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ONE HUNDRED NINTH LEGISLATURE
SECOND SESSION
LEGISLATIVE RESOLUTION 427
Introduced by Riepe, 12.
PURPOSE: The purpose of this resolution is to propose an interim study to
review the performance and policies of managed care organizations in the
medical assistance program. Managed care organizations administer comprehensive
health care services for a significant majority of Nebraska's medicaid
beneficiaries, primarily low-income residents, children, seniors, and disabled
individuals. Nebraska contracts with three managed care organizations to
provide medical, behavioral health, long-term care, and related services under
the medical assistance program. Health care providers, patient advocates,
beneficiaries, and other stakeholders have raised concerns regarding the
transparency, timeliness, and consistency of managed care organizations'
processes and requirements that may affect access to medically necessary care.
The interim study shall include, but not be limited to, an examination of
the following:
(1) Prior authorization processes. Review prior authorization requirements
used by each managed care organization, including non-acute hospital admin day
payments, criteria, documentation requirements, turn-around times, and appeal
procedures;
(2) Coding and downcoding practices. Analyze denials or adjustments of
claims based on coding decisions that may reduce provider reimbursement,
increase administrative burden, or affect continuity of care, including (a) the
use of artificial intelligence, (b) the reclassification of nonemergent
emergency room reimbursement based on initial admission or the presenting
complaint rather than the final discharge diagnosis, and (c) the frequency and
basis for the reclassification of inpatient stays as observation stays when the
patient stays at least two midnights; and
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(3) Managed care structure and contracting. Evaluate the effectiveness of
contracting with three separate managed care organizations, including
competition, performance metrics, accountability, and cost outcomes.
NOW, THEREFORE, BE IT RESOLVED BY THE MEMBERS OF THE ONE HUNDRED NINTH
LEGISLATURE OF NEBRASKA, SECOND SESSION:
1. That the Health and Human Services Committee of the Legislature shall
be designated to conduct an interim study to carry out the purposes of this
resolution.
2. That the committee shall upon the conclusion of its study make a report
of its findings, together with its recommendations, to the Legislative Council
or Legislature.
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