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Electronic claims processing is coming of age. nearly half of the more than 3.6 billion claims providers submitted during 1995 were transmitted electronically. Providers submitted an estimated 47% of all claims electronically last year, compared to 41.5% in 1994.
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Providers are submitting a growing majority of claims electronically. But physicians trail hospitals and pharmacies in the use of EDI.
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The role of the regulator in health insurance is examined in the context of the change in nature of regulatory oversight necessary to monitor the activities of the regulated parties. Health insurance to this point has been largely regulated by insurance departments that have historically focused on monitoring the solvency and meeting the contractually required reimbursements for indemnity carriers. Now as the indemnity carrier has either migrated to managed care or faced a declining book of business, the historic role of regulation must change to match the new environment. This article examines the role of the health insurance/managed care regulator department under this new paradigm and identifies where and how the regulator can exert influence in such a system.
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The federal law pertaining to the creation of the Medical program, USC 42, recognizes the Medicaid beneficiaries sometimes receive healthcare services at facilities outside of their home states. This law, therefore, requires that Medicaid plan provide for the inclusion of out-of-state providers in their programs. The regulation promulgated to implement this law, 42 CFR section 341.52, states the Medicaid plans must provide a mechanism for paying out-of-state healthcare providers that treat the plan's beneficiaries. The law says that a state must "pay for services furnished in another state to the same extent that it would pay for services furnished within its boundaries..." However, many providers that render service to Medicaid patients from other states often do not receive the reimbursement they are entitled to because they do not carefully monitor this segment of their patient population. Healthcare providers can take steps to ensure they receive payment for the services they provide to out-of-state Medicaid patients. These steps include billing for such services properly, investigating additional sources of reimbursement, appealing reimbursement decisions, and participating in bordering states' Medicaid programs as contract providers.
This document makes technical corrections to final regulations published on July 10, 1995, at 60 FR 35498, concerning Medicaid agencies' actions where third party liability (TPL) may exist for expenditures for medical assistance covered under the State plan.
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