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Providers say prior-authorization and coding changes left legitimate programs unpaid; Access officials point to fraud response
Summary
Providers including The Haven and trade groups told senators that October 2024 coding and prior-authorization changes, and delayed payments, forced closures and unpaid claims; Access officials said many claims are still paid (84% approval in prepayment review) while acknowledging timeliness and staffing problems and pledging more technical assistance and data.
Providers and provider groups testified that policy changes and prepayment-review processes implemented after the fraud revelations have disrupted cash flow for legitimate behavioral-health providers.
"Every day that funding is withheld from legitimate providers like the Haven, more people lose access to life-saving treatment," Amy Graves, CEO of The Haven in Tucson, told the committee, saying the organization is owed about $375,000 for AIHP services. Heather Dukes and Michelle Coldwell testified that delayed prior authorizations and months-long enrollment or contracting timelines threatened provider solvency, especially in rural areas.
Lynn Emmons, assistant deputy director for fee-for-service programs, said Access has added prior authorization for some intensive outpatient services and that prepayment-review claims have an approval rate of about 84%. She acknowledged lengthening turnaround times as volume increased following October 2024 coding and policy changes and outlined a ticketing system for provider technical assistance (initial response within ~3 hours; average resolution under 14 days for tickets).
Senators pressed for metrics and examples: how long claims take today versus 2020, the percentage of denials overturned on appeal, and a year-by-year breakdown of suspensions, terminations and recoupments. DFSM agreed to provide further data and to build a dashboard showing turnaround times, provider appeal outcomes and the list of providers on 100% prepayment review (382 added since Jan 2024 was cited).
Ending: Access committed to provide the committee with requested operational data, including denial-overturn metrics, timelines for prior-authorizations and an org chart of recent hires; the chair asked for deliverables within 30 days.
