Behavioral health providers struggle to stay afloat as umbrella agency's billing woes persist

Arizona Complete Health, which holds the area’s Regional Behavioral Health Authority (RBHA) contract, is under a second state sanction and for now is not being automatically assigned new members because of its reported claims-processing failures.

The problems have caused some agencies in Southern Arizona to join larger providers, while other agency leaders say they are not sure how much longer they can stay open if the problems they report persist.

In addition to coordinating and paying for the behavioral health care of foster children and those with serious mental illnesses, Arizona Complete Health, which holds state contracts for over $1 billion, also provides crisis services for the Medicaid and non-Medicaid population.

In October, AHCCCS, the state’s Medicaid agency, leveled a second sanction against the contractor for problems that started in October 2018, when a system’s changeover left over a million claims unpaid. AHCCCS has now more than doubled its initial fine for a total penalty of $375,000.

The sanction letter describes an “alarming” number of unpaid claims and “failure of leadership, competence and expertise.”

In contract year 2019, the state paid $381 million for behavioral health services through the RBHA for Southern Arizona.

Under its AHCCCS Complete Care contract to provide integrated health services to the remaining Medicaid-eligible people in 10 central and Southern Arizona counties, Arizona Complete Health received another $865 million, for a total of $1.2 billion in state and federal funding.

Behavioral health providers here cite long delays in claims processing, some still unresolved after 18 months, as well as unexplained rejections of claims.

The problems are hurting Pima County’s smaller agencies most because they lack the financial flexibility of bigger agencies. Some have had to join larger providers in order to survive. The Star interviewed eight local providers, and four asked not to be named because they fear it could compound their financial problems.

Arizona Complete Health spokeswoman Monica Coury did not respond to an Arizona Daily Star interview request but instead emailed a written statement:

“Arizona Complete Health is committed to timely and accurate payments for our providers. Current claims for Arizona Complete Health are meeting AHCCCS timeliness and accuracy standards, which require 95% of claims to be paid within 30 days, and 99% to be paid within 60 days, with accuracy of 95%,” she wrote.

“Arizona Complete Health and our provider partners have engaged in innovative and life changing programs for those Arizonans we collectively serve. Some of these many initiatives include projects around addressing homelessness, employment and re-entry for those who have been involved in the justice system.”

Bigger agencies faring better

For about two to three months starting last summer, one of the area’s largest providers of behavioral health services here was not receiving any payments from Arizona Complete Health.

But La Frontera was able to weather it.

“We’re large enough that we could handle cash receivables for some period of time,” CEO Dan Ranieri said. “It was an annoyance, but not an unmanageable hardship.”

Here’s what Ranieri thinks is a big part of this complex problem: Many insurers have moved away from paying a monthly sum for each enrolled patient, and instead offer what’s called a “fee for service” arrangement. This approach, which includes agencies getting paid based on the volume of services provided, doesn’t work well, he said. That’s because there’s no real managed care taking place.

“A good managed care model is one that knows how to stretch those finite resources and target them do the greatest good for the greatest number of people in need,” he said.

“The whole model that they’ve implemented has been challenging. They’ve had a really hard time processing and paying those claims, which consequently makes it difficult to monitor and manage spending.”

Capitated funding, on the other hand, gave agencies an incentive to find the best and most cost-effective treatment for patients and consumers.

Even so, over the last few months, Ranieri said things have improved considerably for La Frontera.

“We’re not completely paid off for last fiscal year (which ended Sept. 30), but I think our payments versus our billing is now 93 or 94%, which is much better than it was,” he said.

“They are closer to fixing it than they have been in some time. It’s just a shame it had to get to this point.”

Like other larger providers here, La Frontera has acquired smaller ones that have not been able to weather the chaos. One of the acquisitions was Southeastern Arizona Behavioral Health, based in Cochise County.

“If we hadn’t, they would have become insolvent,” he said. The sense of urgency grew, he said, when the organization experienced delayed reimbursement by Arizona Complete Health and had difficulty transitioning to the fee-for-service model. Arizona Complete Health worked closely with both La Frontera and Southeastern Arizona Behavioral Health to expedite the transaction, he said, and avoid service interruptions.

Intermountain Centers for Human Development, like La Frontera, has also absorbed other providers including the Pinal Hispanic Council, Community Partners Inc., and Pantano Behavioral Health.

With so many changes underway, it seems agency leaders should come together and assess what Pima County needs most, said Rose Lopez, CEO of Intermountain.

“It’s hard but ultimately, in the end, we have to remember that these organizations belong to the community and so we have to make the best decision for the community,” she said.

For now, Lopez said, Intermountain is still getting caught up with Arizona Complete Health.

“They have made significant progress in the processing of our claims, but there are still issues,” she said. “A lot of our claims from the past are still getting paid and processed.”

“Continuing hardships”

Arizona Complete Health, formerly Cenpatico Integrated Care, failed to resolve its system deficiencies and get caught up on payments by a deadline of last April, AHCCCS records show. As a result, another round of sanctions was issued in October.

The issues for Arizona Complete Health continue to be widespread, AHCCCS wrote, and have “imposed continued hardships on providers of essential services for AHCCCS members.”

As part of the recent sanction, Arizona Complete Health is required to resolve identified issues within 90 days and submit documentation substantiating its progress. AHCCCS is currently reviewing the submitted documentation, according to AHCCCS spokeswoman Heidi Capriotti.

The problems and delays first started in October 2018 when AHCCCS launched its Complete Care integrated health plans to offer physical and behavioral health care services under single provider networks to the majority of its members.

At that time, under the new structure, Cenpatico — now Arizona Complete Health, after its merger with Health Net of Arizona — became one of three insurers in the region providing coverage that includes both physical and behavioral health care.

The transition meant new contracts and new reimbursement rates had to be negotiated between provider agencies and insurance companies. The other two insurance providers for Pima County residents are Banner University Family Care and United Healthcare Community Plan.

For almost 20 years, Southern Arizona behavioral health agencies had the same RBHA: a Tucson-based nonprofit called Community Partnership of Southern Arizona (CPSA).

Some agency leaders say the last several years have been marked by turmoil since a for-profit company won the RBHA contract with AHCCCS in 2015.

“No explanation”

Some of these problems have less to do with the current payment problems than with the insertion of for-profit insurers into public behavioral health care, said Clarke Romans, who retired last summer as executive director of NAMI, the National Alliance on Mental Illness.

Reimbursement rates have also gone down in the new paradigm, he said, and so provider agencies are grappling with that at the same time.

A couple of years ago, when the RBHA was Cenpatico, NAMI’s support was cut off without warning and employees had to be let go in order for the local chapter to stay open.

“The fact that they’ve devastated the provider community is of no consequence to them but it’s certainly of consequence to this community,” he said.

Patients are now struggling to get their medications, Romans said, and are being discharged prematurely from crisis facilities and hospitals. Overall, there’s far less individualized care, he said.

There’s also a shortage of case managers to follow up with patients, he said, and many are now living without anyone advocating for their care.

Like NAMI, the nonprofit Higher Ground, which provides social-emotional learning programs to children, was recently dropped by Arizona Complete Health.

Jansen Azarias, CEO for Higher Ground, said he was contacted by the insurer in December.

“They dropped us from their plan with no explanation,” he said, explaining the change takes effect in March. “We just got a letter that our services will no longer be covered.”

It’s not the first time his small agency has been through this kind of thing with Arizona Complete Health. Two-thirds of Azarias’ 30 employees were furloughed last year because of reimbursement problems and cut rates.

Prior to the transition in October 2018, Azarias said they were growing and expanding. Now, he said, “they are choking us out of business.”

“Helped us grow”

Some local organizations are faring better with Arizona Complete Health, according to leaders of two local peer-and-family run agencies that use a block, or capitated, payment system instead of simply billing claims.

One example is the Autism Society of Southern Arizona, whose partnership with Arizona Complete Health helped start a “Triple P Stepping Stones” program. This training was offered in collaboration with the University of Arizona’s Cooperative Extension’s Family Engagement program for families that have children with special needs.

Most of the Autism Society’s programs are free, with fundraising support coming primarily from the Autism Walk & Resource Fair and, now, Arizona Complete Health.

That Triple P Stepping Stones series has brought about “a significant decrease in the intensity of both child misbehavior and associated parental stress, depression, and anxiety,” said Brie Seward, executive director of the nonprofit.

“I witnessed parents walking in with a heavy weight on their shoulders and after they learned key strategies that will improve the state of their home, the weight had been lifted.”

Arizona Complete Health also helped Seward’s agency secure a community reinvestment grant that enabled it to upgrade outdated technology, create more work stations, and improve phone systems, she said.

Dan Haley with Hope Inc. said his organization, which uses a team approach to help people with behavioral health and substance use challenges, is also doing well with Arizona Complete Health.

“We are a peer and family-run organization and if we had not had the support of CPSA and now Arizona Complete Health, we would not be here today,” he said. “They have really helped us grow and become more business oriented.”