06/19/2018

Medicaid

Recent Oncology Related Issues and News

PENDING MEDICAID ISSUES - UPDATED 6/19/2018

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

June 13, 2018: Attention All Providers: The Michigan Department of Health and Human Services (MDHHS) would like to remind providers of their obligation to adjust claims when a primary or other insurance payer recovers a payment. The claim should be adjusted to update the other insurance dollar amounts or remove the other insurance information completely if no longer applicable. A claim note indicating the reason for the recovery or negative payment amount from the other insurance should be submitted for the claim to be considered for payment. 

Providers cannot bill beneficiaries for services except for the situations outlined in the MSA Provider Manual, General Information for Providers Chapter, Section 11-Billing Beneficiaries. 

Providers with further questions can contact Provider Support at 1-800-292-2550 or Providersupport@Michigan.gov.

June 11, 2018: Attention All Providers: The Michigan Department of Health and Human Services (MDHHS) has identified claims that adjudicated on or after 2015 that reported Medicare primary in the other payer’s information and processed and paid incorrectly.  

The identified claims reported:

• Medicare primary with CARC 2, Coinsurance Amount, and no Medicare primary payment

OR

• Medicare primary with CARC 1, Deductible Amount, over the yearly Medicare Deductible amount for the date of service:
  • 2015=$147.00
  • 2016=$166.00
  • 2017 and 2018= $183.00

Providers should review their paid claim(s) and adjust the claim(s) to make the necessary corrections to the CARC or dollar amount. Providers should include a claim note indicating why the claim(s) are being adjusted.

MDHHS will begin voiding the identified claims on pay cycle 29, July 19, 2018, until complete. The voided claims can be identified with claim note “OICU Recovery due to incorrect OI reporting of Medicare”. 

Providers with further questions can contact Provider Support at 1-800-292-2550 or Providersupport@Michigan.gov.

To visit the Biller "B" Aware website CLICK HERE

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.