RÉSUMÉ DIGEST
ACT 489 (SB 507) 2018 Regular Session Mills
New law requires each Medicaid managed care organization (MCO) to comply with the
following notice provisions regarding contracted provider status and ability to begin
providing services and submitting claims for reimbursement:
(1)Requires each MCO that contracts with or enrolls a provider into its provider
network to furnish written notice to the provider that informs the provider of the
effective date of the contract and enrollment.
(2)Unless otherwise authorized, each provider is prohibited from submitting Medicaid
reimbursement claims for any services provided prior to the effective date indicated
in the written notice.
(3)The written notice is to be sent to the last mailing address and last email address
submitted by the provider.
Requires MCOs to comply with the following notice provisions regarding contracted
provider re-credentialing:
(1)Provide a minimum of three written notices to a contracted provider with
information regarding the re-credentialing process, including requirements and
deadlines for compliance. Requires the first notice to be issued no later than six
months prior to the expiration of the provider's current credentialing and the notice
is to include the effective termination date if the provider fails to meet the
requirements and deadlines of the re-credentialing process.
(2)Notice to be sent to the last mailing address and last email address submitted by the
provider.
(3)Provides that upon failure of a provider to timely submit all required documents and
meet all re-credentialing requirements, the MCO is to send a termination notice to
the provider with an effective date of termination to be 15 days after the date of the
notice. Requires that the managed care organization is responsible for paying any
claims for services delivered prior to the termination date.
Provides for termination and removal from a provider network for reasons other than failure
to comply with re-credentialing process and for written notice to be sent by certified mail
to the last known mailing address submitted by the provider. Provides for termination 15
days from date of the notice. Provides for immediate termination due to loss of the required
license or other certain circumstances specified in new law.
Requires each MCO to be responsible for ensuring that any provider it contracts with or
enrolls into its network has attained and satisfies all Medicaid provider enrollment,
credentialing, and accreditation requirements and all other applicable state or federal
requirements in order to receive reimbursement for providing services to Medicaid
recipients. Provides that if the MCO fails to ensure proper compliance with Medicaid
provider enrollment, credentialing, or accreditation requirements then it is liable for
reimbursement to the provider for any services rendered to Medicaid recipients until such
time as the deficiency is identified and notice sent to the provider. Provides that
reimbursement for any services provided during the 15 day remedy period after notice of the
deficiency was identified or during a longer period if allowed by the department, shall be
withheld if the provider elects to continue providing services while the deficiency is under
review. Provides that if the deficiency is remedied, the organization shall remit payment to
the provider and if the deficiency is not remedied, then the MCO may recoup funds from the
provider.
Provides that if a provider cannot remedy the deficiency within 15 days and believes that the
deficiency was caused by good faith reliance on misinformation by the MCO and the
provider asserts that he acted without fault or fraudulent intent, the provider may seek
departmental review if he believes there is no deficiency or that because of his reliance on
misinformation from the MCO, he cannot remedy the deficiency within 15 days. Provides
for exceptions to allow reasonable time to come into compliance so as to not disrupt patient
care. Requires that the provider prove absence of fault or fraudulent intent by producing guidance, applications, or other written communication from the managed care organization
that bears incorrect information including whether the misinformation or guidance was
contradictory to applicable Medicaid manuals, rules, or policies.
Requires the department to review all materials and information to render a written decision
within 30 days of the date of receipt for a review. Authorizes the imposition of penalties on
the MCO.
Provides for immediate termination of a provider's contract if the department's decision is
not in favor of the provider. Provides that the written decision by the department is the final
administrative decision and no appeal or judicial review shall lie from this final
administrative decision.
Provides that each MCO is responsible for mitigating fraud, waste, and abuse of the funds
it receives in the form of per-member per-month rates for the provision of services to its plan
enrollees. Provides that failure of the MCO to execute the provisions of their responsibility
to mitigate fraud, waste, and abuse shall not be considered a risk of the MCO for purposes
of calculating per-member per-month rates and all claims associated with fraud, waste, and
abuse shall be voided. Voided claims shall not be used for purposes of rate setting or by the
MCO to seek an increase in rates or payments. Provides that the MCO is not precluded from
recouping and retaining improper payments and overpayments to a provider.
Provides that in addition to its responsibility to void all claims and encounters associated
with fraud, waste, and abuse of payments made to a provider, the department may impose
penalties on the MCO. Provides for liability of the MCO to the department for any other
costs, expenses, claims, or reimbursement incurred or expended by the department due to
the provider's fault or fraudulent intent.
Requires that each MCO report every instance of suspected fraud, waste, or abuse to the
department and the attorney general and also authorizes the attorney general to investigate,
enforce, impose sanctions upon, and seek recoveries from any MCO pursuant new law and
the Medical Assistance Program Integrity Law. Requires that any recoupments be returned
to the department and that all other sanctions, penalties, civil monetary penalties, and
additional recoveries or costs of investigations obtained by the attorney general shall be
deposited into the Medical Assistance Programs Fraud Detection Fund. Provides that no
MCO or any officer, director, employee, representative, or agent of the MCO shall have any
liability to the provider or any other person for reporting any suspected fraud to the
department or to the attorney general.
Does not prevent the department or the attorney general from enforcing and imposing
penalties otherwise provided by law or regulation nor does it supersede or conflict with
provisions regarding interim credentialing.
New law is subject to approval by the Centers for Medicare and Medicaid Services.
Effective August 1, 2018.
(Adds R.S. 46:460.72 and 460.73)