By
Benny Polacca
Osage Nation health officials are in reaction mode after learning the renamed Wah-Zha-Zhi Health Center’s pharmaceutical billing procedures were no longer working after the Nation assumed control of the Pawhuska IHS clinic last fall.
As a result, the clinic is behind on billing for pharmaceuticals since Oct. 1 when the Nation took over the clinic as part of an IHS compact to assume control of the clinic operations and to oversee its operating budget. The pharmaceutical billing is a critical component to fund the clinic operations because the clinic bills insurance companies for services and medications issued to patients covered by their own health insurance plans.
On the final day of its 10th special session, the Fourth ON Congress learned more about the snafu as it considered a resolution (ONCR 16-11) to authorize a sovereign immunity waiver with a Kansas City-based health company to provide pharmaceutical and other professional services to the clinic as part of a contract between the company, PHA health and the Nation.
The Congressional Health and Social Services Committee met on Jan. 27 to consider the resolution after the Congress voted that morning to amend the special session proclamation to consider ONCR 16-11, which was filed by Congressman James Norris the day before. The billing issue dominated the discussion as several government officials in the meeting heard many details for the first time.
Manon Tillman, the Nation’s Health and Wellness Division Leader told the committee that once the clinic became aware of the billing issue, outgoing Chief Pharmacist Carl Murray began contacting other tribes to find companies that could handle the clinic’s third-party contracts, which led to the selection of the company PBA Health. Tillman said the Muscogee (Creek) Nation also uses PBA Health and waived sovereign immunity in its contract and the company is requesting the same waiver from the Osage.
According to ONCR 16-11, the limited sovereign immunity waiver will be granted in a contract between the Nation and PBA Health. As part of the sovereign immunity waiver, the contract will state the Nation will consent to the state and federal courts of Jackson County, Mo. and will consent to Missouri state law in the interpretation of the contract – should a legal dispute arise.
Tillman said the purpose of contracting with PBA Health is so the company can manage the clinic’s third-party contracts and to keep them current “instead of us having to do that because that would be a real tedious job, you’d have to hire extra staff in order to keep up with all that.”
“Because it’s taken two to three months to get this done, we’re now behind on our billing,” said Tillman who added the clinic is working on a paper claim billing process so the clinic can attempt to recoup losses from unprocessed insurance claims for patient medications since the Nation assumed control of the clinic on Oct. 1, 2015.
Norris asked Tillman how much money is waiting to be collected from the unprocessed billing. She replied: “According to the pharmacy, it’s about $75,000 a month and it’s going to cost us about $100 per month to use this company” to handle the billing for the rest of the year, which is the length of the proposed contract with PBA Health.
Tillman also said contracting for the medical side of the clinic is taken care of by a separate company for its billing and is not affected by this issue.
Murray, whose last workday at the clinic was that same day, told the committee the clinic handles roughly 8,000 insurance claims per month for prescription medications. He said PBA Health is also known as a PBM which is a “pharmacy benefit manager” and the service the company is providing is a contracting service. “In order for us to bill electronically … I can’t bill (electronically to the insurance companies) without a contract. I can paper-bill them, but that would be cumbersome,” Murray said, adding about 85 percent of pharmacy claims across the Nation go through a PBM.
ON Attorney General Holli Wells told the committee she objects to any waiver of sovereign immunity waiver and said she’s been aware of the PBA Health contract since late November and stated she is concerned the company would be contracting on behalf of the Nation and other terms she believes are unfavorable to the Nation. Wells said she also raised her issues with the contract to avoid setting a “bad precedent” for future contracts after negotiations with the company went nowhere regarding the sovereign immunity waiver issue.
Several officials attributed the issue to poor communication and Murray said he was led to believe from the Area Office the clinic would have access to the federal contracts, but the clinic started receiving billing rejection letters when the compact took effect. Once signed, Murray said the Nation’s contract with PBA Health will be for one year.
Assistant Attorney General Clint Patterson said he and other ON staff tried to negotiate changes to the PBA Health contract, but were unsuccessful and said he was not made aware of the billing issue until late in the negotiation process and had he known, the office would’ve gone in a different direction due to the situation.
Congressman Archie Mason said he also opposed the sovereign immunity waiver, but noted the severity of the situation for the clinic to collect revenue.
After the committee meeting discussion, the Congress reconvened and voted unanimously 10-0 to pass the resolution with two absences that day from Congress members Ron Shaw and Shannon Edwards.
Original Publish Date: 2016-02-11 00:00:00
