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[The following is a paid advertisement.]
Consider the case of a patient with severe pain due to sickle cell crisis, when blood flow to an area is blocked by the sickled cells. The patient goes to an emergency department for treatment. The patient meets nationally recognized clinical guidelines for inpatient care, so is admitted to stabilize their emergency condition.
But the Medicaid managed care organization (MCO) insuring the patient denies inpatient coverage. Over a week later, during a peer-to-peer review, the MCO medical director agrees the patient meets the MCO’s clinical criteria for inpatient care. MCO leadership, though, says the criteria should be ignored because there “has to be more than just IV pain meds to approve an inpatient admission.” The denial is upheld.
The example above is one of numerous instances of MCOs managing their costs by denying needed medical services, instead of improving healthcare for Medicaid customers as promised 12 years ago.
The Illinois hospital community is asking legislators to pass commonsense legislative reforms developed by the Illinois Health and Hospital Association (IHA). These reforms address harmful prior authorization practices and eliminate barriers to healthcare for 3.6 million Illinoisans—with NO impact on the State’s Fiscal Year 2025 budget. Support IHA’s MCO reform package.
posted by Advertising Department
Tuesday, May 21, 24 @ 11:08 am
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Previous Post: It’s just a bill
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