Concerns on kids rise as therapists balk at contract

Print Friendly and PDF By: Andy Miller Published: Jun 3, 2013

Shannon Allen recently received a disturbing letter from the occupational and speech therapy services provider that works with her three special-needs kids.

The organization, Walker Therapy of Gainesville, “told us they’re going to have to drop my children,’’ Allen says. The reason is that the organization won’t agree to sign a new contract with a care management organization (CMO) that serves Georgia Medicaid and PeachCare children.

“We’re kind of stuck for the moment,’’ Allen says. “All three of my kids have made tremendous progress’’ through Walker Therapy, she adds.

Dissatisfaction with the contract that the CMO, WellCare, and its subcontractor are offering is not confined to one organization. Occupational, speech and physical therapists say many are refusing to sign the contract. They say it would reduce their payments and jeopardize the care of children.

WellCare, in a statement to GHN, said there will be no change in benefits for children and no limits on access or services under the new arrangement. The Florida-based company said it’s employing a subcontractor firm to monitor use of therapy services.

But Kay Nelson, owner of a private practice, Therapy Works, in Lawrenceville, told GHN that payments would be less under the new contract being offered by WellCare and its subcontractor, which takes effect July 1.

The WellCare contract, she said, will pay a set amount for all care, regardless of how many visits a child needs or receives.

“I’m very concerned that children who need 10 visits will only get one,” Nelson said. “We feel like it’s going to be very difficult for children to get services.’’

“I don’t think I can ethically sign the contract,’’ Nelson, an occupational therapist, told GHN.

The Department of Community Health, which oversees the CMOs and the Medicaid and PeachCare programs, declined to comment on the contract situation.

Using a subcontractor, Tampa-based WellCare says, ensures that “treatment is appropriate and is provided in a cost-effective manner, resulting in better outcomes for our members and our government customer — the state of Georgia.’’

Under the current arrangement, use of outpatient speech, occupational and physical therapy last year “was far higher in Georgia than in other states,’’ said Julie Pulliam, communications manager for WellCare’s South Division, said in the statement. The Georgia utilization rate was more than double the average rate in Florida and Ohio, Pulliam said.

Therapy providers in Georgia recently went through another financial storm when a subcontractor hired by a second CMO, Peach State Health Plan, went bankrupt.

“Oversight is poor in monitoring these contracts,’’ said Tom Bauer, a lobbyist representing Georgia occupational therapists.

The special-needs children, with conditions such as cerebral palsy and Down syndrome, have “so many problems,’’ Nelson said. “These are the formative years’’ for them.

“We’re concerned about who’s going to hold the CMOs and their contracts accountable,” she said.

Easter Seals of North Georgia, which manages the “Babies Can’t Wait” program in Gwinnett, Newton and Rockdale counties for young children with developmental disabilities and delays, says none of its therapy providers is signing the new WellCare contract.

About 150 of the 800 children it serves are members of WellCare, said Donna Davidson, president of the Easter Seals chapter. Statewide, about 1,300 young kids in the Babies Can’t Wait program currently have WellCare and could be affected by the contract situation, she added.

Facing such payment hassles may lead therapy providers to just give up their Medicaid and PeachCare business, Davidson said. Switching to another CMO may be difficult for families, she added.

“We want to make sure children continue to get services,’’ Davidson said.

WellCare, in its statement, said that it “understands that transition to a new way of managing therapy services raises a number of questions and uncertainties among therapists as they seek to understand the impact this change will have on their practices and patients.”

If therapists decide not to join the subcontractor network, WellCare said, “members can continue to see their therapists until a date for the transition is determined. At that time, we will move members to other network therapists.”

A bill introduced at the end of this year’s Georgia General Assembly session would create oversight over subcontractors of CMOs and would guarantee therapy payment rates at regular Medicaid levels currently used for aged, blind and disabled beneficiaries.

The proposal would still be in play for the 2014 legislative session.

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  • cottis

    I was a medical case manager for a non-profit, where all of my clients were Medicaid recipients. It’s not just Wellcare that is causing alarm right now. The Medicaid CMO Peachstate (not to be confused with peachcare for kids) has become increasingly selective in therapeutic and rehabilitative services it will approve for both adults and children. I fought denial letters from Peachstate for months over treatment for a child with Cerebral Palsy. Any further investigation GHN can provide about this overarching problem would be beneficial.

  • Thom

    Therapists are not seeking to understand, as WellCare says. They fully understand that the rates WellCare proposes will put them out of business, so they refuse to sign the contract.
    Regarding PeachState, they brought in a subcontractor from Miami that pre-approved therapy, then wrongfully refused to pay. PeachState lost a big court case over it, too. When the subcontractor got pressure to pay their claims, they bailed.
    When there are no providers left to provide services, the state still will not save. They will still be paying the CMO’s, who won’t be paying out for services. Sad state of affairs.

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