MIDDLESBORO — Some patients of Middlesboro Appalachian Regional Healthcare (ARH) may have to find a new medical provider in the months to come. CoventryCares, a managed care organization that is also Medicaid provider, will be terminating its contract with ARH effective May 4.
Coventry stated that it refused to re-negotiate the agreement. Coventry made the termination announcement on March 29.
Coventry’s reason for terminating the agreement was due to the Commonwealth of Kentucky’s failure on these issues: failure to implement a risk adjustment methodology, failure to find a solution to the supplemental hospital payment issue and errors in the original data book, and failure to ensure that all MCO’s (managed care organizations) meet the same robust standards for network adequacy, adding that the Commonwealth’s unfair and unequal treatment has significantly disadvantaged Coventry and distorted the movement of higher-risk members to CoventryCares.
The termination of the agreement will affect about 25,000 Medicaid recipients if the issue is not settled. Those affected include obstetrics, pediatrics, and cancer patients.
“A good portion of my pregnant patients are currently covered by CoventryCares,” said Dr. Nathan Mullins, an ARH OB-GYN. “The thing that upsets me the most is it’s really affecting my patients’ care.”
Some patients may be forced to travel close to an hour away for treatment.
“This is a Medicaid population,” said Mullins. “People that are already hurting economically. Now, they are adding the extra cost of travel out-of-town on top of their care. The people that are suffering the most are our patients.”
Mullins stated that patients can apply to switch to WellCare, which is the only one of the MCOs that continue to recognize ARH as a medical provider. Patients can apply for this through a hardship form. According to Mullins, there have been some cases that have been denied that hardship switch.
“I’m not sure what criteria the insurance company is using to make those decision, but it’s unfair to our patients,” said Mullins about Coventry denying the hardship waiver.
Mullins stated that he has a patient that is 34 weeks pregnant and is experiencing some complications, which require her to be seen on a frequent basis throughout the pregnancy. Her husband is an unemployed miner that is not receiving an unemployment check.
The patient attempted to switch insurance companies so she could continue seeing Dr. Mullins, and she was denied a hardship. She will now have to travel to Corbin to see the doctor.
“I have a relationship with this patient. I know what’s going on with her medical, but that wasn’t taken into consideration,” said Mullins.
Rebecca Smith is another ARH patient that is being affected by the change. She is seven months pregnant with her second child, and is currently seeing Dr. Susan Robertson.
Smith stated that she had previously had a miscarriage and was concerned going into this pregnancy. She said that Robertson had helped ease those concerns.
Originally Smith had Kentucky Spirit, but decided to switch to Coventry because ARH did not accept Kentucky Spirit.
“I chose them (CoventryCare) because I thought that they would take care of me,” said Smith. She found out that Coventry was terminating their agreement when she took her daughter to physical therapy at Middlesboro ARH.
“It poses a problem because my doctor (Dr. Robertson) is part of ARH and that means that she will not be accepting Coventry also, and the nearest hospital with an OB is Corbin,” said Smith. “That poses a really big problem for me and everybody else.”
Smith said that changing doctors is one of the biggest issues with the termination. “When you meet a doctor you build a relationship with them. They know your history and how you are feeling,” said Smith. “Now I am going to have to find another doctor, and hopefully they will understand my history and they will be able to help me through the rest of my pregnancy.”
She added that driving to Corbin is a long drive for a pregnant woman or anybody. “It poses a problem financially because you have to make sure you have money for gas to get there and back,” said Smith.
Smith said that she is stressed about the situation, and that she find herself laying in bed at night worrying about the situation.
“It’s not right. Everyone deserves good health care … and ARH has given me good health care,” said Smith.
Smith cannot switch to WellCare for another year because she has already switched once this year (from Kentucky Spirit to Coventry). ARH has written a hardship letter to Coventry for Smith.
Smith contacted Kentucky Medicaid and they stated that she could fill out a dis-enrollment form. This form tells her story and request that she be dis-enrolled from Coventry so that she can sign up on WellCare. Smith said that she has not heard back from the company.
Smith does not want to change doctors, but she will probably have to because the issue between Coventry and ARH will not be settled by May 4. Not only will she have to see a new doctor, but that she will also have to find a new pediatrician for her n
Smith will also have to fine a new pediatrician for her newborn and other child, because the pediatricians located in Middlesboro are affiliated with ARH.
“If Governor Beshear could do something, I know this would get resolved quicker,” said Smith. “Someone is going to have to step in and say that we deserve good health care close to home, and if he (Beshear) would step in and say that I think that it would be okay.”
Dr. Mullins stated that he believes that the area is being targeted because it is a Medicaid populated area. “I feel like this region is being singled out and taken advantage of possibly because we don’t have a voice in the government that is strong and fighting for our patient’s rights,” he said.
All of this came prior to ARH filing a lawsuit against Kentucky Spirit, the Cabinet for Health and Family Services, and CoventryCares. In the lawsuits, ARH alleges that it has provided health care to Medicaid covered patients but has not been properly reimbursed by either Kentucky Spirit or Coventry.
ARH is awaiting payments of about $5.7 million from Kentucky Spirit and $12.5 million from CoventryCares.
The lawsuit against the Cabinet for Health and Family Services, which is the state agency responsible for setting Medicaid reimbursement rates and oversees the three managed care companies, involves the Cabinet’s rates for inpatient, acute care hospital services.
The rates only cover approximately 75 percent of ARH’s cost, which ARH claims violates Kentucky law.
ARH filed the lawsuits against Kentucky Spirit and the Cabinet for Health and Family Services on April 12. They filed the lawsuit against CoventryCares on April 16.