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STOP implementation of TX Medicaid Superior Health Plan proposal for Travis County

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Texas children receiving speech, occupational and physical therapy services Need calls FOR AN IMMEDIATE INJUNCTION BARRING IMPLEMENTATION OF THE SUPERIOR HEALTH PLAN PROPOSAL FOR TRAVIS COUNTY.

WHAT WE HAVE LEARNED: HHSC or HHS as they like to go by now and the state legislature (House) are promoting Value Based Programs. In Medicare language this a program that rewards physicians with better outcomes with increased reimbursement. The Texas House mandated that MCOs to find innovative ways to provide higher levels of care with increased savings and of course some language about increasing beneficiaries access to care. Superior HP the largest Medicaid MCO in the state (not all MCOS are in every region of the state) presented information that stated that SLPs who evaluated and who treat the same patient were more likely to over-utilize a service for monetary gain. Therefore, if the evaluating therapist worked for a utilization management company (the same people who say you can not have a name brand drug you must use a generic or refuse requests for some surgeries because they are experimental or investigative or who give you half the frequency for therapy that you ask for); there would be less utilization. Utilization Partners (UP) is the designated evaluation provider.

PROBLEM 1. UP is licensed by the Texas Department of Insurance to do reviews of medical necessity, et. It is a licensed review agent. This license allows the agent to hire healthcare professionals to review requests for authorization. It is not a healthcare supplier. It is not enrolled in TX Medicaid. It is not recognized by CMS as a supplier of service.

PROBLEM 1. There is no need for a utilization management company to be suppliers of evaluations. Utilizations units whether in house or outsourced can deny anything. They do not need to do the evaluation.

PROBLEM 2. The evaluating therapist will set the POC and will never be able to treat the individual that they evaluated or developed the POC for. The re-evaluation will be completed by a therapist who is also hired or contracted with UP. That therapist would evaluate progress based upon the POC created by the evaluating therapist. So even if say in the use of an OT assistant, the treating therapist will be supervising implementation of POC created by another person.

PROBLEM 3. UP is owned by COFK (Care Options for Kids). The legislators were told that UP and COFK were separate entities. The UP agent answers directly to the owner of COFK (it is on their website).

PROBLEM 4. COFK was selected as the Preferred provider but is not an outpatient provider. It is a Home and Community Based Service Provider (non-Medicare certified licensed only Home and Community Support Service Agency , HCSSA, in Texas). ST is an outpatient service except when under a HH POC or inpatient.

PROBLEM 5. The Texas OIG audit indicated that COFK was the provider that was paid the most for therapy by TX MCOs and paid the third most by FFS. A fantastic batting average for the poster child of lower utilization. PROBLEM 6. COFK is 100% Medicaid. Medicaid recipients are to be treated the same as the general public and therefore, are entitled to to go to outpatient providers enrolled in their Medicaid MCO and have their POC developed by the treating therapists as well as appropriate advocacy. To be treated by a recognized provider not a utilization management company.

PROBLEM 7. In Preferred Provider Agreements approved by HHS, the recipient must have the right to opt out. Evaluations and re-evaluations are healthcare services but the Superior plans does not allow for opting out.

PROBLEM 8. This plan is being considered for roll-out across the state. This is not a Value Based Program, it is fraud in the disguise of cost effectiveness. So what do we do? Some of our members have been in contact with ASHA and TSHA. ASHA has suggested
contacting regulatory agencies. Tomorrow we make calls to the TX House members on the HHSC Committee, to the TX OIG, to CMS, to the TX Medicaid Fraud Unit, to your TX House representative and to your US Congressional Representation, to HHSC. When you make those calls Be a mama bear or papa bear or your best impression of PMS and demand an injunction (member told by one of state therapy association the only avenue), tell whoever you contact who else you have contacted and will contact.

One person who calls is a conspiracy theorist. Two is a conspiracy theorist and their friend but 40 people who call know something. Families (do parents of children or disabled adults want a utilization management company to determine if their child gets therapy--small conflict of interest) affected by this as well as your significant others and your mother and father can call as this is about taxpayer monies.


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