Hundreds of Delawareans may lose mental health care because of Medicaid insurance problems

Every day, patients in the Wilmington area and beyond visit YOUr Center in Penny Hill. The practice offers behavioral health and substance abuse counseling, psychiatric services and medication management for people of all ages.

Many of the practice’s patients rely on Medicaid to pay for their treatment, with about 400 of them using AmeriHealth Caritas as their primary insurance provider.

But after nearly a year's worth of issues with reimbursements and a grueling audit process, the center is planning to cut ties with the provider – meaning many patients will no longer be able to afford treatment at YOUr Center.

“I don't want to disrupt anything else for (the patients’) lives, but we can't keep up like this,” said YOUr Center co-owner and psychiatric nurse practitioner LaKeetra Josey.

Josey said the issues with AmeriHealth Caritas began in January.

The insurance provider notified Josey they were conducting a “provider integrity” audit of the center. The audit – which can be conducted by the company regardless of whether a complaint has been filed – wasn’t an issue in and of itself, Josey said.

It was the lack of transparency – and over $47,000 in missing reimbursements – that Josey said has left her without any other options.

AmeriHealth Caritas Delaware acknowledged in a written statement that they “are having discussions with YOUr Center to address certain contractual issues.”

“We are hopeful that we can successfully address those issues and believe they are best handled in a confidential manner directly with our provider,” the insurance company said.

Lawyers for AmeriHealth and YOUr Center are in contact, Josey said, but so far no solution has been reached.

A lack of reimbursements

YOUr Center had never had major issues with AmeriHealth Caritas in the past. The reimbursement process was straightforward: see a patient, submit a claim and receive the money to pay the clinician.

There was the occasional mix-up or rejected claim that needed to be resubmitted, but most of the owed money made its way to the correct paycheck.

In the last cycle, YOUr Center submitted 116 claims to AmeriHealth Caritas for reimbursements, Josey said. Only six were approved.

When Josey asked for a peer-to-peer review to determine why the claims were denied, the insurance company declined, stating that they were not denied because of medical eligibility but providing no other explanation.

Josey said some of the confusion appeared to come from the fact that many of the claims are submitted under the name of her husband, as he oversees many of the other practitioners. But even after trying to explain this to the insurance company, reimbursements were still withheld, Josey said.

As part of the audit, YOUr Center has been required to send paper copies of patient medical records to AmeriHealth Caritas. Josey said this not only presents an opportunity for invasion of privacy, but it also requires the center’s administrative team to spend hours every week printing out and mailing the information.

AmeriHealth employees have also contacted patients over the phone or in person to ask about their treatment, prompting concerned calls to YOUr Center. For some patients, seemingly random contact from the insurance company exacerbated mental health symptoms, amplifying paranoia and dredging up trauma.

It’s an impact that Josey said could have been avoided if she’d been able to explain the situation – that the insurance provider is within its rights to ask patients about their treatment and would be doing so – to patients beforehand.

Josey tried to raise these issues to AmeriHealth, but said emails and calls to AmeriHealth have gone unanswered or gotten passed around for months. None of her requests to schedule meetings to discuss the problems have been fulfilled.

“It’s extremely frustrating,” Josey said.

Seeking support

YOUr Center’s ongoing issues with AmeriHealth Caritas are not the only problems that Delaware health providers have had with insurance companies this year.

In April, nurse practitioners banded together to demand full reimbursements from Medicaid provider Highmark Health Options after the insurance company began reimbursing nurses at 15% less than doctors for the same services.

HIGHMARK: Nurses say they were never told Medicaid reimbursements went down. Now they want answers

Lt. Gov. Bethany Hall-Long, who chairs the state’s Behavioral Health Consortium, was a major proponent in supporting the crusade for equal reimbursements, which eventually led to Highmark reversing their decision.

Hall-Long has recently been made aware of the issues YOUr Center is facing with AmeriHealth Caritas, a spokesperson said, and she and her office “will stay in communication with the center as (they) explore it.”

“The lieutenant governor believes access to mental health care and breaking down barriers to that care is critical,” the spokesperson said.

The Delaware Department of Health and Human Services learned of the difficulties YOUr Center is facing on Aug. 31, a spokesperson said. The Division of Medicaid and Medical Assistance has since contacted AmeriHealth Caritas to ensure patients will still be covered at YOUr Center for the rest of the year.

The division will not be taking further actions, the spokesperson said. He stated that because this is an issue between a provider and the company, it is “not appropriate” for the state to intervene.

DHSS said it has not received any other complaints from contracted providers related to AmeriHealth Caritas.

However, Josey said other local providers told her they have had to stop accepting insurance entirely because of similar issues.

Serving vulnerable populations

A core part of YOUr Center’s mission is helping some of the most vulnerable – and traditionally underserved – members of the community.

The diversity of the center’s staff reflects the make-up of the demographic they serve, Josey explained. The majority of YOUr Center’s patients are people of color, and Josey said many come to the center “because they appreciate having the opportunity to see clinicians that look like them.”

Many of the roughly 50 clinicians on staff also do community outreach, hosting mobile outpatient therapy for children and adolescents and “seeing (patients) in places where they need the help.”

It’s a service that, even while waiting on thousands of dollars of reimbursements, YOUr Center’s staff continues to provide.

But as the center notified patients on Sept. 1, unless something changes, people relying on AmeriHealth Caritas to pay for treatment will need to find care somewhere else.

“We want to continue to do what we can for our community,” Josey said, “but I can't expect my clinicians to continue to see people and not get paid.”

Send story tips or ideas to Hannah Edelman at hedelman@delawareonline.com. For more reporting, follow them on Twitter at @h_edelman.

This article originally appeared on Delaware News Journal: Mental health center may drop Medicaid provider over reimbursements