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Speed of payments to Medicaid providers depends on many factors

Medicaid serves 1.1 million Oregonians who meet certain income eligibility requirements.

SALEM — Although the state dispensed $4.9 billion in medical assistance payments to coordinated care organizations in 2016, the Oregon Health Authority doesn't track how long it takes those CCOs to pay Medicaid service providers.

Medicaid serves 1.1 million Oregonians who meet certain income eligibility requirements. Oregon paid $6.7 billion to health care providers who saw Medicaid patients in 2016.

Most people on the Oregon Health Plan are enrolled in one of the state's 16 coordinated care organizations — essentially, regional groups of providers that see OHP patients.

Each CCO has a contract with the Oregon Health Authority to provide Medicaid services for a monthly per-patient fee, known as a capitated payment. OHA makes those payments on the first of the month.

The CCO in turn pays its providers, and those arrangements — including the length of time in which payments are made for medical services — vary from CCO to CCO.

For FamilyCare, a Portland-area CCO, more than 98 percent of its claims are paid within 30 days, according to spokesman Jack Coleman. Ninety percent are made within 14 days.

Capitated payments to CCOs accounted for about $4.9 billion of total payments to OHP providers in 2016, according to an audit released by the Oregon Secretary of State in May.

The rest — about $1.8 billion — went to services for patients in a "fee-for-service" pool. Those people aren't members of a CCO.

For those patients, providers bill OHA directly for individual medical services.

The length of time it takes money for a specific medical service to get to a Medicaid provider depends on several factors, including the patient, the service and the provider.

With most commercial insurers, Hermiston's Good Shepherd Health System negotiates a contract requiring payment within 30 days, and can enforce interest on payments that don't meet that deadline.

It typically receives payments for services for Oregon Health Plan patients in 20 to 25 days, spokesman Nick Bejarano said in an email Tuesday.

Good Shepherd has separate contracts with its coordinated care organization and with the state directly for fee-for-service clients.

Both contracts stipulate the payments be made in 45 days, Bejarano said, although they typically get payments in about half that time.

Patients on Medicaid are subject to pre-authorization, where a service, such as an ultrasound, has to get approved before a patient can receive it.

That requirement can cause delays. But payments for "clean" claims for fee-for-service patients that have been pre-authorized are made "in real time," said OHA spokesman Robb Cowie.

For OHA, routine procedures typically take 16 days to get pre-authorization, whereas urgent pre-approvals are conducted within 72 hours, and emergent pre-approvals within 24 hours.

In some cases, the payments are processed manually, such as when there are issues with the claim like a duplication. Some providers submit claims by mail or fax, and the agency doesn't track response times to those claims, Cowie said.

The Oregon Health Authority also does not collect data on how long it takes CCOs to pay providers.

Recent issues with the state's system for verifying Medicaid eligibility have thrust the Oregon Health Authority's data systems into the legislative spotlight.

To manage payments, the agency uses a system called the Medicaid Management Information System, or MMIS.

The secretary of state's audit found in May that the MMIS successfully enrolled patients in CCOs and made payments.

The state auditor's review focused mainly on capitated payments to CCOs.

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