Health Net addresses problems with explanation of payment On August 21, 2018, Health Net notified providers that some paper explanation of payment (EOPs), commonly known as explanations of benefits, for commercial exchange enrollees were not displaying amounts correctly. This problem prevented providers from properly reconciling the amount Health Net is responsible for or the patient cost-sharing. Health Net reports it has resolved all issues related to the misprinted EOPs, except in instances where the enrollee’s cost share may not be correctly displaying a figure that includes any coinsurance amount. Health Net advises that a fix for the cost ... September 12, 2018 Managed Care Commercial Payors, Payor Issues and Reimbursement, Practice Management 0 0 Comment Read More »
UnitedHealthcare to discontinue use of fax numbers for medical prior authorization requests UnitedHealthcare announced in its September 2018 Network Bulletin that it will begin retiring fax numbers utilized for medical prior authorization requests beginning January 1, 2019. Providers will be directed to utilize the Prior Authorization and Notification tool on Link, the UHC website currently utilized to check eligibility and benefits, manage claims and update provider demographic information. The following fax numbers will be retiring as of January 1, 2019: (877) 269-1045 (866) 362-6101 (866) 892-4582 (866) 589-4848 ... September 12, 2018 Managed Care Commercial Payors, Practice Management 0 0 Comment Read More »
L.A. Care issues recoupment letters for services dating back to 2012 The California Medical Association (CMA) has learned that L.A. Care Health Plan, the publicly operated Medi-Cal health plan serving more than 2 million Los Angeles County residents, issued letters to physicians in late July requesting the refund of claim overpayments dating back to 2012. The letters, dated July 28 and received by practices through mid-August, cited that the overpayments were a result of processing errors, including the following: L.A. Care incorrectly processed Medi-Medi claims as the primary payor instead of secondary to Medicare. ... September 12, 2018 Medi-Cal Payor Issues and Reimbursement, Practice Management, Public Payors 0 0 Comment Read More »
Health Net Federal Services continues to address TRICARE transition issues As previously reported, Health Net Federal Services (HNFS) has experienced implementation issues since taking over as the new Defense Heath Agency (DHA) managed care contractor for the TRICARE West Region on January 1. In recent discussions with the California Medical Association (CMA), HNFS said it continues to address the breakdowns in process and resulting consequences that have impacted TRICARE providers in the areas of provider contracting and credentialing, beneficiary reassignment and provider directory inaccuracies. Updates are as follows: Contracting and Credentialing Because of staffing and operational issues, physicians may have experienced ... September 12, 2018 Managed Care Commercial Payors, Payor Contracting, Payor Issues and Reimbursement, Practice Management 0 0 Comment Read More »
Medi-Cal to unveil updated provider enrollment system this summer The California Department of Health Care Services (DHCS) will soon be releasing an update to its Medi-Cal provider enrollment system, called the Provider Application and Validation for Enrollment (PAVE). The current iteration (2.0) of the PAVE system, originally launched on November 18, 2016, transformed DHCS’ provider enrollment from a manual paper-based process to a web-based portal that providers could use to complete and submit their applications, verifications and to report changes. The original launch included most physicians and allied provider types. The new update (3.0) will include even more eligible ... August 15, 2018 Medi-Cal Medi-Cal, Practice Management, Public Payors 0 0 Comment Read More »
Coding Corner: NCCI Policy Manual updates: Part 2 CPR’s “Coding Corner” focuses on coding, compliance, and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care. Each year, the Centers for Medicare and Medicaid Services (CMS) releases an updated version of the National Correct Coding Initiative (NCCI) Policy Manual. The annual updates reflect changes to the CPT® and HCPCS code sets, as well as new and revised coding guidelines. This month, we’ll discuss the most significant, ... August 3, 2018 General Payor Issues and Reimbursement, Practice Management 0 0 Comment Read More »
Noridian to present in-person Medicare seminars in Irvine and Sacramento Noridian, the Medicare administrative contractor for California, has announced several in-person seminars around the state in September. The all-day presentations will be divided into morning and afternoon sessions, including information on the following: Morning Session: 8:30 a.m. to 12 p.m. What's New Preventive Services Telehealth Incident to Services Top A/B Errors Afternoon Session: 1-4:30 p.m. NCDs/LCDs Review Entities Documentation/Signature Requirements Education Corner The seminars are ... August 3, 2018 Medicare Public Payors, Practice Management, Professional Development & Education 0 0 Comment Read More »
United Healthcare releases latest Premium Designation physician results United Healthcare (UHC) recently released its latest Premium Designation assessment results to California physicians on July 20. The Premium Program Version 11 results, based on claims data from January 1, 2015, through February 28, 2018, will be released publicly via the payor's online physician directory beginning September 2018. Physicians within 16 specialty categories, encompassing 47 subspecialties including pediatric internal medicine (new for 2018), will again be ranked by UHC on both national and specialty-specific measures for quality and various cost-efficiency benchmarks. Physicians meeting or exceeding these benchmarks will receive a ... August 3, 2018 Managed Care Commercial Payors, Practice Management 0 0 Comment Read More »
United Healthcare Smart Edits go live August 16 UnitedHealthcare (UHC) will implement its Smart Edits program for professional claims for all of its commercial, Medicare Advantage and Community Plans effective August 16, 2018. UHC notified physicians in its 2018 United Healthcare network bulletin that it would implement Smart Edits, a new functionality introduced into the electronic data interchange (EDI) workflow allowing the payor to autodetect claims with potential errors in the claims pre-adjudication phase. Once a potential error has been identified, UHC will notify the physician (via the 277CA report) within 24 hours, returning the claim to ... August 3, 2018 General, Managed Care Commercial Payors, Payor Issues and Reimbursement, Practice Management 0 0 Comment Read More »
Best practices: Review your monthly capitation reports Participation in capitated reimbursement contracts (financial arrangements where physicians are paid a fixed amount for each patient assigned to them) can offer physicians a routine and sustained source of monthly income for their practice. Capitation, however, can be a complicated process. It is essential that physicians monitor their monthly capitation reports to ensure they are being paid per the terms of their agreements. Under many capitation arrangements, physicians are typically paid a fixed amount per member/per month for each patient assigned to them, regardless of whether the patient receives care ... August 3, 2018 General Practice Management 0 0 Comment Read More »
