New Panel Eyes Changes To Children's Medical Services

State Department of Health officials Friday hosted the first meeting of a panel aimed at easing Florida's transition to Medicaid managed care for children who need specialized medical services.

They got an earful.

The meeting followed a series of administrative challenges and media reports critical of the state's oversight of the Children's Medical Services program, which serves kids with chronic and serious conditions.

Until August 2014, the program operated as a direct-service provider network, meaning that children received services based on their needs, while their health-care professionals were reimbursed each time.

Since then, however, Children's Medical Services has switched to a managed-care model, which has spending caps --- and thousands of kids lost their eligibility in the process.

After a storm of criticism, the department created what it called the Children's Medical Services Managed Care Plan Technical Advisory Panel, a "team of experts to aid in the continued transition of the Children's Medical Services plan from a direct service provider network to a managed care plan," according to a department news release.

Members of the panel made it clear at their inaugural meeting Friday that the transition had often been difficult.

A particular problem, said Jacksonville-based pediatric specialist Mobeen Rathore, is that insurance plans for families in Children's Medical Services can be "flipped" to other carriers without the parents realizing it. Often they show up at their former pediatricians for previously scheduled appointments.

"The child is there, the mother is there, they've traveled 45 minutes to come and see us," Rathore said. "What do we do? Well, we end up seeing the child. We don't get paid for it, but what do we do?"

Barbara Meeks, the chief nurse executive at Nemours Children's Hospital in Orlando, said the issue also can delay and decrease access to care.

Department officials said they had a "continuity of care" agreement whereby health-care professionals could still be reimbursed for up to 60 days after serving their former Children's Medical Services patients whose managed-care plans had changed.

"The new plan has to honor it," said Children's Medical Services administrator Melissa Vergeson.

Rathore urged department officials to put out a communication to local Children's Medical Services providers to that effect.

"We face this all the time," he said. "If by the end of this meeting, we just do that, you will have many happy providers."

Other challenges, panelists said, ranged from finding providers --- especially those specializing in dental or mental health --- to the turnover of nurse care coordinators.

Carmen Anchorena, whose son Nicolas is enrolled in Children's Medical Services, represents consumers on the Technical Advisory Panel. She said a doctor who had treated her son for years was forced to stop doing so for financial reasons.

After the meeting, department Chief Operating Officer Jennifer Tschetter said the problems the panel identified were readily fixable, including the "continuity of care" for billing purposes.

"Our experience is that health care professionals are very busy caring for children, at least certainly the ones that serve our managed-care plan," Tschetter said.

"And so often, they will have billing offices that take care of those things for them. So this was probably an opportunity for those specialists and professionals today to learn more detail than they've had the luxury to in their own offices, where the waiting room is always full."

But pediatric cardiologist Louis St. Petery, a frequent critic of the department, said that as of Friday, none of the 34 physicians at Tallahassee Primary Care Associates, with which he's affiliated, had received continuity of care payments.

The changes to Children's Medical Services were mandated by the Legislature, which approved a plan in 2011 to shift almost all Medicaid beneficiaries statewide into managed-care plans.

Under the new system, state officials hoped to whittle the Children Medical Services program's rolls down to children with the most serious problems.

But children's advocates contend that the department used a new eligibility-screening tool to deliberately screen kids out of the program and into less-expensive managed-care plans.

In September, an administrative law judge ruled against the department in the matter. The screening process has been suspended, while a rule-making process to approve a new screening tool is underway.

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