Plain English Breakdown
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Medicaid Managed Care: Limits on Claim Payment Methods
This act changes Louisiana's Medicaid managed care rules to stop certain healthcare companies from using a specific math method called 'extrapolation' when checking claims made by doctors and hospitals.
What This Bill Does
- Changes the law so that managed care organizations cannot use extrapolation to check claims made by healthcare providers.
- Requires any additional payments or refunds between healthcare providers and managed care organizations to be based on actual overpayments or underpayments, not estimates from extrapolation.
- Allows state departments to continue using extrapolation for audits as long as it follows existing laws and regulations.
- Makes sure that contracts cannot override the new rules about extrapolation.
Who It Names or Affects
- Healthcare providers who receive payments through Medicaid managed care organizations in Louisiana.
- Managed care organizations that handle Medicaid claims in Louisiana.
Terms To Know
- extrapolation
- A math method used to estimate results for a larger group based on a smaller sample, which is now banned by the act when managed care companies audit healthcare providers' claims.
- electronic funds transfer
- An electronic payment system that uses federal standards and networks to move money between accounts.
Limits and Unknowns
- The law does not specify what happens if a managed care organization violates the new rules.
- It is unclear how this change will affect existing contracts or agreements between healthcare providers and managed care organizations.