Published by Katie Jennings on www.politicopro.com. 

A state audit released earlier this week found issues with the provider directories of insurers that offer coverage to low-income New Jerseyans through the Medicaid managed care program.

The Division of Medical Assistance and Health Services within the state Department of Human Services is supposed to monitor the provider networks — hospitals, doctors, specialists and dentists — that are available to the 1.6 million residents who receive coverage through NJ FamilyCare.

The insurers each receive a monthly payment per enrollee. In 2015, the state spent $8.1 billion on the managed care program.

“We found the division does not effectively monitor the adequacy of the … provider networks regarding access to care and provider availability,” according to the report from the Office of the State Auditor which examined data from July 1, 2013 to May 31, 2016.

There are five Medicaid managed care organizations in the state — Aetna, Amerigroup, Horizon Blue Cross Blue Shield of New Jersey, UnitedHealthCare and WellCare.

None of the insurers was listed by name in the report.

Per the state contracts, the insurers must satisfy certain requirements related to access to providers. For example, more than 90 percent of enrollees within a county must be within 15 miles or 30 minutes driving time of a general acute care hospital.

Four of the five managed care organizations had incorrectly listed “a total of 41 facilities in 14 counties” as general acute care hospitals.

There was also an issue with access to dental providers, whereby dentists were not actually practicing at the locations listed by the insurers. Of 52 dental providers sampled, who were listed at a combined total of 795 locations, the dentists were only found to be providing care at 64 locations.

Online directories maintained by the insurers were found to have incorrect information. For example, 65 of 251 specialists were not practicing at the locations listed in the online directories and 21 of them did not accept the insurance, according to the audit.

In a response letter, Meghan Davey, director of the division, said the state runs “systematic quality reports … to identify potential inaccuracies” and “conducts stringent reviews.”

Last year, the agency tasked the New Jersey Health Care Quality Institute and New Jersey Association of Health Plans, the insurance trade group, with making recommendations for how to better maintain the directories.

One of the issues, according to the working group, was that the current directories pull misleading credentialing data.

“Certain providers may be credentialed at several different practice locations to ensure reimbursement at all locations even though they rarely practice there and do not schedule visits at those locations,” according to the working group report.

One of the recommendations was for the state to provide “universal credentialing of providers and maintenance of provider data.”

In the letter, Davey wrote the “planning and design” of the state’s universal credential program is “underway.”

Ward Sanders, president of the New Jersey Association of Health Plans, said the insurers “are confident that the new streamlined system for creating provider directories will further enhance the consumer experience.”

Read the audit here: http://politi.co/2jqdCp3