GENERAL LAYOUT

LEGAL FRAMEWORK FOR THE PORTAL:

The Portal was established by 44 Ill. Reg. 4616 and became effective as of March 3, 2020. HFS now utilizes the Portal to encourage prompt resolution of disputed claims between Providers and MCO payors. Under the new Illinois laws and regulations, Providers may submit disputed claims to the Portal through a uniform complaint system (limited to 100 complaints per submission) to resolve the claims. There are however many caveats to this noble arrangement.

PROCESS:

• First, Providers can only submit these disputed claims to the Portal after the internal dispute resolution process (es) of the subject MCO payor has been completed. If Providers do not complete this internal dispute step, HFS and the Portal will reject the complaint.
• Second, there is a limited time window within which to submit the complaint. Provider cannot submit the complaint until 30 days after submitting the claim to the MCO through the internal dispute process, and no later than 30 days after the unsatisfactory resolution of the internal MCO process or 60 calendar days after submitting the dispute to the MCO internal process. Providers must follow this strict period for the claim to be eligible for use through the Portal.
• Third, the Dispute Resolution itself does not objectively favor Providers. The system is set up in such a way that after the complaint is submitted through the Portal, HFS will submit the complaint to the MCO and the MCO will review the complaint and issue a proposal for resolution. Arguably, if the MCO has already denied the claim through its internal dispute process, it will not change its previous denial if nothing has changed. Further, if the proposal that the MCO submits is unsatisfactory to the Provider’s liking, the Provider can only appeal to HFS. The current Illinois rules and regulations are not specific enough nor clear enough to protect Providers from the erroneous MCO denials from being upheld. There are no specific requirements that HFS utilize skilled, unbiased reviewers. There are no requirements that clinicians review matters involving clinical denials. In fact, there is no requirement that HFS even utilize a process that ensures established guidelines or rules as to why HFS upheld or overturn a denial.
• Fourth, the decision is FINAL. If HFS upholds the MCO’s proposal/denial – Providers have no further recourse. Providers lose all rights for recovery once the Portal process is complete.

SAC RECOMMENDATION

We strongly encourage our clients to consider the contractual protections they have agreed to in their established, well negotiated, MCO contracts and understand that such protections offer more effective advocacy. The Dispute Resolution provisions within MCO agreements have clear, unique, specific guidelines that the Portal lacks.

In addition, for denials regarding clinical claims and claims for no authorization that require medical records and expert testimony, Providers should avoid using the Portal. The Portal system does not require expertise or specialization. HFS rules and regulations are not specific nor defined enough to establish the definition of medical necessity or convince an undetermined HFS reviewer that even if a claim lacks authorization, the claim should still be paid because the services were medically necessary and the Provider performed the medically necessary services. Providers are more likely to make successfully this foundational argument in dispute venues other than the Portal.

While we understand HFS intended to allow for expedient, effective MCO claim dispute resolution, we must remind out clients that HFS and the state are an interested party in this matter and the Portal does not protect Providers from that bias. The effective accountability of neutral third parties through either the Courts or Professional Dispute Resolution Systems like AAA offer additional protection that the Portal does not have. Should a judge rule improperly, or an arbitrator go way off the ranch – a Provider may be able to appeal. Under the Portal, Providers have no such recourse. Further, unlike the Portal, in a lawsuit or arbitration – it is possible to introduce precedence of prior rulings in similar matters that can effectively persuade a neutral third party. The Portal does not establish, nor require, nor efficiently implement the use of precedent and previous rulings when considering your complaint.

For those Providers handling MCO claims in non- contracted situations, we encourage our clients to consider the cost –benefit analysis of a lawsuit against an MCO versus a submission through the Portal. The quick, relatively simply process of the Portal is quite attractive, but rife with potential restrictions and limitations.

As always, we serve you and we will continue to advocate for your best option for recovery.

Should you have any questions, please do not hesitate to contact me at mmorrow@sacfirm.com or at (312) 626-1870.

Marcus R. Morrow, Esq.
Attorney at Law
The Law Offices of SAC