Keystone First, biggest Philly Medicaid plan, faulted by feds for denying certain services
Keystone First, which is part of the Independence Blue Cross group of companies, said it discovered the problem in its claim review process and fixed it before the audit.
A federal audit found that Keystone First, the biggest Medicaid plan in Southeastern Pennsylvania, improperly denied overnight skilled nursing services for children in 10 of 50 cases examined.
The audit by the Office of Inspector General at the U.S. Department of Health and Human Services covering 2018 and 2019 was the first to be released in a series of audits underway across the nation, federal officials said. The audits, examining prior authorizations, were prompted by news reports that companies paid to manage Medicaid benefits were throwing up hurdles to care.
“This work is very important, looking that Medicaid enrollees receive high-quality services and that they are not denied inappropriately and also important that the enrollees are informed about all of their rights if they are denied requested services,” said Nicole Freda, a Philadelphia-based regional inspector general for audit services.
In early 2020, the Pennsylvania Health Law Project, a nonprofit that helps people obtain or keep Medicaid insurance, issued an alert about barriers consumers were facing when they wanted to challenge service denials by Keystone First and AmeriHealth Caritas, both part of Independence Health Group.
The audit focused on pediatric skilled services because that type of care involves an extremely vulnerable population, said Charles Hubbs, assistant regional inspector general in Philadelphia.
The audit covered the 2,482 denials of pediatric skilled nursing services. The auditors selected 50 of them for closer examination and found that in 10 cases the entire request was denied because Keystone didn’t have documentation proving that the child’s primary caregiver had work or school during the day.
“These requests should have been partially approved, meaning Keystone First should have approved the overnight portion of the request because overnight care is not dependent on the caregiver’s work or school schedule,” Hubbs said. “Denying overnight care that should have been approved could place the health and safety of vulnerable children at risk.”
Keystone First, which in October had 570,000 Medicaid members in Southeastern Pennsylvania, said it discovered the problem in its approval process on its own, before the audit, and fixed it. “Keystone First is committed to ensuring quality and timely services for members,” the company said in a statement.
“They had identified it, but they didn’t really take a lot of action on it,” Hubbs said. “What we wanted them to do is come up with a policy.”