged to sell contract rates
  • Continue to and have paid for services that were provided by rural hospitals to BCBS members
    • Total charges have reached $40 million
    • $35 million in one month for urine testing
  • Have been in contact with the hospitals and their council regarding this contract dispute, requires a mediator
  • Unnecessary friction has been created

 

Questions to the panel

  • Kolkhorst – testimony is that middlemen go directly to a hospital to contract a higher rate lab work, do they even do the lab work at the rural hospital?
    • Spangler – there is controversy and fact issues around that
  • Kolkhorst – cannot stand the profiteering in healthcare, who thinks that this is a good practice – think that that is literal fraud. Need to find a regional approach to hospitals. Not defending health insurance plans, but we should pass a bill that says hospitals cannot sign contracts like this. It is not right to be running labs in an area that the patient is not at
  • Perry – agree. They have conflicting information – did Knox get paid on every clean claim?
    • Dawson – No
  • Perry – Not going to have the time to determine who is lying and who is not
  • Perry – I knew this was not an MCO, not sure why you are at the table; that said, MCOs have a way of finding ways to make things feel better
  • Perry – When we talk about insurance and TDI, there is clarity we expect; not sure why a mediator has not been selected yet, but if that it what we are waiting on that’s fine
  • Perry – My hospitals are saying that are not getting paid on clean claims, hospitals will close without these payments
  • Perry – Fraud is a large issue, infers intentional action & I don‘t think hospitals were defrauding insurance
  • Perry – Important to get TDI involved, can even be to the favor of insurance companies
  • Buckingham – Difficult time, unfortunate that we are seeing profiteering in health care
  • Buckingham – Under these tax arrangements, does the patient or provider have choice of labs, or is the choice dictated by the management company
    • Dawson – Metro hospitals are engaged in the same practice, they refer samples out and make money; when rural hospitals turn a profit, they get a target on their back
    • There are arrangements between the hospital and all of their vendors
  • Buckingham – On the insurance side, do the patients have any decision-making power on where labs go?
    • Spangler – Patients can have discussion with providers and determine basically where the labs go
    • Contracts have reference lab provisions occasionally, but no hospital services
    • It is our belief that these tests are directed by medical marketers in fashion that best suits them
    • Hospital labs can provide hospital services patients, contention in these cases is that these are hospital services contracts and not reference lab services
  • Buckingham – And the doctor does not have an idea where labs go in reference lab situations?
    • Spangler – That is roughly the case
  • Buckingham – Seemed like in the past when doctors could direct labs that prices were cheaper & prices rose when we started regulating
  • Buckingham – My concern is that hospitals suffer, patients ultimately get the bill; Are there any disclosure requirements regarding affiliations with outside labs?
    • Spangler – No, this is part of consternation
  •  Buckingham – How do existing federal laws apply to these management companies?
    • Spangler – It is Blue Cross’ understanding that these companies avoid Medicare/Medicaid/federal claims so they can avoid solicitation or kickback provisions
  • Buckingham – Are those exceptions pretty much rural hospitals carved out?
    • Spangler – Rural hospital have an exception to the Shell Lab Rule, but that does not exempt labs from false claim provisions
    • They are allowed to bill in ways other facilities aren’t, but cannot make false claims
  • Buckingham – Texas can’t be the only state this happens in
    • Spangler – No, it is nationwide
  • Buckingham – What are other states doing?
    • Spangler – Missouri has had auditors go through and determine if payments are appropriate, there is a federal investigation in Missouri now
  • Buckingham – Are they talking about lab benefit managers?
    • Spangler – Not aware that this is an option
  • Kolkhorst – It was said that if rural hospitals do this, they get targeted, but nothing happens to urban hospitals; can someone clarify?
    • Dawson – Labs are tested across the same way across the country, hospitals like St David’s have hospital contracts and labs with capabilities
    • Hospital contracts have the exact same payment structure, these urban hospitals can make the exact same money and claim as Knox does, but Knox historically has not made this money
  • Kolkhorst – How long have you had a middle marketer?
    • Dawson – I believe 2-3 years
  • Kolkhorst – So fairly new practice
  • Kolkhorst – So we have these deals where labs are moved around and can make a profit; we can all agree rural hospitals need to survive, but I think we can all agree this is not a best practice, should be asking what we can do to save rural hospitals
  • Kolkhorst – I’m hearing this doesn’t apply to Medicaid and Medicare, only applies to private insurance payments, so this is on very shaky ground for me
  • Schwertner – The exact same thing happens in reverse too, e.g. Insurance company A can buy the contract/fee schedule, etc. from Insurance company B to be able to pay a practitioner contracted with Insurance company B to avoid having to pay out-of-network; entire networks can be sold
    • Spangler – SB 822 prohibited the resale of physician contracts, Blue Cross testified in favor of this bill
  • Buckingham – This also touches on who employs physicians, concerned over someone being able to direct physicians to order tests
  • Schwertner – The further away you get a provider from the person paying for it, the more difficult it gets
  • Kolkhorst – I think we need to say “buyer beware” right now to rural hospitals, though I think what we are hearing is that our rural hospitals need assistance
  • Perry – I’m not angry with either side, but disappointed that it is a year and a half later without resolution; in terms of TDI, we need to guard against processes used as a battering ram
  • Perry – Communication broke down somewhere to clarify if contracts require mediation, which all of these contracts do
    • Dawson – There is an ADR provision, but prompt payment statute provides that TDI is original jurisdiction & this cannot be contracted out of
  • Perry – So mediation would be at TDI level? Or TDI could hire the mediator?
    • Dawson – We have both options, hospitals can go to TDI
  • Perry – So there is a dispute on who does it, but it is a part of the contract
  • Rep. Frank – Ultimately there is a question of whether Knox has followed the contract; they appear to have and Blue Cross seems to have done virtually none of what they said they would do, virtually none of the response has come from Blue Cross
  • Perry – We have a statute that we are supposed to provide cost reimbursement to help rural hospitals cover operating costs, around $40 million was put in & we need to support these

 

David Kostroun, Health and Human Services Commission

  • Hospitals must abide by established standards and ensure patient safety in delivery of services, HHSC issues licenses and has oversight, clinical labs must adhere to Clinical Laboratory Improvement Amendments (CLIA) & HHSC works with CMS on these
  • Labs must be certified before they can accept human samples
  • Schwertner – Regarding reference labs, does these need additional registration or certification?
    • Would need to check on this, does not fall under certificates under CLIA
    • Jamie Walker, TDI – I have no personal knowledge of this
  • Schwertner – This whole issue hinges on how samples can be referenced out to another facility, was wondering if there was a regulatory certification and obviously there is not

 

Jamie Walker, Texas Department of Insurance

  • TDI does not regulate self-funded employer plans or Medicaid/Medicare plans
  • TDI estimates fully insured plans are approx. 17% of market
  • Regarding prompt pay, insurers must determine if claims are subject to prompt pay framework and if it is a clean claim; one of the issues that can ran against this is address not matching were services are provided
  • If a submitted claim meets requirements, carrier must pay, deny, or audit; if a claim is audited then the carrier is required to pay full amount & may recoup any overpayments after audit
  • Penalties for not paying clean claims begin to accrue after 30 or 45 days, depending on method
  • TDI will enforce when we receive evidence that clean claim was submitted and not paid according to framework
  • There is a duty to report for reasonable suspicion of fraud within 30 days of discovery, info obtained by TDI is confidential
  • Perry – Under the contract, if there is a dispute over the claim, if you audit you still pay the contracted rate and then argue about the difference?
    • If it is subject to the framework and if its clean, then yes
    • Key question for Knox seems to be “is it a covered service under the contract?”
  • Perry – So if it is not within confines of contract, there is no prompt pay requirement?
    • Correct
  • Perry – Even on those rates that were agreed, all claims then become subject to being nonpaid
    • If it is covered under the contract and clean, then it is paid, denied, or audited
  • Perry – But the insurance company can withhold all payments?
    • If they are related to the noncovered claim
  • Perry – So say you have a $100 rate agreed upon that is now coming in at $120 due to reference lab issues, so the insurer could withhold payment of the full $120 if the payment is outside the bounds of the $100 agreed rate?
    • If it is covered under the contract, I don’t have access to the contract
  • Perry – So the $100 is covered and the $20 would have been outside and under dispute? Insurance is taking the position that the $120 is not paid
    • My understanding is that the dispute is if lab services are covered under the contract or not
  • Schwertner – Who determines covered services? Do you have authority
    • That would be a contract dispute, would need to comply with contract provisions to resolve
  • Schwertner – If there is a dispute over what is covered or not, is an insurance company able to implement an all claims payment hold because of dispute over covered or not
    • If the contract has very clearly covered services, those are subject to prompt pay
  • Schwertner – So if these are considered covered and its clean, then it should be adjudicated within 30 or 45 days or audited?
    • Yes, and if not then penalties accrue
  • Schwertner – Asks other TDI staff

 

Kyson Johnson, Texas Department of Insurance

  • We receive 14,000 reports of fraud per year and have 400 open cases, TDI takes every report seriously and evaluates each case individually
  • TDI requests evidence when we believe elements are met & investigates
  • Schwertner – How do you separate contract issues from fraud?
    • No it needs to be clearly fraud, material misrepresentation under the Penal Code
    • TDI looks at claim & evidence, then looks to see if resources need to be devoted
  • Schwertner – When there is a disputed service and claim is clean otherwise, if an insurance company disputes covered status, what do you do?
    • Walker, TDI – We indicate that this is a contractual dispute
  • Schwertner – So you can pay, deny, audit, or it’s a contractual dispute?
    • Walker, TDI – Statute sets out prompt pay is with a contracted provider
    • Most of the claims we get in are denied because it’s a non-covered service
  • Perry – Is there a maximum time in which something has to get resolved due to an audit
    • Walker, TDI – Yes, 180 days from when a clean claim was received
  • Perry – Can you say whether this is a fraud element today, is there an ongoing investigation with these mid-level guys around the state?
    • Johnson, TDI – Can’t answer that