Public Interest Firm Sues TennCare MCO Access MedPLUS

The Tennessee Justice Center, a not-for-profit public interest firm, filed suit March 29 against Access MedPLUS, saying the Tennessee insurer should be held in contempt of court for "systematically denying, delaying, reducing and terminating medical care to" TennCare beneficiaries, the Nashville Tennessean reports. Access MedPLUS, the second-largest health plan participating in TennCare, Tennessee's Medicaid managed care program, is under state supervision because a "failed computer system" made it unable to reimburse care providers promptly or accurately for more than one year. The latest legal action stems from a "long-standing lawsuit" the justice center has against the state. The justice center alleges that TennCare health plans have refused to cover health services that beneficiaries' doctors order and that beneficiaries are unable to appeal the denial of care. In response, the state last summer signed on to a "consent decree," expanding beneficiaries' rights to appeal. But Access MedPLUS has failed to abide by the consent decree, the justice center maintains.

Patients v. Insurer
In documents filed last week with the court, 10 Access MedPLUS enrollees or enrollees' parents described problems they had encountered in obtaining medical care, which the justice center attorneys "primarily" attributed to a "lack of doctors" in the insurer's network (Snyder, Nashville Tennessean, 3/30). A doctor, several patients and patient advocates testified April 2 that "a lack of specialists willing to treat the 360,000 TennCare enrollees covered by Access MedPLUS continues to be a serious problem." Patricia Whitfield, appeals coordinator for the TennCare Consumer Advocacy Program, added that most -- 40% -- of the complaints she receives are from Access MedPLUS enrollees. But the insurer testified that it has maintained a sufficient number of doctors and was "able to provide full services to all" its membership. Glen Watson, CEO of Medical Care Management Co., the company that operates Access MedPLUS, said the insurer "is coming out of its difficulty" and noted that most of the problems enrollees experienced in obtaining services occurred last year, when Access MedPLUS "was the only statewide TennCare plan open to new enrollees." The hearing was expected to conclude this week (Snyder, Nashville Tennessean, 4/3).

Hospital Network to Drop Access Contract
In other Access MedPLUS news, 15 hospitals under the HCA system announced that they are ending their contract with Access MedPLUS and no longer will provide routine care to nearly 104,000 enrollees because the insurer owes them "multiple millions of dollars," the Tennessean reports. Access MedPLUS officials said they have a back-up network -- operated by Austin, Texas-based USA Managed Care Organization -- that can provide services for enrollees (Snyder, Nashville Tennessean, 4/4).