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Illinois bills would reform Medicaid managed care

The Quad City Times - May 5, 2019 -- Two bills introduced to the Illinois Statehouse would reform managed care companies under Illinois' Medicaid program.

House Bill 2814 and Senate Bill 1807 aim to "provide a path to rein in repeated abuses by managed care organizations in their oversight of hundreds of millions of dollars of care each year provided by hospitals who treat Medicaid low-income patients," according to a press release.

"We have a broken system here in Illinois, and it's threatening the very nature of our health care providers and the patients they serve all around the state," Senate Majority Leader Kim Lightford (D-Dist 4) said in a press conference Tuesday.

Before 2011, Illinois used a fee-for-service program with Illinois Department of Healthcare Family Services overseeing providers, Lightford said. "In 2011, we started to transition to a managed care program [with] private insurance companies, many of them for-profit companies, were brought in to take over Medicaid," she said. That was done to coordinate care and try to save the state money. "Unfortunately, neither have worked."

Lightford alleges the MCOs are denying and delaying. When the General Assembly asked the Auditor General to audit MCOs in 2018, they found Family Services didn't maintain complete and accurate information to monitor $7 billion in dollars paid to MCOs. "Instead of coordinating care and services and saving the state money, MCOs get their savings by denying claims submitted by hospitals at an average of 26 percent statewide."

The proposals would:
  • Treat hospitals as expedited providers who regularly need quicker payments
  • Discharge patients more quickly upon a doctor’s release or pay for keeping the patient hospitalized
  • Update health care provider rosters weekly and reimburse those providers with MCO contracts for medically necessary services regardless if the provider is on the updated MCO roster
  • Provide reasonable time to fix errors on non-electronic health care claims

"Every week, I hear from different health care providers calling about the problems they're having with the MCOs," Rep. Camille Lilly (D-Dist. 78) said. Among those being denied claims are hospice facilities and nursing homes. "The way managed cared organizations have been implemented in Illinois today have harmed the most vulnerable people in our state, and it's unfortunate that they are suffering."

"We need to make sure that managed care organizations adopt common sense business practices to cut down on payment denials and delays for medically necessary care that hospitals are providing in good faith," said co-sponsor Sen. Andy Manar (D-Dist. 48).

(by Matt Enright