How to Contest a Drastic Reimbursement Cut by Medicaid....
Approximately 70 percent of all Medicaid patients are covered by Medicaid Managed Care Plans (“Plans”). An insurance company administers a Plan. The Plan receives money from the state Medicaid program to take care of Medicaid patients. The Plan, in turn, signs up patients and contracts with health care providers, including DME suppliers. The Plan is in the business of making money, meaning that it is motivated to pay as little as possible to providers. It is becoming all too common for a Plan to (i) enter into a “sole source” contract with one DME supplier (often, an out-of-state supplier) or (ii) reduce reimbursement to such an extent that only the Plan’s “preferred” supplier can afford to service the Medicaid patients ... in which case the products are substandard, and the services are nonexistent. This program will discuss the steps that DME suppliers can take to oppose sole source contracting and drastic reimbursement cuts. Such steps include (i) talking to the state Medicaid program; (ii) talking to state legislators with jurisdiction over the state Medicaid program; (iii) working with state legislators to sponsor legislation to counter the Plan’s actions; (iv) running an ad campaign; and (v) within certain parameters, educating the Plan’s covered lives about the problems arising out of a sole-source contract and drastically reduced reimbursement.
1. Understand how a Medicaid Managed Care Plan comes into existence.
2. Understand the rights granted to and obligations imposed on Plans by state Medicaid programs.
3. Learn the steps that DME suppliers can take to oppose sole source contracting and drastic reimbursement cuts.