06/05/2018

Medicaid

Recent Oncology Related Issues and News

PENDING MEDICAID ISSUES - UPDATED 6/4//2018

Michigan Managed Medicaid Plan Medical Benefit Drug Restrictions

MSHO continues to address the disparity in drug approvals between traditional Medicaid and the managed Medicaid plans. The managed plans are required to approve therapies that are a medical benefit with traditional Medicaid.  Thank you to those that sent in examples.  Those examples are in the hands of Medicaid and we are awaiting the next steps.  Stay tuned....

Update 6/4/18 - MSHO has submitted the first case to traditional Medicaid who has agreed to follow up with the managed plan, Total Healh Care, within 30 days.  Stay tuned.

5/15/18 - MSHO conferenced with traditional Medicaid and established a plan to address the disparities and step edits in place with many of the Managed Medicaid plans.  This process will begin later this week addressing a couple of companies at a time.  We will continue to update as issues are resolved.

5/1/18 - MSHO and Medicaid have set a call to discuss the best approach to address the outstanding issues.  This call will occur next week.

Most Recent Bulletins That May Affect Medical Oncology

June 1, 2018 - MSA 18-16 - Updates to the Medicaid Provider Manual; Clarification for Services Provided to Beneficiaries Receiving Hospice Services; Code Updates

June 1, 2018 - MSA 18-11 - Medicaid Laboratory Reimbursement Rates

 CLICK HERE  to review all MSA Bulletins

May 22, 2018: Attention ALL Providers: As outlined in L-Letter 17-61 the Michigan Department of Health and Human Services (MDHHS) will be making changes to the Level of Care Determination (LOCD) tool. The system changes will take place in CHAMPS as part of the June 22, 2018 update. 

MDHHS will offer virtual training dates to discuss in further detail these  LOCD  system changes:

• LOCD screen will have a new search by NPI feature
• Completed LOCD’s will have an end date of 365 days from the conducted-on date
• Conducted on date will be a visible field in the LOCD tool screen
• Ability to view the LOCD from the admission screen

To register for a virtual training date please visit our Medicaid Provider Training  webpage.

Office of Inspector General Announcement: AdvanceMed

June 2018
Dear Medicaid Provider:
Pursuant to MCL 333.26368, Sections 14.2 and 16 of the General Information for Providers section of the Michigan Medicaid Provider Manual, and the Medical Assistance Provider Enrollment & Trading Partner Agreement, the Michigan Department of Health and Human Services (MDHHS) Office of Inspector General (OIG) is authorized to perform post-payment reviews of paid Medicaid claims to identify and recover any overpayments made to Medicaid providers.

The purpose of this announcement is to introduce AdvanceMed, which is the Unified Program Integrity Contractor (UPIC) for the Centers for Medicare and Medicaid Services (CMS). AdvanceMed will be conducting these post payment audits on behalf of MDHHS OIG, and MDHHS OIG will oversee these audit activities for the State of Michigan.

The CMS’ UPIC operates under multiple legislative authorities.  For Medicaid Integrity Program responsibilities, the UPIC is authorized by The Social Security Act §1936, 42 U.S.C. 1396u-6 (a) et seq. The State of Michigan resides in CMS’ UPIC Midwestern Jurisdiction and shall include, but not be limited to, the following program integrity activities: data analysis, audits, and medical review of provider’s billing claims submitted to the State of Michigan Medicaid Program. 

AdvanceMed will utilize statistical random sampling and extrapolation, as well as claim-specific auditing methodologies.  The audit actions may include, but are not limited to:

• Recipient Interviews
• Provider Interviews
• Onsite Visits
• Medical Records Requests

Medical documentation reviews will be conducted by qualified Registered Nurse reviewers, Certified Coding Specialists, and physician peer reviewers, as required. Providers will be notified of the findings of these audits. Providers that agree with the final findings will be required to correct the relevant claim(s) via the appropriate claims processing system. Providers that disagree with any or all the findings will have an opportunity to appeal within the timeframe identified in the Final Notice of Recovery Letter. Detailed appeal instructions will accompany the Final Notice of Recovery Letter.  

To visit the Biller "B" Aware website CLICK HERE