December 9, 2019

December 09, 2019

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HealthyChoice Illinois Deadlines Approaching

Illinois Medicaid is transitioning to HealthyChoice Illinois. Time is running out for providers to enroll with the state-contracted managed-care organizations. Providers who have not signed managed-care contracts with the state contracted managed-care organizations will not be in network to provide Medicaid services as of April 1, 2018(MMAI remains a separate system). Managed-care organizations are required to accept all willing providers. However, providers are seeing variations from the standard contract. We recommend that all providers have their managed-care contracts reviewed by legal counsel.

Providers are seeing several issues related to contracting: 

  1. Several managed-care organizations are seeking additional credentialing materials prior to enrolling providers. Unless the provider is enrolling as a provider in lines beyond HealthyChoice Illinois, there should not be credentialing beyond the IMPACT system.

  2. MCOs are requiring that overpayments should be returned within 60 days of receipt. The provision should be "returned when the overpayment is identified."

  3. Make sure your physician providers are enrolling in MCOs. Participating with an insurer in their commercial line of business does not necessarily enroll you as a provider for Medicaid purposes. 

  4. Watch the quality initiatives. Some MCOs are including the number of appeals the provider files as a quality incentive. Most of the state is experiencing this program for the first time so there may need to be a larger volume of provider appeals initially. 

  5. Watch the timing of your appeals. The MCO owes you a substantive response within 30 days. If they keep negotiating piecemeal you could lose your 180 day formal appeal right. 

  6. Per HFS, Providers are entitled to interest if the MCO does not pay within 30 days of a clean claim. 

  7. Understand how you will be paid. Ask for the provider manual before you contract with the MCO.

  8. Watch the investigatory powers requested by the MCO. Try to limit their access to your records to those that are required by law. 

  9. Long-term care providers should negotiate the claims period to run from the last day of the month after the admit pack is approved, not the date of service. There can be substantial liability for services if a resident’s Medicaid approval is delayed. 

  10. If you want to contract with a MCO and don’t have a contract, just request one. MCOs are required to accept all willing providers. 

  11. Make sure you get a signed copy of the contract so the MCO cannot later claim that you are out of network.

© 2019 Heyl, Royster, Voelker & Allen, P.C

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About this Author

Deanna Mool, Heyl Royster, healthcare regulatory lawyer, Estate Planning attorney, FCA
Of Counsel

Deanna’s practice is primarily focused on healthcare regulatory law (including HIPAA, Stark, and Anti-Kickback compliance, False Claims Act issues, and contracting), and Estate Planning.

In the practice of healthcare law, Deanna has represented hospitals, nursing homes, assisted living facilities, physicians, audiologists, nurses and other healthcare professionals. She gained valuable healthcare law experience as General Counsel to the Illinois Department of Public Health (1996-2001). She also served as in-house counsel at the SIU School of...

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