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Cleaning Up

Federal money is expanding drug treatment in Baltimore--and causing providers headaches.

Photographs By Christopher Myers
Baltimore substance abuse system's Greg Warren: "We're now about to do something that we've never had to do before, which is start an advocacy campaign."

By Edward Ericson Jr. | Posted 6/23/2010

The first of a four-part series

Read part 2, part 3, and part 4

Page 3 of 4.   1  2  3  4  

The pros and cons of the new system are on display behind the glass-enclosed reception desk at Glenwood Life Counseling Center, a methadone clinic that also offers outpatient talk therapy in the Woodbourne-McCabe neighborhood of North Baltimore.

On a Thursday morning in early June, George Lincoln, the administrator at Glenwood Life, is downstairs with the staff that processes clients who are milling about in the lobby and in front of the building, smoking cigarettes and conversing jovially at volumes normally encountered in a sports stadium. "I'm down here looking to see if things are going smoothly," Lincoln says. "They aren't."

Dressed casually in a white shirt and a blue ball cap, Lincoln exudes the relaxed attitude of the computer expert (he has managed the information technology here since his hiring 18 years ago). Lincoln got Glenwood's billing duties a bit more than a year ago. "Even without PAC, it was overwhelming," he says. "Billing is easy. Collection is hard."

Collection is hard because of the population Glenwood serves, he says. Poverty and addiction make its clients less reliable than the average person. Nick Usher, a case manager who has been signing up clients for PAC for the past five years, says 85 percent of those who walk through his door lack the Social Security card or other identification paperwork required by the state to confirm eligibility.

Once they get eligibility, he says, he can get them PAC coverage in a few weeks--if they don't move away from the address they gave him during that time. He says about a quarter of his clients do move, and as a result don't get the packet the state sends them. If and when they get PAC coverage, they must reapply via the same process every nine months, he says.

While Usher signs up new PAC clients, Lincoln manages those already on the rolls. Because of the vagaries of PAC insurance rules, "We have to check at least weekly--it really should be daily--every client's eligibility," he says. "Our clients are not prone to come to us and say, 'Ya know, I just got insured,' or, 'Ya know, I just lost my insurance.'"

So Lincoln--or someone, most likely his intake coordinator, Aredenia Langley--has to go to a state government database and key in each client's name and ID number to discover if their PAC insurance status has lapsed or changed. "It's about 60 seconds per name," Lincoln says, adding that he can't make a computer program to automatically check the names. Sixty seconds times 600 patients is about 10 hours of work each week--a quarter of a normal work week just to check eligibility.

Eligibility is actually easy compared to authorization.

Just because someone has PAC insurance doesn't mean a particular service is covered. First, it has to be "authorized" by the managed care organization (MCO) that administers the PAC insurance. (PAC is publicly funded, but managed by private health insurance companies such as United Healthcare, which decide whether to pay for a particular service based on whether the claim form is "clean"--filled out correctly--the service is "medically necessary," and the client is both eligible and authorized to receive the service.) If eligibility is like a nine-month rail pass, authorization is more like a monthly bus ticket. Or sometimes a 13-week ticket. Sometimes it's 26 weeks, Lincoln says. It depends on the rules of the MCO.

Lincoln says he underestimated the billing process, much of which initially fell to an assistant who was quickly overwhelmed by the task. He reluctantly let her go, and from July of last year until February of this year, Lincoln picked through insurance denials totaling more than $200,000, he says. That is more than 20 percent of the grant funding Glenwood is scheduled to receive this coming year. He is currently battling over another $20,000 in bills he says United Healthcare misrouted.

Glenwood has traditionally had about two-thirds of its patients on grant and one-third on insurance of some sort--mostly public plans like Medicaid. Under PAC that ratio is supposed to flip--one-third grant and two-thirds insured.

On July 1, Glenwood Life Counseling Center will have 230 grant-funded slots. Right now, Lincoln still has 275 on the grant rolls--45 more than will be covered by the grant in three weeks. "I can guarantee you this 45 will not have insurance by then," Lincoln says. "So, July 1, we're gonna be losing money. How much, I can't tell you. But we're gonna be losing money."

Methadone programs such as Glenwood are better adapted to PAC, because opiate-assisted treatment has been, "and I hate this term, 'a billable service,'" says Lillian Donnard, the clinic's executive director. Yet even with long experience dealing with MCOs, Glenwood has chafed under the new program. In the early months of PAC, Donnard says, one of her staff counselors "canceled a couple of group therapies because his treatment plans were all due." If the treatment plans were not submitted to billing, Glenwood Life could not be paid. The extra step costs the counselor hours, and hours cost more than money, she says. "If you got to fill out the paper to get paid, it doesn't take an idiot to figure out that that's time you spend that you would have spent doing something else."

That something else might turn out to be more important than the higher-ups in the drug treatment industry had imagined.

Page 3 of 4.   1  2  3  4  

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