Commonwealth Coordinated Care (CCC) Updates

Anthem HealthKeepers Willing to Contract with Lab Providers other than LabCorp.  As you know, one of the ancillary provider issues that emerged under CCC was Anthem’s exclusive use of LabCorp for lab services.  This caused significant concern among nursing facilities as is was not clear that existing lab services providers would be reimbursed for CCC residents, nor was it entirely clear how efficiently LabCorp could work given their previous business practice of not serving nursing facilities in terms of  phlebotomy.

While this Anthem CCC issue has been mitigated somewhat during the continuity of care period under CCC, Anthem was pleased to inform VHCA last Friday that the HealthKeepers CCC plan will now be able to contract with lab providers other than LabCorp.  Anthem indicated that they are starting to recruit lab providers for their CCC plan and have encouraged nursing facilities to send their current lab provider lists to Amy Brunt, Director, Contract Administration, at  

Medicare Authorization Updates.  As you know, there have been several concerns raised by nursing facilities surrounding MMPs authorizations of Medicare (both Parts A and B).  The Managed Care Ad Hoc Workgroup at VHCA, the Department of Medical Assistance Services (DMAS), and the three Medicare/Medicaid Plans (MMPs) met late last week to discuss these concerns.  

Part A.  Specifically for Part A, we continue to hear of instances where an individual who had already been Medicaid custodial has a hospitalization and is discharged back to a NF with an order for Skilled (Part A), yet the MMP denies Part A but authorizes Medicaid custodial and Part B.  Both hospital staff believes Medicare criteria are met for Skilled (as evidenced by the discharge order) and NF staff believes criteria are met at the first admission assessment, yet the MMP believes Part B is sufficient.  This issue has seemed to be isolated to Anthem Duals Plan (HealthKeepers) according to the feedback we have received.

Because this issue appears to boil down to interpretation of Medicare criteria, we are discussing with DMAS the best way for our members to provide, on a case-by-case basis, information where we disagree with the MMPs assessment that skilled criteria are not met so DMAS can see first-hand what our members are experiencing in the field on this issue.  It is not clear to VHCA that the reporting requirements imposed on the MMPs are reflecting the scope of this issue to DMAS.  We will continue to update you on this issue as it evolves.

Part B.  Regarding Part B authorizations, the loudest complaint we have heard is that the process to authorize therapies is taking too long, and is requiring inordinate amounts of NF staff time to track down the authorization (5+ hours on the phone, for example) – this particular concern seems to be across the three MMPs.  In addition, we had also heard that one MMP, Anthem, is denying Part B therapies provided while the NF is awaiting the authorization, even when the authorization is subsequently approved.  In other words, because the authorizations are talking so long (10-14 business days, according to feedback received) NFs have taken upon themselves to provide the needed services in anticipation of authorization, receive the authorization at some point, yet get denied payment for the services provided prior to the authorization date (even though the MMP agrees that the services were needed, as evidenced by their subsequent authorization).

In our meeting last week, the MMPs all informed us that their processing goal for Part B authorizations is 72 hours.  They reiterated that this was a goal, not a requirement, and that they were dependent on the information submitted by the provider (to that end, DMAS provided an updated MMP contact list:

Anthem indicated that they had a processing issue that was causing delays in their authorization process, but that the issue had been fixed as of January 1.  Further, all three MMPs indicated that the authorization was relevant back to the date of submission, not from the approval date forward.  Obviously, if your experience is different than that articulated by the MMPs, VHCA needs to know.

Miscellaneous.  Finally, there were a couple authorization issues causing confusion in the field, both related to “third-parties” under contact with Anthem.  First, Anthem is utilizing Orthonet for authorizations of physical therapy, occupational therapy, and spine and back pain procedures.  However, Orthonet is only the authorizing entity for office and outpatient settings other than skilled nursing facilities.  In other words, as of now Orthonet will not be managing any NF or SNF member authorizations for the Anthem MMP.

Also, a few members have experienced some confusion between Caremore and Anthem regarding authorizations.  Caremore is a primary care physician network within the Anthem MMP network.  There was confusion over re-seeking custodial care authorizations from Caremore when such authorizations were already in place from Anthem.  According to Anthem, Medicaid nursing home custodial authorizations do not need to be changed or re-requested from Caremore.  Anthem is and remains responsible for such authorizations.  Anthem is encouraging providers if they are being asked to re-request authorizations to reach out to Amy Brunt (  However, authorizations related to Medicare services will be managed through Caremore as the primary care gatekeeper and the member card references Caremore as the primary care physician.

Enrollment Update.  As of January 10, 2015 according to data provided by DMAS, there are 27,333 CCC participants across the five CCC demonstration regions.  Within the total enrollment figure, 3,769 are categorized as nursing facility participants.  Relative to the currently estimated “CCC eligible” nursing facility population of 9,471, this represents an enrollment rate of approximately 40 percent.  In terms of MMP participation of the nursing facility population, Humana and Anthem have the lion’s share (42 percent and 40 percent, respectively), with VA Premier at 17 percent of the population (numbers do not add to 100 due to rounding).

Since the first set of data was provided to VHCA in October, total enrollment in CCC has declined by just under 8 percent.  Specific to nursing facility CCC enrollees, the decline in enrollment is just over 9 percent.  Based on anecdotal information from the membership and the MMPs, it appears that the “mis-assignment” of primary care physicians and Medicare denials by the MMPs have been the primary factors behind the enrolment decline.