07/10/2018

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 7/10/18 - MSHO continues to work with traditional Medicaid to address issues with Managed Medicaid plans not offering the same benefits as traditional Medicaid.  There has been some success with approvals on a case by case basis for Meridian Advantage.  Efforts continue.

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 29, 2018 - MSA 18-14 - Hospital 340B Final Settlement Adjustment Process

June 27, 2018 - MSA 18-21 - Timely Hearing Requests

 CLICK HERE  to review all MSA Bulletins

July 6, 2018: System Outage: Due to system maintenance, the CHAMPS system will be down between 6:00 PM EST Saturday, July 14th through 9:00 AM EST Sunday, July 15th, 2018. This outage will affect the CHAMPS system access for all functionality.

July 3, 2018: Attention Outpatient Hospital Providers: This is an update to the notification posted April 13, 2018. MDHHS has resolved the system issue affecting claims that have a payment status indicator K or G on Medicare’s Addendum B and the supporting payable procedure is on MDHHS wrap around list with an assigned MDHHS status indicator. This issue was fully resolved for all providers and all dates of service with the April 2018 OPPS/ASC quarterly updates implemented on June 22, 2018. Providers with affected claims are advised to rebill claims for correct adjudication. For claims that are outside of timely filing providers will need to append the claim note “OCE 99”

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

July 3, 2018: Attention Outpatient Hospital Providers: The April 2018 quarterly APC/OPPS software was successfully updated as part of the CHAMPS system  update on June 22, 2018. MDHHS will attempt to reprocess all claims that were processed under the previous quarters software. If providers find claims that were missed by MDHHS during the recycling process we suggest that providers rebill or adjust the claims with claim note “ Previous TCN XXXXXXXXXXXXXXXXXX rebilling April 2018 quarterly updates”

Providers with further questions can contact provider support at 1-800-292-2550 or ProviderSupport@Michigan.gov.

July 2, 2018:  Attention All Providers: The Michigan Department of Health and Human Services (MDHHS) has recently updated the CHAMPS web-page www.Michigan.gov/medicaidproviders >> CHAMPS. The page has a new look and feel while preserving the previous materials. 

If you have any questions, please email ProviderOutreach@Michigan.gov.

To visit the Biller "B" Aware website CLICK HERE

CMS Issues Guidance to States on Medicaid Coverage of Drugs Approved by FDA under Accelerated Approval Pathway

Today, the Centers for Medicare & Medicaid Services (CMS) released guidance to states through State Release #185 which provides information pertaining to State Medicaid Coverage of Drugs Approved by the FDA under Accelerated Approval Pathway. This release is now available for download at the following link: https://www.medicaid.gov/medicaid/prescription-drugs/program-releases/index.html. 

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.