- The Washington Times - Sunday, November 27, 2005

D.C. health officials say they are planning a shake up of the city’s more than $90-million-a-year health program for the poor, moving to eliminate administrative missteps and provide financial incentives to reduce HIV, heart disease and other illnesses.

The city-funded D.C. Healthcare Alliance provides care for tens of thousands of low-income D.C. residents who do not qualify for Medicaid through a network of hospitals and clinics. The five-year Alliance contract expires in May. The Alliance was created in the wake of the closing of D.C. General Hospital in 2001.

City health officials say they plan to continue providing coverage to Alliance members, but that they also are planning to overhaul administrative and financial aspects of the program.

Dr. Gregg A. Pane, director of the D.C. Department of Health, said the Alliance will likely be restructured so that its 28,645 members receive coverage through the District’s network of Medicaid managed care organizations rather than through the separate, stand-alone Alliance program that exists now.

Under the restructured Alliance, the managed care groups would work under financial incentive agreements with the District, in which future city contracts and potential bonuses would hinge on improving the health of enrollees.

“Contractors will be accountable for members’ health,” said Emil Parker, deputy director of the D.C. Health Department’s Health Care Safety Net Administration, which oversees the Alliance.

The switch to the managed care arrangement also should result in better access to specialists for Alliance members, officials said. Mr. Parker said the managed care groups maintain more extensive rosters of specialists. Specialists are in high demand in the Alliance.

In addition, city officials say they plan to create a “single point of entry” for low-income residents entering the city’s Medicaid and Alliance programs. As a result of faulty screening in the past, the District paid millions of dollars for the treatment of Alliance members who could have qualified for federal reimbursement under Medicaid.

The Alliance is entirely funded by D.C. local tax dollars, while Medicaid is jointly funded by the D.C. and federal governments. There are about 140,000 D.C. residents on Medicaid.

“We’ve taken huge steps to clean that up,” Dr. Pane said, referring to instances in which the District has paid for Alliance members who were already eligible for Medicaid.

D.C. Council member David A. Catania, at large independent and chairman of the council’s Committee on Health, said he hopes that folding Alliance members into the Medicaid managed care organizations will reduce administrative costs.

“Having two separate eligibility systems, two separate billing systems and two separate everything doesn’t seem to make sense,” he said.

Mr. Catania said he has organized monthly meetings to ensure a smooth transition when the Alliance contract expires next spring.

Claims for the Alliance program are currently handled by D.C. Chartered Health Plan Inc.

Two recent Health Department-commissioned internal audits, obtained by The Washington Times through the Freedom of Information Act, show a mixed bag of progress and setbacks in the administration of the Alliance program.

For example, a review of Alliance claims-processing practices found that D.C. Chartered Health Plan has improved its screening to “weed out duplicate and erroneous coverage of Medicaid participants,” according to the report by Hyattsville-based Consortech Inc..

The same report also noted that some Alliance claims are processed repeatedly instead of being rejected at the time of receipt, with the District paying a processing fee “each time these claims enter the work pool.”

Another report disclosed hundreds of thousands of dollars in accounting adjustments by Chartered Health Plan last year, after a new policy barred certain administrative costs from being charged to the Alliance.

The adjustments came after a revised policy ruling out-of-town travel, “related party consulting,” seminars, meals, audit fees and political contributions were not “chargeable” to the Alliance, according to the draft report by D.C.-based Gardiner, Kamya & Associates P.C..

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