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MEDICAID MANAGED CARE: 2018 Session Review

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Legislators on the Health/Human Services Budget Subcommittee have continued to hear your concerns about Medicaid managed care and spent the entire session investigating these problems.  The House of Representatives passed two bills to address billing errors, poor communications, and expectations when dealing with Medicaid members.  The votes were unanimous (97-0 & 95-0), but the Senate did not bring them up for a vote.  

While legislators talked about this for 118 days, decisions came down to the final hours.  Ultimately, MCO oversight was added to the Health/Human Services Budget (SF 2418).   It is important to note that this is now the law.  While many of the things noted below are included in the MCO contracts, contacts can be changed by DHS and the Governor.  The law can only be changed by legislators, during a legislative session.   

Medicaid MCOs are now required by law to do the following:

  • Pay claims accurately, use the right rates, and give reasons for any full or partial denials. They are to do this in a way that is consistent with national industry best practices.  

  • Correct any errors they find in their systems “within a reasonable timeframe" and reprocess claims affected by the error within 30 days of the correction.  DHS will determine what a "reasonable timeframe" is for corrections.  

  • Give 60-day written notice to affected individuals when there is a program or procedural change.  That would include the persons getting the service as well as the providers of the service.  However, DHS will develop a list of changes that require 60-day notice by July 1, 2018, so not all changes will be subject to this new law.  Changes that may be included in this notificiation period include billing and collection procedures, provider network provisions, member/provider services, and prior authorization requirements.  Watch for updates on this after July 1.
  • Approve and pay for at least three days of court-ordered substance use disorder treatment or mental health services before requiring prior authorization or medical necessity standards be met.  This makes sure hospitals can stabilize a person in crisis without fear that the MCOs will deny coverage or delay approval.
  • Use a standard Medicaid provider enrollment form and a uniform credentialing process developed by DHS.
In order to ensure better member services and make sure MCOs are complying with their contracts and the new laws, DHS is now required to do the following:
  • Convene a Health Home Work Group with integrated health home providers, chronic condition health home providers, and MCOs to review health homes, look at what is required in the state plan amendment, discuss the rationale for any proposed changes, develop a consistent delivery model that clearly defines outcomes and data reporting requirements, and implement a communications plan that keeps stakeholders informed on the operation and administration of the programs.   A report on the group's work is due December 1, 2018, including recommendations and actions taken.
  • Review the effectiveness of MCO prior authorizations.  The Medicaid director has publicly said services that are nearly always approved should not be subject to prior authorization.  Why go to the extra work to get a service authorized if it is approved 99% of the time?
  • Hire a dedicated provider relations staff to help providers to resolve billing conflicts with MCOs (including claims denials, technical omissions, incomplete information). These staff will watch for trends, and report them to DHS for further review.  
  • Maintain and update Medicaid member eligibility files in a timely manner.  MCOs have said some of the errors stem from bad information in DHS eligibility files; legislators hope this will lead to fewer errors and service denials.
  • Hire an independent external quality review consultant to randomly sample decreased level of care determinations to make sure the MCOs are providing appropriate medically necessary services and are following national industry best practices in their decision-making. The consultant is to report on findings, with a plan of corrective action, by December 15, 2018.   
  • Annually review all appeals dismissed, withdrawn, or overturned to watch for any negative patterns or trends.  Members whose appeals are subject to this review will have their services continued while the new assessments are being done, up to 90 days. DHS is to report these findings twice a year (biannually).
  • Contract with an independent review organization to perform small claim (less than $2,500) audits denied or paid to long term care services and supports providers during the first quarter of calendar year 2018 (with report and findings by February 1, 2019).

The focus of most of these changes is on internal processes and administration which legislators feel is the main reason for system problems.  It does not address payments to providers, which many think is the real reason for service disruptions and denials.  Again, we'll be watching this closely and will report back as these groups meet and as these changes are implemented.