West Virginia Bureau for Medical Services TPL/COB Overview Provider Outreach & Education Presentation April, 2013
Agenda ► Third Party Liability (TPL) Programs ► Coordination Of Benefits (COB) Process ► Disallowances ► Credit Balances ► Contact Information 2
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 www.wvrecovery.com and mywvhipp.com ,respectively 3
Coordination of Benefits Process Mary Smith, a Through HMS, Is the other COST CO Medicaid Medicaid made aware coverage AVOIDAN ANCE CE member, had of other coverage YES currently and avoids paying other insurance “CAV” active? claims coverage NO Through HMS, Commercial MEDICAL Medicaid bills the Insurance Did carrier that was RECOVERY (CI) Carrier Medicaid liable at the “CI BILLING” No pay a claim date of service Action NO while Mary Needed had other coverage PROVIDER Through HMS, Medicaid RECOUPMENT Medicare & requests that Commercial “Claims Medicare and Disallowance providers bill Commercial Insurance the liable Who should carriers should have program have paid paid before Medicaid YES Mary’s claims? 4
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 10 - 15 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
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 2012. Any monies due providers will be applied via an adjusted claim. 6
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 portal @ https://ecenter.hmsy.com ► For additional information on the HMS Provider Portal, please contact HMS’s eCenter Help Desk toll-free at 877-828-4839 or by email at ecenterhelp@hms.com 7
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
Contact Information Rick Levock HMS Provider Relations TPL Program Director For Disallowances 304-342-1604 x16 866-409-1185 rlevock@hms.com Lorenzo Jackson Charlotte Wickline Credit Balance Supervisor BMS TPL Supervisor 678-564-1166 x2109 304-356-4927 lljackson@hms.com Charlotte.D.Wickline@wv.gov 9
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