Illinois Medicaid Managed Care Transition

Published November 1, 2018 by Carol Hamerski

We are officially 6 months into the State of Illinois State Wide Medicaid Managed Care Transition.  Of course some areas are running smoother than others.  Now is a good time to take note of what is working in your office and what isn’t.

Implement eligibility checks through your clearinghouse to ensure you have the correct payer for the date of service. MEDI or clearinghouse eligibility should show you if the patient is in fee-for-service traditional Medicaid or with an MCO.

Many of the MCO’s require prior authorization for certain procedures.  Your office and billing staff should be aware of which procedures require prior authorization and how to communicate authorizations obtained with the billing office.    Appropriate coordination and communication between these staff members is essential to ensure payment for those services so the claim matches the provider and procedure with the authorization on file at the carrier.

As the MCO’s are working through this implementation process, there have been multiple claim processing issues come to light.  It is important to promptly notify them of or appeal any claims which appear to be processed incorrectly.  We have found inconsistencies between the carriers in processing of the add-on payments for children and maternal health, sequestration reductions, and fee schedules.  By working with the payer representatives on specific issues and examples, we have been able to get various processing issues addressed and corrected.

If you are still considering contracting with the MCO’s but aren’t sure which one, consider the facilities you provide services in and which MCO’s they participate with, talk with your patients, and review the provider requirements of each carrier.  If you continue to see MCO patients out of network, you are required to have a prior authorization for any service provided, including office visits, which is very time consuming for staff but necessary to be paid for the service.

https://www.illinois.gov/hfs/SiteCollectionDocuments/201809MCOEnrollmentReportforWebsite.pdf

Carol Hamerski
CPA, CPC, CPCO
Partner-in-Charge

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