HAP Resource Center

Comment Letter: Office of Medical Assistance Programs, Recommended Changes to HealthChoices RFP

July 1, 2019

Deputy Secretary Sally Kozak
Department of Human Services
Office of Medical Assistance Programs
P.O. Box 2675
Harrisburg, PA 17050

Dear Deputy Secretary Kozak:

I am writing on behalf of The Hospital and Healthsystem Association of Pennsylvania (HAP), which represents approximately 240 member institutions statewide, to provide specific suggestions relating to changes to the Request for Proposal (RFP) process as the Department of Human Services (DHS) moves forward to renew the HealthChoices physical health care program.

In our May 31, 2019 letter to you about this topic, HAP provided a series of recommendations relating to the RFP, HealthChoices agreement, and the procurement process in general. During a follow-up conversation, DHS advised that many of our suggestions were not feasible or practical, but that DHS would be willing to entertain specific changes to the RFP relating to issues that align with the commonwealth’s policy interests.

As a follow-up to our conversation, we recommend the following additions to the Work Statement Questionnaire in the upcoming RFP. As we discussed, HealthChoices bidders will be required to respond to these questions, and the commitments included in the proposal response will become part of the agreement between DHS and the managed care organizations (MCO).

In making these recommendations, we included the questions in the format the department has adopted in its most recent RFP document.

  1. Value-Based Purchasing—Information sharing between plans and providers is critically important to provide quality care for Pennsylvania citizens. In order to provide high-quality, efficient care to their patients, providers need timely and actionable data, not all of which may be housed in their electronic medical records.

While the current MCO contracts call for data sharing when hospitals are engaged in value- based contracts, there are varying degrees to which this requirement is in compliance across MCOs. In addition, the exact data specifications are not delineated in the contract.

Additionally, the proliferation of quality metrics, value-based program design, and variances in measurement creates administrative burdens on providers and distracts them from focusing on what will actually create better outcomes at lower costs for patients.

To help address this issue, and improve the effectiveness of DHS’ value-based payment initiative, HAP recommends the inclusion of the following questions in the “Management to Improve Quality” section of the work statement questionnaire.



Describe the approach to working with hospitals and other providers with whom you execute value-based purchasing (VBP) agreements to provide claims-level data that can be used to support population health improvement efforts and provide actionable information necessary to succeed in VBP arrangements. (Limit to two pages)


Describe the department’s approach to identifying meaningful performance measures that align with other payors’ measures both topically and methodically as a means to minimize administrative burden in day to day operations. (Limit to two pages)


Describe the approach to align the design of the programs with other VBP programs operated by your organization and other plans, in order to better align provider efforts and enhance the effectiveness of VBP efforts overall. (Limit to two pages)


  1. Inappropriate Payment Denials—Claims denials, downgrades and payment delays—for medically necessary services delivered in good faith—are putting extreme financial pressure upon hospitals and physicians, which jeopardizes access to care.

During the past several years, hospitals have continued to experience an increasing number of situations where insurers may utilize the prior authorization process as a means for non-payment of medically necessary services provided to patients. Ultimately, the patient is disadvantaged when prior authorization is delayed or used as a means to deny payment for a service.

To help address this issue, HAP recommends that DHS add the following additional questions to the “utilization management” section of the work statement questionnaire, which currently only contains two questions.



Describe the prior authorization process in detail, including the last quarter average turnaround time (when information provided is complete) and explain what steps are in place to ensure that reviews are consistently done in a timely manner, especially on the weekends. (Limit to two pages)


Describe the clinical criteria philosophy, including which industry standard clinical tool(s) your plan uses for medical case review (i.e. InterQual, Milliman, etc.) As part of the answer, explain whether your plan uses other criteria to make clinical decisions and, if so, what those are and how they are communicated to providers. (Limit to two pages)


Describe your observation payment policy in detail, specify what process is in place to ensure timely responses to provider questions or concerns, and outline what processes are in place to ensure that outpatient downgrades to inpatient stays are appropriate. (Limit to two pages)


Please explain your plan’s denial process in detail and explain how the language meets the DHS specificity requirements for a valid denial. (Limit to one page)


  1. Telemedicine—Telemedicine allows patients to access specialists located across the state while remaining in their own communities, surrounded by their own support systems. Services delivered through telemedicine also can save time and money, as well as improve health outcomes and population health. One example is its ability to amplify the reach of providers capable of intervening in the opioid crisis.

We also know that Pennsylvania’s Medicaid Program is supportive of this concept, and that the Centers for Medicare & Medicaid Services (CMS) has sent a clear message that they do not think that the status quo is good enough. While some telemedicine is being reimbursed by some insurers, many insurers—including MCOs—are lagging behind.

To encourage the use of telemedicine, HAP recommends that DHS include the following questions in the work statement questionnaire, either in its own stand-alone section or incorporated within the “Management to Improve Quality” section.



Describe what telemedicine service(s), including the relevant procedure codes the plan covers and reimburses for and how the use of telemedicine services improves access to care. As part of your answer, describe how the level of reimbursement for telemedicine services compares to in person visits. (Limit to two pages)


Describe your plan to expand the use of telemedicine services over the term of this agreement, and summarize the anticipated impact of the expansion of the use of telemedicine services on program outcomes. (Limit to two pages)


  1. Credentialing—DHS has taken strides in addressing credentialing delays by including a requirement that HealthChoices plans process “clean” credentialing applications within 60 days. Despite this requirement, a number of HAP member hospitals have indicated that compliance remains a problem.

To encourage efficient credentialing activities, HAP requests that DHS include specific language in the RFP (specifically within the “Provider Network Composition and Network Management” section) requesting that bidders outline the steps that will be taken to ensure that they comply with the 60 day requirement, and promote consistent credentialing approaches across the program.



Describe your credentialing process in detail, including the average length of time from the date of application receipt at the plan to provider approval (when provider information is complete). As part of your answer:

  • Describe the internal process to ensure compliance with DHS’ agreement requirements that Medicaid MCOs process clean credentialing applications within 60 days.
    •  Indicate whether the plan will perform provisional credentialing.

    • Explain whether the plan will begin its credentialing process before the provider has an MA ID number from DHS.

    • Indicate whether the plan will accept a standardized credentialing template (i.e. CAQH). (Limit to three pages)


  1. Workforce Development—Pennsylvania is experiencing a health care provider shortage. According to a study released by the Association of American Medical Colleges (AAMC), the United States will face a shortage of physicians during the next decade. Its projections show a shortage ranging between 61,700 and 94,700, with a significant shortage showing among many surgical specialties. Pennsylvania is already experiencing this physician shortage.


Pennsylvania also is experiencing a nursing shortage that experts anticipate will grow more severe, in part because of the aging/retiring nurse workforce and the aging/retirement of nurse educators—which limits available slots in nursing schools, and results in fewer in-state nursing graduates.

To help address this issue, HAP recommends that DHS add the following additional questions to the work statement questionnaire:



In light of Pennsylvania’s physician and nursing shortage—which affects the delivery of care to Medicaid patients—describe the specific steps being taken to ensure access to care. (Limit to two pages)


Describe the community outreach programs the department supports to promote and develop the health care practitioner pipeline. (Limit to one page)


Describe the efforts to support the transition of veterans who have received military medical education and training to careers in health care. (Limit to one page)


Thank you for your consideration and please feel free to reach out with any questions or for additional clarifications.


Jeffrey Bechtel
Senior Vice President, Health Economics and Policy


Ms. Leesa Allen, Executive Deputy Secretary, Pennsylvania Department of Human Services
Ms. Laurie Rock, Bureau Director, Managed Care Operations
Ms. Jolene Calla, Vice President, Health Care Finance and Insurance
Ms. Kate Slatt, Senior Director, Innovative Payment and Care Delivery
Ms. Judy Miller, Director, Financial Systems Analysis
Ms. Mary Marshall, Director, Workforce and Professional Development



Topics: Access to Care, Insurance, Medicaid, State Advocacy, Telehealth, Value-based Care, Workforce

Revision Date: 7/1/2019

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