In brief: Medicaid managed care, NuFairs, sleep ‘dream team’

WASHINGTON – Some people enrolled in Medicaid managed care may not be receiving all of their medically necessary health care services, according to a new study from the Office of Inspector General. 

There are three key factors causing concern, the OIG says: the high number and rates of denied prior authorization requests; the limited oversight of prior authorization denials in most states; and the limited access to external medical reviews. 

What the OIG found 

Overall, the MCOs in OIG’s review denied one out of every eight requests for the prior authorization of services in 2019. Among the 115 MCOs, 12 had prior authorization denial rates greater than 25%, or twice the overall rate. Despite the high number of denials, most state Medicaid agencies reported that they did not routinely review the appropriateness of a sample of MCO denials of prior authorization requests, and many did not collect and monitor data on these decisions.  

Its review 

The OIG identified and selected seven parent companies of managed care organizations with the largest number of people enrolled in comprehensive, risk-based plans across all states. These companies operated 115 MCOs in 37 states, which enrolled a total of 29.8 million people in 2019. The agency collected data from the selected companies about prior authorization denials and related appeals for each MCO they operated. The OIG also surveyed state Medicaid agency officials from the 37 states to examine selected aspects of state oversight of MCO prior authorization denials and appeals, along with state processes for external medical reviews and fair hearings. 

The OIG noted that CMS's oversight of denials by private health plans is more robust. For example, each year CMS reviews the appropriateness of a sample of prior authorization denials and requires health plans to report data on denials and appeals. Further, Medicare Advantage enrollees have access to automatic, external medical reviews of denials that plans uphold at the first level of appeal. These differences in oversight and access to external medical reviews between the two programs raise concerns about health equity and access to care for Medicaid managed care enrollees. 

Its recommendations 

The OIG recommends that CMS: require states to review the appropriateness of a sample of MCO prior authorization denials regularly; require states to collect data on MCO prior authorization decisions; issue guidance to states on the use of MCO prior authorization data for oversight; require states to implement automatic external medical reviews of upheld MCO prior authorization denials; and work with states on actions to identify and address MCOs that may be issuing inappropriate prior authorization denials. CMS did not indicate whether it concurred with the first four recommendations, but it concurred with the fifth recommendation. 

Numotion offers full slate of educational opportunities  

BRENTWOOD, Tenn. – Numotion has announced an array of updated clinical education events, workshops and courses – both in-person and virtual. These events help further clinician and ATP education on adult and pediatric mobility, medical supplies, health care, insurance, and seating and positioning. “We designed clinical education opportunities that balance the value of offering in-person, hands-on interactive learning and offering a virtual learning experience for those that need it,” said Danielle Mains, Numotion’s director of clinical education. “Our courses and programs are designed specifically for PTs, OTs and ATPs and are relevant to current events in complex rehab technologies. Our commitment to fostering excellence in CRT education has led us to develop these unique and robust educational programs.” The 2023 Numotion Clinical Education opportunities include:  

NuFairs  

In-person events where top industry speakers will provide the education needed to succeed in the provision of CRT. Each NuFair is divided into multiple educational tracks,  allowing attendees to choose their desired track of interest or broaden their horizons into a new area of CRT. To register, go to the NuFair page on Numotion Academy of Mine: https://numotion.aomlms.com/2023-nufairs  

Live webinars 

The Numotion live virtual webinars are scheduled for 60 minutes monthly and focus on current topics within CRT and are presented by top industry speakers from Numotion and leading industry suppliers. All webinars presented are submitted for the following approvals for 0.1 CEU: IACET, AOTA, & Redefine Health Education. Learn more and register for these webinars at numotion.aomlms.com/2023-webinar-schedule  

On-demand education

Numotion offers a wide selection and a growing library of on-demand CEU and free educational courses to be viewed anytime. The courses are specifically focused on CRT for clinicians, OTs & PTs and ATPs, with the ability to view by your preferred discipline. Learn more and see the full list of available courses by clicking On-Demand Courses: numotion.aomlms.com/ceu-page. 

NRRTS seeks board noms 

LUBBOCK, Texas – NRRTS seeks nominations for its board of directors ahead of its annual elections in August. The organization is looking to fill three openings: two directors at large, who are voting members of the board; and one review chair, who is a voting member and who receives all completed NRRTS registrations for approval. Candidates for the latter must reside in Connecticut, Delaware, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island or Vermont.  “NRRTS is in a growing phase at this time,” the organization says. “The registry is growing. The education offerings draw hundreds of people to our website. In the first quarter of 2023, more than 1,600 CEU certificates were awarded.” The board of directors meets every third Monday of the month. From time to time, members may also be asked to volunteer or be assigned to committees or tasks for NRRTS. Send nominations and a brief bio to wwalker@nrrts.org before July 31. 

Star Sleep & Wellness assembles ‘dream team,’ opens five locations  

DALLAS and FORT WORTH, Texas – Star Sleep & Wellness has recently opened five locations throughout the Dallas metroplex, in Dallas, Denton, Frisco, Irving and Plano, to offer comprehensive services to patients. Star Sleep & Wellness CEO Dr. Kent Smith has assembled a "dream team" of sleep specialists, including sleep physicians, a licensed psychologist, nurse practitioners, physician assistants and sleep dentists. "Star Sleep & Wellness is able to not only diagnose sleep disorders through testing but also provide care from start to finish in one office with therapies that range from oral appliances to psychiatric treatment, from CPAPs to weight loss support," he said. "With all our expertise and locations, help with sleep issues is more accessible for everyone." Star Sleep & Wellness estimates about 33% of Texans regularly get insufficient sleep in a 24-hour period, meaning up to one-third of Texan residents may face issues like insomnia, loud snoring, sleep apnea and nocturia every night. Without treatment, these sleep issues can lead to many health problems, including high blood pressure, mental illnesses, and extreme fatigue, as well as drowsy driving and auto accidents, the company says. 

Aeroflow Healthcare hails passage of Texas tax exemption 

ASHEVILLE, N.C. – Aeroflow Healthcare is celebrating the passage of Texas SB 379, legislation that will eliminate tax on numerous care products such as diapers and breast pumps, starting Sept. 1, 2023. Aeroflow Healthcare directly lobbied with the Texas House and Senate on the tax elimination and pushed for adding breast pumps to the exemption, resulting in its inclusion in SB 379. As a result, Texas residents will now be able to obtain the following products, tax free: adult and child diapers, breast pumps, bottles, baby wipes, feminine hygiene products, maternity clothing and wound care dressing. “We are encouraged to see SB 379 pass, yet another reflection of the work our government relations team has conducted to ensure more patients and caregivers can access medically necessary products and resources to live a healthier life,” said Ryan Bullock, COO at Aeroflow Healthcare. “Both Texas and the recent addition of Florida this past May are two significant additions to the growing number of states our team has successfully lobbied in to enact important legislation changes. We look forward to continuing our mission of breaking down legislative barriers that currently block patients from obtaining products and care in other states.” Florida also recently decided to permanently exempt breast pumps, diapers and senior incontinence supplies from the state sales tax.