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Why some Medicaid providers in Colorado aren't getting paid

Colorado Community Health Alliance said it's a system issue, but for a second time in a few months, Medicaid providers in Colorado are working and not getting paid.

DENVER — You work, you get paid.

Except for the second time in a few months, Medicaid providers in Colorado are working and not getting paid.

Some of the state's most vulnerable rely on Medicaid services.

"We specialize in working with children, teens and families. And specifically, we work a lot of children who are either in foster care currently or have been adopted from foster care," said counselor Sybil Cummin, Clinical Director of Arvada Therapy Solutions.

Cummin has an email inbox full of service denials.

"I wake up and get 30 denials in my inbox," said Cummin. "Therapists that accept Medicaid for CCHA are not getting paid due to a claims error on their side."

Colorado Community Health Alliance (CCHA) handles the Medicaid program for eight counties in the state: Boulder, Broomfield, Clear Creek, El Paso, Gilpin, Jefferson, Park and Teller. Providers submitting claims for certain services covered by CCHA have been denied this month.

"I received an email today stating that they have not fixed the problem and that they are not sure how long it will take for me to get paid," said Cummin.

In an email from the CCHA clinical services director, 9NEWS was told: "There was a brief, 10-day, claims system configuration issue identified on February 7th that impacted the billing of five specific CPT (Current Procedural Terminology) codes. Providers were notified of this issue on February 10th and informed that these claims would be automatically reprocessed by CCHA. The issue has been resolved and the claims reprocessing is underway. Once reprocessed, we will still be within the 30-day time frame to pay a claim."

According to Cummin, some of the five codes being denied include therapy sessions that last around 30 minutes and 45 minutes.

"I have actually had to look into maybe getting a small business loan, so that I can continue to cover payroll and cover health insurance for my team," said Cummin. "And then as the business owner, that means that, guess what, I don't get paid."

Cummin signed on to a letter with 40 other counselors seeking a no-interest loan fund provided by the state to pay providers when CCHA does not. That letter was sent to specific state lawmakers and the Colorado Department of Health Care Policy and Financing.

"I've looked into some small business loans, and I'm going to have interest of up to 10%," said Cummin. "I can't even tell you how long this is going to be because they can't tell me how long they're not going to pay me."

"I'm receiving denials stating that they are not covered benefits," said counselor Carla D'Agostino-Vigil, Clinical Director of Ignite Counseling. "No money, this latest round, has been since the end of January."

This is the second time D'Agostino-Vigil has dealt with claims issues with CCHA.

Late last year, CCHA sought reimbursement from 199 counselors for services the therapists said they provided, but that CCHA could not verify.

Following coverage by Next with Kyle Clark and The Colorado Sun, CCHA stopped seeking the money back.

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"We serve those that are struggling with Obsessive Compulsive Disorder, trauma and PTSD and substance use disorders are our specialties," said D'Agostino-Vigil.

In October, D'Agostino-Vigil submitted a resignation request with CCHA. She said CCHA requires six months' notice.

"My team and I are not accepting new Medicaid clients," said D'Agostino-Vigil. "Nearly 70% of our practice was serving Medicaid."

She has received a request to rescind her resignation, while now waiting to get paid.

"Our most vulnerable are going without adequate care," said D'Agostino-Vigil.

"This is actually the first year I have ever thought about ending my contract with Medicaid," said Cummin. "The more providers that leave the Medicaid panels that are no longer are going to see our Medicaid population, means that our foster children are not going to get scene. It means that people with trauma are not going to get seen. It means people with addiction are not going to be seen.

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