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Summary of Georgia’sMedicaid Care Management Organization (CMO) Law
August 19, 2008
Robert D. Stone, Esq.Alston & Bird LLP
1201 West Peachtree StreetAtlanta, Georgia 30309
404-881-7270
©Alston + Bird LLP 20072
Introduction & Background
• Brief History of Medicaid Managed Care in Georgia
• Basic Structure• Provider Complaints• Myers & Stauffer Report
• Development of CMO Bill
©Alston + Bird LLP 20073
Major Provisions
General• Effective Date [INSERT]
• Definition of CMO• Every CMO must be an HMO• Under Contract with DCH
• “Subject to” provisions• HMO Law• Managed Health Care Plans
• Role of Insurance Commissioner• No authority to modify CMO contracts• But - retains oversight of CMOs as HMOs and because
CMO Law is part of Title 33 – Insurance Code
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Specific Payment/Coverage Provisions
Payment of Emergency Services
• Specific criteria must be considered• Out of network coverage rate equal to DCH rate
Coverage of Newborns
• Coverage by Mother’s plan until discharged home
Verification of Eligibility Procedures
• Services provided with 72 hours of verification
©Alston + Bird LLP 20075
Provider Enrollment –Dentists
CMO may not deny participation to a licensed dentist
who meets general enrollment requirements and who:
• Will provide services pursuant to a federally funded educational loan forgiveness program
• In area designated as “dental professional shortage area”
• CMO has opportunity to show it has sufficient coverage
©Alston + Bird LLP 20076
Information Technology
Websites
• CMOs required to maintain websites with current, searchable list of providers
Electronic Payments & Claim Adjudication
• CMOs required to maintain capability for electronic payment and claims adjudication
• Remittance advices must be provided within one business day of payment
©Alston + Bird LLP 20077
Additional Provisions
Standardization of Timeframes• Same timeframes as DCH for submissions, processing,
payment and appeal
Prohibition on Leveraging Contracts• CMOs prohibited from requiring a provider to enter
separate contract to enroll as Medicaid provider• Providers prohibited from requiring CMO from entering
into separate contract with a different provider
Hospital Statistical & Reimbursement Reports (HS&R)• CMOs must provide within 30 days of request
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Complaints and Appeals
Special Remedies for Critical Access Hospitals
• A finding that CMO “substantively & repeatedly breached” contract may result in treble damages
Arbitration Option
• Provider has option to seeks ALJ review or binding arbitration
• Costs of arbitration (except attorney’s fees) shared equally
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Complaints and Appeals
Interest Applied to Underpayments
• Improperly denied or underpaid claims are subject to interest at 20% per annum
• Interest calculated from 15 days after claim submitted
• No interest if claim was inaccurate or had material omission
Consolidation of Claims/Appeals
• Claims must involve “same or similar payment or coverage issues”
Summary of Georgia Medicaid Care Management Organization Law
Georgia Hospital AssociationT2421 - WebinarAugust 19, 2008
Robert D. Stone, Esq.Alston & Bird LLP
1201 West Peachtree StreetAtlanta, Georgia 30309
404-881-7270
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