CVS Buying Aetna for $67 Billion
I’m completely fascinated by the thought of a pharmacy chain buying a major payer. I read somewhere that they want to add small walk in clinics to all the stores and steer people there for services like preventive service and other non urgent treatments.
New Medicare Card Images
CMS released images of the new Medicare card along with some details on the new design. The release is still several months away but they’ve started sending out marketing materials already. I really wish some of those materials would include telling them to stop carrying their old card.
Details of the new design:
- Consumer tested by people with Medicare
- Positively reviewed among 10 possible cards designs
- Strong preference to maintain red, white and blue palette
- Easy to read, copy, scan at provider offices
- Smaller size to match the size of a standard credit card
- Bilingual in English/Spanish
- Gender & signature line won’t appear on new Medicare cards
- All cards, including for Puerto Rico, will be printed on white paper
Have you see the “Guard Your Card” commericials?
Medicare Eligibility Response Changes 11/4/2017 Release
CMS will be releasing some changes on November 4th for the HETS eligibility response that are pretty significant. I’ve summarized the items below and included a link to the full document. Numbers 3, 4, and 6 were particularly interesting to me.
CMS 270/271 Release Notes November 4th
1. The following new preventative benefits will be added when requested in the inquiry.
81528 – Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result
G0297 – Low dose CT scan (LDCT) for lung cancer screening
G0442 – Annual alcohol misuse screening, 15 minutes
G0443 – Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes
G0472 – Hepatitis C antibody screening, for individual at high risk and other covered indication-
G0473 – Face-to-face behavioral counseling for obesity, group (2–10), 30 minutes
G0475 – HIV antigen/antibody, combination assay, screening
2. New insurance type codes added for Medicare Secondary payer response
• AP – Auto Insurance Policy – this indicates a No-Fault Medicare Set-Aside Arrangement (NFMSA)
• LT – Litigation – this indicates a Liability Medicare Set-Aside Arrangement (LMSA)
3. An indication of QMB enrollment will be returned for beneficiaries if CMS shows them enrolled during certain periods based on the dates requested.
4. All admissions during a date span will be returned individually. Previously if the beneficiary had multiple admissions during a date span, the response would show the admissions as one admission.
5. Hospice information will only be returned for beneficiaries with Part A entitlement.
6. The response will indicate if the beneficiary isn’t eligible for preventive codes G0402, G0403, G0404, and G0405.
7. Preventive information won’t be returned for beneficiaries that have QMB for the dates requested.
New BCBS Alpha Numeric Prefixes
All of the BCBS plans have been posting announcements about the new alpha/numeric prefixes that they’re going to be rolling out next year. Below is the announcement that Anthem put in a recent newsletter:
New member ID prefixes coming in 2018 The Blue Cross and Blue Shield Association (BCBSA) assigns member ID prefixes for all Blue Cross and Blue Shield branded Plans – Anthem Plans as well as non-Anthem Plans. There are a limited number of unused three-character, alpha only prefixes remaining, and they are expected to be exhausted in the 2nd or 3rd quarter of 2018. When that happens, the BCBSA will begin assigning prefixes that contain a combination of letters and numbers, or alpha-numeric prefixes.
What does this mean to you?
- It will be even more important to ask your patients for their most recent identification (ID) card.
- When submitting claims, enter the identification number exactly as it appears on the member’s ID card.
- Check your EDI Software to make sure it can accept alpha-numeric prefixes.
- Check any internal documents you may have and update any references of “alpha prefix” to “prefix”.
Note: Current three-character, alpha-only prefixes will not be affected by this change. Current prefixes will still be valid once the new alpha-numeric prefixes are issued, unless there is another need to change or remove a prefix currently in use.
New Medicare Card Initiative
I’ve been seeing a lot of emails about this lately so I thought I would share some of the information I’ve received recently. This is a bulletin CMS sent recently:
New Medicare Cards with New Numbers: 3 Changes You May Need to Make
The Medicare Access and CHIP Reauthorization Act of 2015 requires CMS to remove Social Security Numbers (SSNs) from all Medicare cards by April 2019. CMS will begin mailing new Medicare cards with a new Medicare number (currently called the Medicare Claim Number on cards) in April 2018. You may need to change your systems to:
- Accept the new Medicare number (Medicare Beneficiary Identifier or MBI). Use the MBI format specifications if you currently have edits on the current Health Insurance Claim Number (HICN).
- Identify patients who qualify for Medicare under the Railroad Retirement Board (RRB). You will no longer be able to distinguish RRB patients by the number on the new Medicare card. You will be able to identify them by the RRB logo on their card, and we will return a message on the eligibility transaction response for a RRB patient. The message will say, “Railroad Retirement Medicare Beneficiary” in 271 Loop 2110C, Segment MSG. If you use the number only to identify RRB patients beginning in April 2018, you must identify them differently to send Medicare claims to the RRB Specialty Medicare Administrative Contractor, Palmetto GBA.
- Update your practice management system’s patient numbers to automatically accept the new Medicare number or MBI from the remittance advice (835) transaction. Beginning in October 2018, through the transition period, CMS will return a patient’s MBI on every electronic remittance advice for claims submitted with a valid and active HICN. It will be in the same place you currently get the “changed HICN”: 835 Loop 2100, Segment NM1 (Corrected Patient/Insured Name), Field NM109 (Identification Code).
New Medicare Card Provider Page
Anthem/Humana Merger, UHC eligibility change, Future of ACA
A judge has blocked the Anthem/Humana merger but Aetna may appeal.
UHC announces Change to the eligibility response effective 3/1.
UNITEDHEALTHCARE SYSTEM NOTIFICATION
Date: 02/06/2017
Re: Referral Required Message to Display on Eligibility and Benefit EDI Response (271) Transactions
UnitedHealthcare is adding an Electronic Data Interchange (EDI) referral indicator to eligibility response (271) transactions as of Mar. 1, 2017, for all lines of business.* If the member is enrolled in a plan requiring a referral from their Primary Care Physician (PCP) before seeing a network specialist, the following message should appear notifying the care provider: PCP to submit a specialist referral. Referrals should be requested electronically as a 278 EDI transaction.
The following steps outline the changes UnitedHealthcare is making to the 271 transaction (005010X279A1):
1. EB11 Authorization or Certification Indicator in the 2110c and 2110d loop include the Y value to indicate preauthorization/notification/referral is required at the plan level.
2. For the 2110c and 2110d, MSG segment, include the referral reminder message: “PCP to submit a specialist referral.”
Contact UnitedHealthcare EDI Support at 800-842-1109 if you have any questions. Please forward this communication to your customers as needed.
President Trump says that Obamacare replacement may be a year or longer away.
Lessons Learned Checking Eligibility for ACA Members
Over the past 2 or 3 years of fielding questions on eligibility for ACA exchange members, I’ve learned a few lessons that I want to pass along. While I’ve definitely seen a change in the level of education about ACA plans, there are issues that continue to arise consistently. I’m hoping the lessons I’ve learned below will help with a little of the confusion.
Retroactive terminations are a fact of life
This has come up a lot lately and it always seems to surprise providers when it happens, the scenario is usually something like this:
The member paid their premiums for a few months and then stopped. The next month the payer puts the member into a 90 day “grace period” status awaiting the premium payment. Technically they still have coverage but at this point there’s a good possibility they won’t very soon. The person goes to the hospital or physician for services, the provider checks eligibility,and the eligibility response indicates the member is currently eligible. 2 months later, the payer terminates the member and back dates it two months. The provider’s claim gets pended and then rejected and they blame their eligibility vendor for giving them bad information.
Just to recap,in most states the Affordable Care Act only requires the payer to pay claims for the first month of the grace period. This only applies to members that are receiving a federal subsidy/tax credit. If the member doesn’t pay their premiums, the insurance company isn’t going to pay for services incurred during the 2nd or 3rd month of the grace period.
I can’t tell you how many conversations I’ve had with providers that are angry because their claim got denied due to a retroactive termination. Unfortunately this type of risk is part of participating in the program.
“On exchange” plans and “ off exchange” plans aren’t the same
If you’re lucky enough to have a copy of their card, the plan type is usually indicated there. Some eligibility vendors can help with this by adding flags to their responses to help identify these members. Some payers have made the decision to not identify these members but there are ways to tell with the larger payers. The group name or plan name can sometimes indicate the type of plan, Look for words like ACA, HIX, and Exchange in the group name. Also the metal names (silver, gold, etc) will sometimes be in the group name.
Determining on exchange vs off exchange can be a little more tricky.
- On Exchange – refers to Individual and Small Group plans purchased through the Health Insurance Marketplace.
- Off Exchange – – refers to Individual and Small Group plans purchased through other channels such as a broker, sales agent, or directly through a health insurance company
Most payers have different plan names for on vs off exchange plans plus the network name may be different. I think many of the BCBS plans have different prefixes for on vs off plans.
Knowing if the patient purchased their plan plan on or off the exchange can help you determine if the member is in a network that you have a contract with. Along those same lines, it will help you accurately calculate expected reimbursement.
The grace period matters
Some payers are better than others at identifying whether or not a person is in their grace period. If you’re still calling for eligibility, you’ll need to specifically ask that question. If you’re verifying eligibility electronically through a vendor or on the payers website, check the eligibility response for a “premium paid thru date”. I saw a payer website yesterday list it as “Deliquent as of”. If the patient is in their grace period, there’s a possibility you won’t get paid by the insurance company. The “paid thru date” doesn’t necessarily mean the member will be terminated on that date, but it’s good indication that there’s an issue.
You might be able to get paid on appeal for HIX denials but probably not
Insurance companies aren’t particularly sympathetic when it comes to paying claims for someone that doesn’t have coverage anymore. This is true for ACA plans as well as commercial plans. It doesn’t hurt to appeal but don’t expect UHC or Aetna to rush to cut you a check. The best way to cover yourself is to make sure the patient signs something acknowledging their responsibility to pay if insurance doesn’t.
ACA pending claim notifications can help with patient outreach
Once a patient enters the 2nd or 3rd month of their grace period, their claims will be held pending receipt of their payment. Your should be receiving notifications of these claims from your insurance companies. I’ve talked to several providers that have processes in place to proactively reach out to patients in their grace period. This probably isn’t practical for everyone but for hospitals with thousands of dollars at risk, this might be something to consider. I’m not talking about stalking them for payment or pressuring them to send their plan a check. A notice that their claims are pending waiting on their payment may help some patients prioritize their premium payments a little higher.
I’m sure I’m preaching to the choir on most of theses lessons but I still run into people that are completely oblivious on how the ACA works. I’ve included some links to additional reading on ACA plans below. I’m curious to know your challenges with the ACA plans. Please leave me a comment below on the biggest challenge your organization has faced with the Affordable Care Act.
More Reading
Why United Healthcare’s Exit From Obamacare Matters
UHC Three Month Grace Period Guide
Affordable Care Act Tax Provisions
Kaiser Family Foundation Health Reform Page
Medicare Eligibility System Migration
CMS is in the process of migrating submitters from their HETS legacy eligibility system to their new “Redesign” system. Providers and clearinghouses are being moved to this new system in groups and the first group is moved last week. The HETS system is primarily accessed by clearinghouses but I think there are some health systems that are accessing it directly.
There are a few things to be aware of regarding this migration:
- CMS is requesting that each submitter, re-enroll all of the NPIs in CMS new provider ID database. This is a simple process of sending a file and having each NPI attached to a submitter ID but it has to be completed a couple of weeks before the actual migration.
- CMS is requiring that each vendor deactivate any NPIs that are no longer active with the submitter. Rumor has it they’re going to deactivate any NPIs that haven’t sent a transaction in the past 6 months.
- Moving to the new system is bringing a few changes to the way CMS will respond to certain requests. Many of these situations will need to be handled by your eligibility vendor but there are some that users can impact directly:
- Sending an inactive CPT in your request for Medicare preventive benefits will result in an error. Example sending code 90669 for dates of service after 1/1/2016 will cause an error.
- Sending the middle name or middle initial will result in an error. I’m not sure how this will work in situations where SSA has the first name and middle initial in the first name field.
- Sending the beneficiaries gender will result in an error.
If you would like to read the full release summary with all the changes, click the link below:
Also see the new full HETS companion guide if you’re interested in the business logic they use for responses.
I’m hoping that this system migration will be uneventful and straightforward but you can never tell with CMS. This move gets them closer to being able to truly sunset the common working file eligibility queries, which is long overdue. I won’t be surprised if CMS sends out an announcement Q1 2017 regarding shutting off the CWF queries.
Payer News: UHC / BCBS of NC / CMS
Here are a few interesting goodies I’ve run across the past week or two. Have a great day!
BCBS of North Carolina suing over government over ACA Risk payments
UHC Leaves ACA Marketplace in California
CHS to divest 10 low performing hospitals
Anthem/Cigna Acquisition may not close until 2017
CMS unable to keep up with backlog of appeal requests
Aetna digital ID cards and referrals, Texas STAR Kids
I ran across a few interesting tidbits this week that I thought I would share.
Aetna digital ID Cards
I didn’t know that Aetna was moving to digital ID cards this quickly. Have any of you received any of these digital cards? If so is it causing you to change your workflow at all?
They posted this blurb in their provider bulletin this month:
Office News Digital ID cards and eligibility and benefits inquiry
If an Aetna patient shows you a digital or printed copy of their ID card, you should accept it. Old member ID cards could cost you and your patients’ time and money. We’ve got you covered. When you reference a digital ID the information is up to date. That’s why we’ve given you and our members the ability to access digital member IDs.
If a member doesn’t have a copy of their ID card, you should submit an eligibility and benefits inquiry using their name and date of birth. You should complete an eligibility and benefits inquiry for every patient at every visit. You’ll get a response with everything you need to know about your patient.
Learn more Check out our new reference tool and tutorial.
