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Managed Care

MANAGED CARE

By Alexandra Weingarth, Policy and Advocacy Director

One of OCHCH’S main priorities is to alleviate burden surrounding managed care. While we know that the re-procurement process is approaching, we do not want to wait for our issues to be resolved at an unidentified timeline. Therefore, we have suggested regular meetings between provider associations, the Ohio Department of Medicaid, and the plans. Last week was our first meeting with the ODM where we asked them to provide their interpretations of certain statutes, and what authority the managed care plans may or may not have regarding ODM’s interpretations. Internally, we have been collecting data and case information from our members to provide examples to the Department.

This will be an ongoing process, so if you have any additional information that you would like us to include in our conversations, please email alex@ochch.org. Additionally, ODM will be taking a close look at the home health “claims portal.” They have asked to urge providers to submit a claim if there is an issue regarding managed care. This is important because they collect data from those claims to track trends in the managed care plans.

Once ODM sends us their interpretation of managed care rules and statute we will share it with you. We want our members to be well educated on these provisions and let us know if a managed care plan is incorrectly interpreting a statue. We are excited to diligently work on these issues and are always advocating your interests. If you have any additional questions or concerns about this process please reach out to the Policy and Advocacy Director, Alex Weingarth at alex@ochch.org.


Alexandra Weingarth

Help Desk Question of the Week

 

HOME HEALTH:  RCD Claim Approval Rate Calculations

Question: I heard in workshops that under PCR if a non-affirmation is given the provider can resubmit as often as they need to get an affirmation. The attached article does not reflect the same information.

Answer: The provider is confusing PCR affirmation rates with Claim approval rates. These are two different items.

  • The article is for claim approval rates for providers that have the postpayment claim reviews via the ADR process (post pay, spot check, etc.), not PCR. The article is correct.
  • PCR affirmations are for providers who utilize Pre-Claim Review. It is correct that under PCR, if a non-affirmation is given, the provider can resubmit as often as they need to get an affirmation.

OCHCH requested that the article, RCD Claim Approval Rate Calculations, be updated to make it clear which option the calculations are affecting. This was Palmetto GBA’s response:

  • Please note that a claim approval rate is different than the Pre-Claim Review (PCR) affirmation rate. The claim approval rate is for agencies that selected an RCD ADR option (Post Payment Review, Selective Post Payment Review, Spot Check). The PCR affirmation rate is for agencies that selected the PCR option.