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.
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:
Have you see the “Guard Your Card” commericials?
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.
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?
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.
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:
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:
UNITEDHEALTHCARE SYSTEM NOTIFICATION
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.
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.
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.
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.
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.
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.
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.
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.
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:
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.
Here are a few interesting goodies I’ve run across the past week or two. Have a great day!
I ran across a few interesting tidbits this week that I thought I would share.
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:
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.