CN allocates $9.4M to ease MRI constraints
TAHLEQUAH – Cherokee Nation officials announced they are allocating an additional $9.4 million to Contract Health to alleviate budget constraints and re-establish some MRI referrals for patients with “elective orthopedic” cases.
“We are aware our patients have more health needs than we offer and (we) want to help them live healthier lives without exhausting their pocketbooks or going without these needed services,” Dr. Charles Grimm, CN Health Services interim executive director, said. “The Cherokee Nation is making aggressive efforts in several areas to collect more funds from billing patients’ private insurance, Medicaid and other third-party billing streams.”
Grimm attributed the collections increase to improved patient record management using a new electronic health records system and increased provider productivity after implementing a new compensation package. The package rewards providers on productivity and patients treated, leading to more opportunities for third-party billing, he said.
Third-party collections for fiscal year 2018’s first quarter was $36.1 million, up from $26.7 million during the last FY 2017 quarter, according to CN Communications.
The additional funds bring the FY 2018 Contract Health budget to $44.3 million, with $28.4 million received from Indian Health Service and $6.5 million from Cherokee Nation Businesses dividends, officials said.
Previously, Contract Health authorizations for surgeries and MRI referrals were limited to patients classified at Level 1 under the IHS medical priority regulations. The IHS defines Level 1 as “the highest priority medical services,” including “those necessary to prevent the immediate threat to life, limb, or senses.”
If a patient was categorized with an “elective orthopedic” issue such as chronic knee, back or shoulder pain, it would not meet requirements for an approved MRI referral. Instead, patients had to rely on Medicare, Medicaid or private insurance to help cover costs.
“We hope patients understand that Cherokee Nation Health Services strives to meet all needs of tribal citizens, but the same time have had to manage costs, and these additional dollars will help serve even more patients with contract health referrals,” Grimm said. “Our goal is to be able to be able to provide the necessary orthopedic services and related diagnostics for our patients.”
In the CN 2017 Annual Report, 11.8 percent of Health Services’ expenses came from contracted health services, the third-largest expense behind direct patient care at 66.4 percent and community health and education at 12.2 percent.
Grimm said evaluating funding would continue to be an “ongoing process.”
“We will continue to monitor the needs of the patients combined with the payer mix of the various additional funding sources and go from there,” he said.
Contract Health Director Bret Hayes said the tribe always approved referrals for oncology, cardiology and orthopedics. However, elective orthopedics had been halted as referrals grew “exponentially,” while funding grew only “in fits and spurts.”
“Every time we add a doctor we add more patient access. We add more services. Those end up getting more referrals. When I started we had 87 (referrals) a day and now we have 412 a day, so volume has grown exponentially,” Hayes said.
Previously when patients were denied, letters were sent informing them that they could appeal in writing within 30 days and submit their appeals to their local Contract Health coordinators.
“It goes centrally to the Medical Review Committee,” Hayes said. “They just evaluate for medical necessity. For all referrals, they look at the medical background of the case. They can typically appeal it through three levels, so (patients) can appeal it again.”
The process is multi-tiered and for patients to win they must provide relevant medical records.
“We will still evaluate the referrals written by our providers for medical necessity and some referrals may still not meet medical necessity,” said Grimm. “We have an appeals system in place that will enable us to review the cases as they are appealed.”
The Cherokee Phoenix submitted a Freedom of Information Act request for the number of MRI referral approvals and denials, but information was not available as of publication.
While the CN does not have MRI machines available for patients, a new 470,000-square-foot health facility near W.W. Hastings Hospital will feature two when it opens in 2019.
“We will keep (the machines) busy I know,” Hayes said. “It will definitely allow for cheaper and more prompt diagnostics. We do a significant amount of MRIs related to all kinds of things, not just orthopedics.”
However, Hayes said he doesn’t know the financial situation that will occur once the machines are operational. Until demand and cost can meet in the middle, he recommends patients look into government and private insurance options to assure they will receive needed services.
Patient benefits coordinators are available at CN health facilities for those seeking insurance plans related to elective orthopedic MRIs and other services not covered by Contract Health.
Hayes said if patients have private insurance or Medicare then they could get specialty care such as MRIs. He said purchasing insurance through the Affordable Care Act is another way patients can gain access to specialty services, including MRIs.
“There are some really good benefits from the Affordable Care Act if you sign up on the Marketplace and purchase a plan,” he said. “Depending on their plan, the cost is zero and some of those plans have really good deductibles. The other thing is if they’ve got a contract health referral and they’re one of our patients, if they have purchased a plan on marketplace, there is no co-pay or no deductible.”
To enroll in the ACA or change a plan, visit www.healthcare.gov