CMS may end Health Insurance Market Place coverage for thousands due to data inconsistencies.
CMS sent an interesting press release a few weeks ago regarding a letter they sent to 300,000 health exchange members. These members need to provide additional information or clarify information from their original application. If they don’t respond, coverage for these members will end on 9/30/2014.
CMS Offering Payment on Inpatient Claims Pending Appeal
CMS is actively updating this article they posted regarding the measures they’re taking to reduce the number of appeals they have pending for inpatient stays. As I’m writing this, there’s a teleconference to explain the process. Evidently acute care facilities are eligible for a reduced payment of their charges if they withdraw their appeal.
I just added the most recent Medicare Advantage payer lists and I’ve added links to them in the side bar. Please let me know if you have any trouble downloading them.
I’m sure most of you have already seen this but it popped into my inbox three times this week so I thought I would share. This is the article from Modern Healthcare.
Chinese hackers hit Community Health Systems; others vulnerable
An outside group of hackers targeted Community Health Systems’ computer network and stole 4.5 million individuals’ nonmedical patient data, the company disclosed Monday in a regulatory filing.
The Franklin, Tenn.-based chain, which says it has 206 hospitals in 29 states, said a group originating in China used highly sophisticated malware and technology in the criminal attack. It believes the hackers were searching for intellectual property on medical devices and other equipment, but instead stole data on patients who sought care from its physician practices.
It’s been way too long since I’ve done an update. A few interesting things have crossed my desk lately so I thought I would share.
CoventryCares of Nebraska migrates to Aetna Better Health on 8/24/2014.
It looks like Aetna is finally starting to integrate Coventry into their business. We first thought this was just a rebranding to get rid of the Coventry name but this appears to be a true conversion. This is part of the announcement that Emdeon posted yesterday:
The membership of CoventryCares of Nebraska (currently sent using real-time Payer ID 00511) is expected to migrate August 25, 2014 to Aetna Better Health of Nebraska (new real-time Payer ID ABHNE). With this migration, users will no longer have access to the provider look-up functionality unique to the CoventryCares of Nebraska transactions.
Effective on that date, real-time transactions for these plans will need to be submitted using the new plan name and/or real-time payer ID information: Aetna Better Health of Nebraska, real-time payer ID ABHNE. During the time of August 19, 2014 through August 24, 2014, Health Care Services Review – Request for Review and Response 278 transactions submitted to either real-time payer ID, 00511 or ABHNE, will receive an error message indicating the system is unavailable. All Health Care Services Review – Request for Review and Response 278 transactions should be held during this time and resubmitted to real-time payer ID ABHNE beginning August 25, 2014.
Beginning September 25, 2014, Eligibility Inquiry and Response 270/271, Claim Status Inquiry and Response 276/277 and all Health Care Services Review 278 transactions submitted to the legacy plan name (CoventryCares of Nebraska) and/or legacy real-time payer ID (00511) will receive an error message in the response reminding the submitter to re-submit under the new plan name/real-time payer ID.
I expect to see more of these coming soon. I’m hoping Aetna will provide some type of conversion schedule.
Wellpoint Changes Name to Anthem
I’m not sure what this will mean for ID cards and plan names for plans like BCBS of Wisconsin and Empire BCBS. I’m hoping this is just a marketing ploy with very view real world changes.
Wellpoint Name Change
Medicare Therapy Caps Not Updating Correctly
I’ve heard a rumor that there are issues with therapy claim dollars getting applied to beneficiary therapy cap amounts. My understandings is that neither HETS and DDE are showing the correct amounts and you must call your MAC to get the right amounts. If you’ve heard anything about this or talked to our MAC, please leave a comment below.
There’s a lot happening in payer land right now. These are a few of the things that have crossed my desk.
1. Of course as soon as I published the post on Medicare DDE being shutdown this week, CMS postponed the date. The announcement is very vague about when it will be shut down but the rumor is that it won’t go away until 2015.
2. CMS has a release scheduled for this weekend that will add psych and historical hospice data to the Medicare eligibility response. They’ve attempted to add this several times but have had to roll it back each time. I’m keeping my fingers crossed that it will stick this time.
*Update 12:45 4/3/2014 - CMS just announced that this was postponed until 4/12.*
HETS Eligibility Release Notes
3. North Carolina Medicaid made changes to the eligibility response on 3/22 to be CORE complaint. One of the changes was that they stopped telling you if the recipient was actually eligible. They were bombarded with complaints and made another change on 3/29 to “fix” it. I suspect there will be other changes coming up soon.
Updates to Recipient Eligibility Inquiry and Claim Status for CAQH CORE Announcement
4. H.R 4302 was signed by President Obama Tuesday. This bill will delay the implementation of ICD 10 until 2015 as well as delay the Sustainable Growth Rate fee structure for Medicare payments.
5. UHC migrated the United Community Plan members from the old Americhoice PA system to the United Healthcare system effective 3/1/2014. For dates of service after 3/1, you will need to use United Healthcare Online to check eligibility (or your EDI vendor) but you will need to use the United Healthcare Community plan portal for dates prior to 3/1. Also the new claims payer ID will be 87726 for dates after 3/1.
I wanted to thank everyone that has sent me new prefixes to add to my list. Please keep them coming. I did some digging and the Wellpoint plans have published the new prefixes for the health exchange plans. I added those yesterday along with a few more I’ve found. I still have another handful that I’ll add in a few days.
As I’m adding them, I’m changing the format of the tables to make them a little easier to deal with. Please note that the new tables can only display up to 100 lines at a time. If you don’t see the prefix you’re looking for, you may need to go to the next page.
CMS recently released an update to the announcment that the CWF eligibility transactions will be sunset in 2014. The target date is April 7th to discontinue HIQA, HUQA, HIQH, ELGA, and ELGH. If you haven’t switched to using HETS either directly from Medicare or through a vendor, it’s definitely time to start looking for an alternative.
CMS announcement regarding the demise of the CWF:
It seems like I can’t open my email without seeing something about the Affordable Care Act and how it’s going to affect checking patient eligibility. We really hoped that the larger payers that were going to participate as healthcare exchange plans would be on top of things but that hasn’t been the reality.
What we’ve seen so far :
1. Some health plans did not have ACA members loaded as timely as we had hoped. Some are loading the bare minimum with the intentions of loading benefits later.
2. ACA members aren’t being clearly identified in the EDI eligibility responses by some insurance companies.
3. We still aren’t getting a clear picture of how the 90 day grace period is going to be represented in eligibility responses. A couple of payers have implemented very clear messages indicating that the person is within their 90 period but most have not.
The good news is that most payers are still making changes to accomodate the ACA membershship and we expect to see some improvements in February and March. I’ve already seen notifications from at least two large plans that they will be making changes in February to help clarify where the member is in relation to their grace period. I’ll post these changes as I get them.
A couple of interesting acquisitions in healthcare land. It was announced today that Experian (yes credit reporting Experian) is aquiring Passport Health Communications for alot of money.
Experian to buy Passport Health Communications for $850 Million.
This was announced a while ago but it’s still interesting. CHS is buying HMA. Once this deal has closed, they will have a total of 209 hospitals nationwide.
Community Health Systems to buy HMA
Over the next few weeks you’ll notice format changes on the prefix pages. The way the tables are loaded currently, adding additional prefixes is somewhat of a nightmare. I’m going to be converting those pages into a different style of table so they’ll be easier to update. Also I’m looking for someone to help me update them monthly so you’ll see more frequent changes/additions.
If there are prefixes you would like to have added, please send them through Contact Us (it’s in the footer).
I can’t believe it’s already October 1st. Health insurance exchanges will go into effect today and I’m curious how this will effect your business. If you have a few minutes I would love to get your feedback on these questions.
1. Did you get any training on insurance exchanges?
2. How is your office/facility preparing for patient’s enrolled in HIEs?