AAHAM Spring Presentation. Spring 2017
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1 AAHAM Spring Presentation Spring 2017
2 Agenda Items Leadership Updates Clear Coverage Day One Overview Clear Coverage Radiology Overview March 1, 2017 Contact Us Subrogation/Workers Compensation/Coordination of Benefits MedPolicy Blue Appeal/Reconsideration and Other Forms Verscend Edits Modifier 25 and 59 Identification Card Awareness Risk Management Medicare Advantage B L U E C R O S S A N D B L U E S H I E L D O F N E B R A S K A 2
3 Leadership Updates Dr. Joanne Schaffer Executive Vice-President of Health Delivery Engagement Susan Beaton RN.BSN - VP of Provider Services, Care Management and Risk Dr. Debra Esser Chief Medical Officer Dr. Elsie Verbik Medical Director Medical Policy and Quality Dr. Jo Gardner Medical Director Susan Harden Director of Health Network Operations B L U E C R O S S A N D B L U E S H I E L D O F N E B R A S K A 3
4 Clear Coverage Day One Overview BCBSNE is now reaching 90% of the Members at discharge to prevent readmission and address chronic illness. Previously only 10% of members were being reached. Staff Has Been Added to Increase Efficiency 8 Utilization Managers 7 Case Managers 7 Discharge Nurses 3 Health Coaches B L U E C R O S S A N D B L U E S H I E L D O F N E B R A S K A 4
5 Clear Coverage Radiology Overview October April 2017: 37,103 radiology Preauthorization's processed Approve: 88.23% Deny: 7.21% Cancel: 4.56% Average response time: 3.2 days The auto approval rate has increased and is currently over 60% auto approval rate in April. B L U E C R O S S A N D B L U E S H I E L D O F N E B R A S K A 5
6 Customer Service Process Change: Contact Us March 1, 2017, all medical and dental provider claim status questions must be submitted via web inquiry at B L U E C R O S S A N D B L U E S H I E L D O F N E B R A S K A 6
7 B L U E C R O S S A N D B L U E S H I E L D O F N E B R A S K A 7
8 Important Awareness For Submitting Requests Make sure to Indicate that a claim has been processed if appropriate to submit items that are under 30 days old. B L U E C R O S S A N D B L U E S H I E L D O F N E B R A S K A 8
9 Providers can call the numbers below for assistance with these specific concerns. B L U E C R O S S A N D B L U E S H I E L D O F N E B R A S K A 9
10 MedPolicy Blue Medical Policy and the Policy and Procedure Manual is located on our website. Link: B L U E C R O S S A N D B L U E S H I E L D O F N E B R A S K A 10
11 MedPolicy Blue Allows searching by using CPT Code Or Keyword. Please be clear when searching the Procedure Code or Keyword. B L U E C R O S S A N D B L U E S H I E L D O F N E B R A S K A 11
12 Reconsideration Versus Appeal Reconsideration A Reconsideration is a request from a provider for BCBSNE to review a claim using additional information not previously provided. Claims edit information- use this for line item denials for modifier 25 or 59 Medical Records Subrogation or worker s compensation Coordination of benefits An Invoice for Pricing Review B L U E C R O S S A N D B L U E S H I E L D O F N E B R A S K A 12
13 Reconsideration Versus Appeal Appeals An Appeal is a request from a provider for BCBSNE to review a claim with a disposition that the member or provider disagrees with based on the information presented. Medical policy denials Medical necessity denials Experimental denials Investigational denials B L U E C R O S S A N D B L U E S H I E L D O F N E B R A S K A 13
14 Claim Filing Edits Verscend Verscend is reviewing claims for BCBSNE following the AMA guidelines for coding with modifiers 25 and 59. If the claim or a line item from the claim is denied for the usage of a modifier and you have supporting documentation of correct usage of the modifier please submit as a RECONSIDERATION and include Medical Records. B L U E C R O S S A N D B L U E S H I E L D O F N E B R A S K A 14
15 Identification Card Examples BCBSNE Provider Networks B L U E C R O S S A N D B L U E S H I E L D O F N E B R A S K A 15
16 Risk Adjustment (RA) What? Risk Adjustment is a Centers of Medicare and Medicaid Services (CMS) program to help balance payments to insurance plans for caring for sicker patients. Why? In 1997, Medicare Advantage policies began requiring risk adjustment methodology to negate adverse selection. Who? Impacts all Affordable Care Act (ACA) and Medicare Advantage (MA) policies
17 Risk Adjustment for Providers Physician data is the single largest source of diagnosis data for CMS requiring complete medical record documentation. Date of Service Co-existing Conditions Medication Details Risk Adjustment Data Validation (RadV) Audit Annual CMS audit requiring 100% participation BCBSNE contract does NOT reimburse for medical records Angeline Ford, Clinical Risk Educator B L U E C R O S S A N D B L U E S H I E L D O F N E B R A S K A 17
18 Medicare Advantage There is a great deal of information to be found at this link: B L U E C R O S S A N D B L U E S H I E L D O F N E B R A S K A 18
19 Questions? Thank you for coming today! B L U E C R O S S A N D B L U E S H I E L D O F N E B R A S K A 19
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