Help for Medicaid MCO Providers

New portal designed for disputes and denials that cannot be resolved through existing processes
By Arvind K. Goyal, MD, MPH, MBA

PHYSICIANS generally choose medicine as a career in which to serve, care, and comfort. Beyond that our paths may diversify: practice, teach, research, counsel, manage, or hybrids of those core functions.

As the current medical director of Illinois Medicaid, Department of Healthcare and Family Services (HFS), I often field questions from Chicago-area physicians. Now that Medicaid managed care has taken hold in Illinois, providers report encountering issues with individual Medicaid Managed Care Organizations (MCOs), some of which cannot be resolved using existing processes designated by the MCO. This column, submitted at the request of Chicago Medicine magazine, discusses the purpose of a new online portal for resolving denials and disputes.

Presently, there are 12 Medicaid MCO plans contracted with the state, serving several regions. The Medicaid managed care transition was legislated by a 2011 Illinois law that required more than 50% of Medicaid recipients to be enrolled in MCOs. Medicaid covers 3.2 million Illinois residents, a quarter of the state’s total population; 650,000 joined under the Affordable Care Act of 2010. And, 64% of all Medicaid recipients are currently enrolled in a self-selected, or in an assigned health plan (if they failed to choose).

HFS Deputy Director Robert Mendonsa, who himself was once the CEO of a successful MCO, likes to say: “No physician rises in the morning wanting to make trouble for an MCO. And no CEO wakes up promising to anger a physician caring for a plan member before that day is over!” Yet when disagreements and disputes do occur, and the physician has been unable to reach an accommodation even after attempting to communicate directly with an MCO, that’s the time to utilize the new secure electronic web-based portal.

Where Do I Complain When an MCO Fails to Address My Concerns?
“HFS recognizes the importance of providers having a mechanism for reporting and resolving issues encountered with an individual Medicaid MCO when these issues cannot be resolved using existing processes designated by the MCO,” explained HFS Director Felicia F. Norwood in a provider notice sent on Feb. 15. “A major goal of the new MCO provider complaint portal is to facilitate prompt and fair resolution of disputes between MCOs and providers. Issues impacting immediate access to care will be expedited,” Norwood stated.

The new complaint portal does not replace issue reporting and escalation processes already in place between providers and an MCO. Prior to submitting a complaint through the online portal, issues must already have been submitted to and reviewed by the MCO in question. If HFS determines a complaint was submitted to the HFS prior to the MCO being afforded an opportunity to resolve it directly with the provider, that complaint will be closed immediately.

Providers should carefully identify those representatives within their organizations who will be designated to use this complaint system for unresolved issues. The name of the representative submitting the complaint will be shared with the MCO, and outcomes will be reported only to the provider representative whose email is entered in the system with the complaint. HFS will collect and publicly report the volume of complaints received and resolved by provider type, MCO, and other categories.

HFS staff will follow HIPAA privacy procedures when using this secured site and providers must do so as well as a condition of use. Medical providers will be able to upload protected health information to the secure provider complaint portal.

If the complaint relates to a specific individual or claim, or group of related claims, providers must share the relevant member name(s), HFS 9-digit Recipient Identification Number(s), and date(s) of service. Each complaint should be for a single topic for a single MCO; please do not combine several issues or designate more than one MCO on the same complaint.

The complaint portal link can be found on HFS’ Care Coordination webpage, or can be accessed directly from the HFS Managed Care Provider Complaint webpage. Please note this new system is designed specifically for enrolled providers reporting and resolving issues with Illinois Medicaid MCOs. Any provider complaints related to the resolution of Medicaid Fee-for-Service issues should continue to be directed to HFS at 877-782-5565.

For clinical and medical policy concerns or questions about the Medicaid program or Medicaid managed care, please feel free to contact me. If you have suggestions for future topics pertaining to Medicaid managed care, please send them to Elizabeth Sidney (esidney@cmsdocs.org) so she can prioritize them for publication.

Arvind K. Goyal, MD, MPH, MBA, is the Medical Director for Illinois Medicaid, Dept. of Healthcare and Family Services, located at 401 S. Clinton St., 4th Floor, Chicago, Ill. 60607. He can be reached also at 312-793-5277 (Chicago Office); 847-921-3683 (24/7 cell); or Arvind.Goyal@illinois.gov