PEIA Interim Director talks reimbursement for care

CHARLESTON — The Select Committee on PEIA, Seniors and Long Term Care heard testimony from Jason Haught, PEIA interim director and chief financial officer, on Sunday, during the first day of the June Interim Legislative Sessions.

While this was Haught’s third appearance before the committee in as many months, the committee was seemingly left with more questions than answers.

After minutes from the committee’s May 23 meeting were adopted, Chairman Sen. Michael Azinger, R-Wood, once again introduced Haught, stating “He’s been doing a great job. We are looking forward to your presentation.”

“This presentation is going to get into the PEIA reimbursement methodology,” Haught began. “And also, we’re going to do the comparison with out-of-state reimbursement - which is of significant importance.”

Haught explained how, in the past, West Virginia and in-state providers have agreed to accept PEIA rates as a “reciprocal agreement to provide incentive for higher in-state carrier-utilizations and savings to the taxpayer.

“West Virginia reimbursement is at or above Medicare for major hospital physician care, except for in-patient, which is obviously the primary concern of the reimbursement we’ve been discussing,” Haught noted.

According to Haught, PEIA reimburses out-of-state providers based upon the United Healthcare National Network Rate.

“All out-of-state care, with the exception of bordering counties, must receive prior approval,” Haught added.

Del. Heather Tully, R-Nicholas, pointed out that while no border-county requires prior approval to visit an out-of-state provider, different border counties are reimbursed at different rates. Haught advised that this is due to the individual facility’s ability to perform certain procedures and forms of treatment.

“Have we reassessed that recently?” Tully then asked. “A lot of times capabilities and offerings of services change. Have we looked at that yet?”

Haught stated that PEIA will continue to “explore the capabilities of our bordering counties.”

“It has not been analyzed to the degree it was when we were doing the special benefit,” Haught added. “But I do wish to restart that review to see if there are any tweaks we can do to the benefits to keep that type of care in-state.”

Del. Ken Reed, R-Berkeley, was next to question Haught, and asked for an explanation regarding “tiered-reimbursement” for physicians, physician assistants and registered nurses.

“My understanding of the process is that physician assistants have a much lower value assigned to any claim submitted than, say, a physician,” Haught replied.

“We have (also) discussed ‘certificate of need’ multiple times at this level,” Reed went on to say. “Would getting rid of it leave PEIA the same? Would it help it, hurt it, or do nothing?”

“I’m hesitant to speak on that,” Haught said. “I’m not real sure as to the impact.

Haught explained that while he has “limited understanding” of the inner-working of healthcare providers, it has been more than 10-years since any analysis of ‘certificate of need’ has been completed.

“With West Virginia reimbursement coming into the hospitals all over the state, I would hesitate to offer an opinion based on my understanding,” Haught said.

Currently, a PEIA member who seeks treatment out-of-state without prior approval, is responsible for 30% of the cost, as opposed to 20% for in-state treatment.

Del. Matthew Rohrbach, R-Cabell, then commented on certain inconsistencies in Haught’s presentation, stating “You have alluded to (Kentucky’s) Belfont Hospital (as a border-county hospital). There are two problems with that. First of all, that hospital closed about two years ago. So, if we’re still paying claims there, we’ve got big problems.”

Rohrbach then advised Haught that Belfont Hospital was not in a Kentucky-county which borders West Virginia.

“So, there’s two problems with your statement there,” Rohrbach added, before asking Haught how much more PEIA spends annually for out-of-state reimbursement versus in-state.

“Double,” Haught replied. “But again, my understanding is that you have to have pre-certification to go out of state. For everything - except for the bordering-county residents - that’s my understanding.”

A significant point of contention, as Rohrbach explained, is that a PEIA member living in West Virginia is required to receive prior authorization to seek treatment out of state. However, an employee of West Virginia, who resides out-of-state but is still a member of PEIA, is not subject to the same pre-authorization requirement.

“So, the person who pays taxes in West Virginia is getting a worse deal from PEIA than the patient who works for the state of West Virginia, but resides and pays their taxes out-of-state,” Rohrbach stated. “Can I construe that from the facts you’ve just presented?”

“That’s my understanding,” Haught replied. “But I want to follow up.”

Haught added that stricter regulations regarding out-of-state treatment had previously been in effect but was unsure as to when and why those regulations were discontinued.

After nearly an hour of deliberation, the meeting was adjourned. The committee will next hear testimony regarding PEIA during July’s Interim Session.