West Virginia Bureau for Medical Services TPL/COB Overview Provider Outreach & Education Presentation. April, 2013

Transcription

1 West Virginia Bureau for Medical Services TPL/COB Overview Provider Outreach & Education Presentation April, 2013

2 Agenda Third Party Liability (TPL) Programs Coordination Of Benefits (COB) Process Disallowances Credit Balances Contact Information 2

3 TPL Programs Commercial Billings Medicaid bills directly to carrier Cost Avoidance Enters TPL policy into MMIS system making sure Medicaid does not pay Medicare and Commercial Disallowances Claims sent to providers to bill Medicare or commercial carrier Credit Balances Provider self-disclosure, Desk and Onsite Audits Estate Recovery Recovery of Home waiver service and Nursing home charges for those over 55 Casualty Recovery Recovery against third parties when Medicaid pays claims regarding a tort action Eligibility Services Medicaid Work Incentive (MWIN) - Premium Payment collection for Disabled individuals to buy-in to Medicaid Health Insurance Premium Program (HIPP) Paying insurance premiums when cost effective to keep Medicaid recipient on third party insurance More Information on and mywvhipp.com,respectively 3

4 Coordination of Benefits Process Mary Smith, a Medicaid member, had other insurance coverage Is the other coverage currently active? YES Through HMS, Medicaid made aware of other coverage and avoids paying claims COST AVOIDANCE CAV NO No Action Needed NO Did Medicaid pay a claim while Mary had other coverage Commercial Insurance (CI) Carrier Through HMS, Medicaid bills the carrier that was liable at the date of service MEDICAL RECOVERY CI BILLING YES Who should have paid Mary s claims? Medicare & Commercial Disallowance Through HMS, Medicaid requests that providers bill the liable program PROVIDER RECOUPMENT Claims Medicare and Commercial Insurance carriers should have paid before Medicaid 4

5 Medicare and Commercial Disallowances CMS does not allow Medicaid agencies to recover monies on claims Medicare paid incorrectly. As a result, provider based recovery services were needed. Medicare and commercial insurance disallowance cycles were created to help correct discrepancies on provider claims The identified claim discrepancies are listed and mailed to providers in cycles. A Medicare disallowance cycle is sent out every 60 days. Commercial disallowance cycles are sent out every quarter Each cycle length (time given to provider before recovery is made) is typically 90 days. The HMS Provider Relations (PR) unit makes an initial call to providers to ensure the cycle/project letter and listing was received The initial call usually takes place 5 business days after the cycle has been mailed, and is completed within 10 business days after the mailing A final call is then made to providers business days prior to the cycle s close date reminding them of the date the project will close. Final calls are made to providers that have not responded or have outstanding claims In between initial and final calls, the HMS Provider Relations team typically receives documentation from providers supporting whether they agree or disagree with HMS findings. They also answer calls from providers with various questions regarding the disallowance process Once the cycle closes, a recoupment file (which is made up of all the claims in the cycle that the provider has either agreed upon or never answered back to) is then delivered to BMS for processing 5

6 Commercial Disallowance Changes Previously Providers were to bill all disallowance claims with dates of service with in 3 years per Deficit Reduction Act. Providers inability to get claims paid by the primary insurance carrier because of timely filing issues created a need to revise the Commercial Disallowance process. Effective January 1, 2013, providers are requested to bill the primary insurance carrier and if denied for timely filing, send the insurance carriers Explanation Of Benefits or EOB to HMS Provider Relations. HMS will bill the insurance carrier through their CI or Commercial Insurance billing process. Once Medicaid received monies from the carriers on these claims, the lesser than calculation will be applied and an adjusted claim will be issued for any payment due the provider. Claims in which no monies have been recovered will be reviewed and any monies owed the provider will be paid via adjusted claims thru the MMIS. Claims recouped in past disallowance cycles; BMS will look at claims going back to cycle dates during the time period from October to December Any monies due providers will be applied via an adjusted claim. 6

7 HMS Provider Portal HMS Provider Portal for Disallowances The HMS Provider Portal is a web-enabled, real-time, reliable, and secure application within HMS s ecenter platform that is designed specifically to manage third party liability (TPL) and coordination of benefit (COB) activity. What are the benefits of the Provider Portal? Eliminates paper disallowance listings Provides real-time access to disallowance projects Expedites provider involvement Automates communication with providers Ensures current, accurate provider demographic data to HMS Provides up-to-date claim status Offers on-demand reports for effective management There are currently 230 different provider contacts now signed up for HMS Provider Portal in WV. Access to Provider For additional information on the HMS Provider Portal, please contact HMS s ecenter Help Desk toll-free at or by at ecenterhelp@hms.com 7

8 Credit Balance Audits Provider Self Disclosed Provide the least amount of assertion Reviewed for accuracy Does not exclude providers from on-site/remote reviews Desk Audits Usually conducted as a result of historically low volume of credits or remote geographic location Providers are requested to send patient accounting reports, system screen shots and copies of RAs, EOBs and adjustment forms On-site Audits Typically last one to four days Primarily inquiries of provider personnel, followed by analytical review of financial transactions of selected Medicaid recipients Including: Credit Balances Checks Unposted Cash Targeted Claims G/L Reconciliation Other Known 8

9 Contact Information Rick Levock TPL Program Director x16 Charlotte Wickline BMS TPL Supervisor HMS Provider Relations For Disallowances Lorenzo Jackson Credit Balance Supervisor x2109 9