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Medicaid Patients and Physicians Beware

From the Orange County Medical Society

The Orange County Medical Society has been alerted to the latest administrative challenge being presented Medicaid beneficiaries in Florida and the professionals trained to care for them. In a departure from tradition, it appears that Medicaid Managed Care carriers have the authority to impose prior authorization procedures and denials for patients admitted to the hospital. This authority could delay treatment at the bedside and lead to increased denials of physician claims.

The OCMS was alerted to this scenario by one of our members who recently received a series of denials from one of the carriers in our region. Upon query from the OCMS, the Florida Agency for Health Care Administration confirmed that the current contract with Medicaid Managed Care Companies requires the provision of "Post-Stabilization" services without authorization. However, for "scheduled admissions", the carrier is allowed to implement prior authorization protocols for in-patient services and consults. There are timeframes for insurance carriers to respond, but those timeframes vary from 1 hour to 7 days. The assumption is that any admission that did not result from an initial emergency situation could be subject to prior authorization protocols.

This scenario creates a significant amount of uncertainty and administrative burden for physicians. It also creates a real possibility that patients and families will face longer wait times in the hospital as treatment authorization is secured. Our organization strongly believes these administrative procedures will not contribute to increased efficiency or quality care for Medicaid beneficiaries.

The OCMS is committed to taking action on this issue to protect our patients and physician members. Patients may want to ask their insurance company about their in-patient prior authorization protocols and response times.

Additional information will be available for members on the OCMS website.

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