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New Lewin Report Shows Need for National Medicaid Out-of-Network Claims Policy
Date:7/16/2009

WASHINGTON, July 16 /PRNewswire-USNewswire/ -- The Lewin Group today released a new report assessing the financial impact and administrative burden that out-of-network claims pose in Medicaid managed care. The authors of the report recommend a federally mandated payment standard for Medicaid health plans similar to that used in the Medicare Advantage managed care program.

The report, "Medicaid Non-Emergency Out-of-Network Payment Study," was commissioned by Medicaid Health Plans of America (MHPA) and the Association for Community Affiliated Plans (ACAP). The report examined Medicaid non-emergency out-of-network payment policies in Arizona, California, Florida, Georgia, Maryland, Nebraska, New Jersey, New York, Pennsylvania, Tennessee, Texas and Wisconsin. Investigators found that out-of-network claims represented at least 8 percent of total Medicaid claims costs, with most out-of-network claims disputes coming from hospitals, pediatric subspecialty providers, academic medical centers and other public hospitals.

The study notes that Medicaid is unique with regard to out-of-network services and payment because providers cannot "balance bill" Medicaid members for covered services. "In the absence of a clear payment policy, providers will often bill the health plan for full charges and an unwelcome negotiation then ensues as both parties seek to arrive at a mutually acceptable amount," noted Debbie Kilstein, ACAP's Director of Quality Management and Operational Support.

Evelyn Murphy, the Lewin study's principal author, emphasized that "Ultimately, states and taxpayers are the ones paying at commercial, or even above-commercial, levels for much of the out-of-network
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SOURCE Medicaid Health Plans of America
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