Third Party Payer & TPA Day. October 18 th, 2018

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1 Third Party Payer & TPA Day October 18 th, 2018

2 Mike Dooley Director of Provider Contracting and Engagement Ph: Michael Nour Provider Relations Specialist Ph:

3 Universal Provider Agreement Avera Insurance Division Provider Agreement mailed to over 1,300 professional provider practices (by TIN) across the region in April. Professional provider services only. Participation for both Avera Health Plans and DAKOTACARE in one Universal agreement. Universal fee schedule, except John Morrell Food Group (Smithfield Foods), AHP and State Employee Plan, DAS. 97% returned, executed copies being sent back. Disruption notices as needed to member s, employer groups and distribution channels in November.

4 Credentialing Topics Credentialing carries forward under new agreement. Western Providers, Inc. & credentialing. Credentialing & re-credentialing applies for both insurance plans, reduces admin burden. Credentialing policies / alignment both plans Keep data for primary credentialing contact current with Avera Centralized Verification Services. Provider not credentialed denials. ERA (835) message codes: CARC 251, RARC N570

5 Alignment of Health Services AHP and DKC fully-insured and Avera Health Employee Health Plan alignment of medical policy, preauthorization and experimental / investigational. DAS client decisions pending, expected by 1/1/19 (expected to also align). Comprehensive review similarities / differences. Medical policies have been aligned. Preauthorization lists aligned 1/1/19. Experimental / Investigational lists aligned 1/1/19. State Employee Plan under DAS continues to use HMP. Website re-design early 2019 to create consistent look / feel. Simplifying administrative functions.

6 Alignment of Reimbursement Policy Reimbursement Policy Committee comprised of crossfunctional representation of both AHP / DKC staff. Co-chaired by Mike and Scott. Policies posted online in a uniform format. Web re-design work planned with release early AHP policy on pre-payment review of modifier 59 claims to be retired 1/1/19. Will significantly reduce denials for medical records requests and delays in settlement of claims. Fraud Waste and Abuse efforts will be enhanced, shifting efforts to post-payment review. Core claims system platform investment. RFP process wrapping up now. Target 2021 launch.

7 Imaging Preauthorization Changes Preauthorization of MRI, MRA, CT, PET and Nuclear Studies through evicore, will sunset for AHP fullyinsured and Avera Health Employee Health Benefit Plan members 1/1/19. Pre-service notification-only process will replace evicore preauth for these lines of business. More details on notification process forthcoming. Watch for announcements. John Morrell Food Groups (Smithfield Foods) will retain evicore preauth requirements.

8 Inpatient Notification Change implemented effective 1/1/17 IP stays < 5 days notification only Preauthorization required at beginning of 6 th day Note this does not apply to City of Sioux Falls & Minnehaha County employees

9 2018 Provider Satisfaction Survey Please encourage your providers to participate in our upcoming Provider Satisfaction Survey Look for information in our ProviderView newsletter!

10 Submitted Questions Q: Supplies splints braces how to bill. Wellmark allows POS 12 to be paid what are other payers policies on how to bill for these supplies from POS 11? A: A review of our data for commonly dispensed supplies, splints and braces from a physician office setting shows we receive and pay for them routinely with POS codes 11, 12 and 20. We do not restrict this to POS 12. Q: SL Modifier for VFC (State Supplied) vaccines what payers allow / require this modifier? A: State supplied vaccines must be billed with the SL modifier. A charged amount of zero can be accepted but some offices will bill a dollar, likely because the zero charge isn t allowed with their software. The line and associated charge (if any) will deny as a provider liability. We do allow and pay separately for the vaccine administration. Do not append the SL modifier to the administration fee as that will cause that line to deny.

11 Submitted Questions Q: Why is it that quite a few payers won t pay on the same day services? Ex: (initial psych diagnostic evaluation) and either (subsequent inpatient E/M visit) or (individual therapy session)? A: on the same day as denies the as a National Correct Coding Initiative (NCCI) edit, and is considered a mutually exclusive code pairing on the same day as is also an NCCI edit which results in the denial of the Often referred to as incidental services not separately allowed on the same day or comprehensive / component edits. Demo of the Clear Claim Connection Tool

12 Submitted Questions Q: G0444 Annual depression screening, 15 minutes. Why are so many payers not willing to pay on this code when the patient has been diagnosed with depression? A: G0444 is an annual screening service for depression and billing for this service for a patient that has already been diagnosed with depression would be duplicative and not medically necessary. For patients whom have not already been diagnosed with depression, billing G0444 with nearly any other E/M or mental health services code would be denied as an NCCI edit. When documentation supports that the depression screening is medically necessary and separate from your E/M service, a modifier 25 on the E/M code would be necessary for separate reimbursement. Example follows.

13 Submitted Questions Scenario for G0444 with an E/M and use of Modifier 25 You see a patient who complains of dizziness. You treat the patient for the dizziness and provide a depression screening because of warning signs that arise during your visit. In this case, it may be appropriate to bill for a depression screening plus an E/M service because the patient presented for a reason separate from the depression screening. Be mindful of National Correct Coding Initiative (NCCI) rules, which give G0444 a modifier indicator of 1 with common E/M codes (and others), meaning you can bill both services on the same date of service as long as you show medical necessity and append modifier 25 to the E/M code. That modifier shows that the service is separate from the depression screening. As with any use of modifier 25, your notes must clearly show medical necessity for the additional service your provide. Time must be clearly documented for G0444 in the record.

14 Thank you! Brief Web Portal Walk Through Other Questions?