NC Medicaid providers say they're owed big bucks while children go without care

One year into a multibillion-dollar overhaul of North Carolina’s Medicaid program, providers complain that billing delays from insurance companies that manage claims are leaving patients without full treatment and the providers with financial problems.

Providers who’ve reached out to the state’s help line to complain describe the transition as a debacle. Some fear losing their businesses as late payments stretch into six figures.

“I’m losing sleep wondering if I am going to be able to make payroll,” Sharon Jordan, the chief executive of a Charlotte speech therapy company, said in an email to the state ombudsman charged with troubleshooting problems.

“I’m so tired,” Jordan wrote in a June email released through the state open records act. “I’m so depleted. I am tired of fighting. If this is what the state of North Carolina intends to happen with this change, then you’ve won.”

The state’s top Medicaid official and a spokesman for the five insurance companies that manage the plans acknowledge problems, and companies that pay late must pay penalties and interest. The department last week said it couldn’t immediately tally those amounts, which go to the providers.

But DHHS and the companies themselves say they’re generally pleased with how the program’s going, considering they’ve shifted more than 1.7 million people from a single, state-run Medicaid program to five new ones overseen by private insurers. This new managed Medicaid system has handled 17.2 million medical claims in a year, with 14 million paid and 3.2 million denied, according to DHHS. The average processing time is 12.8 days, the department said.

“Overall it’s going relatively well,” said Dave Richard, DHHS’ deputy secretary for Medicaid.

“I know that a couple of those providers that have gone through that process have really been hurt financially,” Richard said. “That’s unacceptable. We need to work through these quicker. We need to make sure that people are getting paid.”

When the state laid out its Medicaid transformation plan, it created a help desk to help walk providers through a newly complex billing system. It also created an ombudsman to handle the most persistent problems.

That ombudsman received 439 calls or emails in June—the second highest monthly total since the program went online in June of 2021, according to DHHS numbers.

Transformation is meant to check escalating costs for the state’s Medicaid program, which provides health insurance to more than 2.8 million people, mostly children, senior citizens and people with disabilities. The program’s annual budget is slightly more than $18 billion, most of which is federal money.

Medicaid reform contracts give $6B a year to five companies

In past years Medicaid spending ballooned unexpectedly, blowing holes in the annual state budget. That led the Republican-led General Assembly to pass transformation, which Gov. Roy Cooper’s administration implemented, picking five insurance companies to manage most claims.

Those insurers—United Healthcare, WellCare, Carolina Complete Health, AmeriHealth Caritas and Healthy Blue, which is part of Blue Cross and Blue Shield—get paid a per-person fee, and it’s up to them to keep health care costs beneath what they’re paid.

With that change came five new ways to bill insurance plans, plus a sixth one for Medicaid patients still in the state’s old program. Providers now dealing with multiple companies describe varying degrees of rigamarole, shifting rules and massive amounts of wasted time as they deal with some combination of the insurers.

Each company is doing different things, according to Jordan, the speech therapy CEO. One week they pay, the next week the same procedure is denied and, “it’s not as easy as picking up the phone,” she said.

“It’s just ridiculous,” said Emma Bentham, a Fayetteville audiologist who said she never had a problem getting hearing aids cleared for children until transformation.

“Kids need these,” Bentham said. “There have literally been children that have gone a whole year now without hearing aids.”

Some providers believe insurers are purposefully denying or delaying claims to save money. That was always a concern for critics of Medicaid transformation: That there’s a profit motive to deny coverage for some of the state’s most vulnerable people.

Peter Daniel, executive director of the North Carolina Association of Health Plans, said that’s not what’s happening. The industry group represents the insurance plans running Medicaid managed care in North Carolina.

Daniel said communication problems, exacerbated by having to hire and train call center workers during the pandemic, are to blame.

“This is a glitch in the system of escalating issues,” he said. “It is not the companies trying to slow-walk providers at all.”

The five insurers have contracts with the state totaling about $6 billion a year, and Richard said the state requires each insurer to spend at least 88% of that money on care. Asked whether the companies have a profit motive to deny claims, Richard said the state “will aggressively review … to make sure that’s not happening.”

Daniel acknowledged that some providers – many of them small businesses – have not been paid. He said the plans “are taking these situations very seriously,” and he predicted rapid improvement.

“You’ll see over the next few weeks a clearing of these flagged claims,” Daniel said in late July. “They’re genuinely trying to get down to what the communications issues are.”

Hospitals have had problems as well. Cynthia Charles, spokeswoman for the North Carolina Healthcare Association, called the bill process “complicated and cumbersome” with “a tremendous amount of administrative burdens put on hospitals.”

Several providers told WRAL News that they saw improvement when the state’s ombudsmen got involved in their case.

“It seemed to push things much faster,” said Jonathan Wilkins, a therapist in Troy.

But Wilkins said his dealings with two of the companies he’s billed was “a nightmare for me as a sole proprietor.”

“Doing my own billing and having to bill these insurance companies that have these clearing houses,” Wilkins said. “And I was getting no communication about whether or not I needed to do something different.”

Corey Peña, who owns Royal Orthotics in Concord, has been fighting insurers for a year. Things improved recently, Peña said, once he went to the media, reached out to state lawmakers and had conversations with Richard, the state’s head of Medicaid.

After that, Peña said United Healthcare and AmeriHealth Caritas both reached out to schedule meetings about his problems. Carolina Complete Health CEO Chris Paterson met with him at the end of July.

“He was very apologetic,” Peña said. “He said, ‘We’re going to make this right.’”

Peña’s company makes leg braces for children, and he said the companies that he bills for Medicaid want “a stack of paperwork” – far more than the state required. Payment delays got so bad that Peña said he was considering selling his house or declaring bankruptcy. In a July email to Sen. Ralph Hise, a leading proponent of transformation when the General Assembly passed it, Peña called the state’s insurance companies “criminal.”

Peña was more upbeat last week. He expected a $69,000 payment soon from Carolina Complete and he had meetings set with other companies. But he remained skeptical. “You hear promises for over a year, you don’t know what to believe,” Peña said.

“I’m still in war mode where I’ve won one battle,” he said. “And now I’ve got to go on to my next battle in this war until I’m done.”