07/24/2018

Payer Issue Tracking Page

Last Updated 7/25/18

WPS MEDICARE

Problem: WPS is taking back payments on Treanda, J9033.  WPS stated; "There was a mass audit on the J9033 code.  Treanda has not been manufactured since 2016 and should not be billed after 2017."  MSHO has researched this and while it is true that Treanda discontinued manufacturing in 2016 and Bendeka, J9034, is considered the replacement product, Treanda, is still being distributed and some physicians have continued utilization since the expiration date is 8/31/19.

Reported: 7/17/18

Update 7/18/18: MSHO has requested that monies be returned and instead, allow a post-payment review to verify the drug utilized was billed correctly and the product was not expired,  MSHO stated; "taking the money back without looking at the documentation is unreasonable and unfair to the physicians."

MEDICAID

Please see the Medicaid section of this newsletter for updates.

BCBSM

No BCBSM system problems reported at this time.

BCN

No BCN system problems reported at this time.

MEDICARE PLUS BLUE (MPB)

See separate article on MPB in this Reimbursement Bulletin

PRIORITY HEALTH (PH)

Problem:  PH now requires that all services be billed on one claim, claims cannot be split.  Split claims are being denied and providers need to resubmit a corrected claim for all services.  This new policy is causing a billing nightmare since for many providers it is impossible to bill everything on the same claim.  MSHO is looking into this issue.

Reported 6/18/18

RESOLUTION 7/24/18 - Effective immediately, Priority Health has agreed to remove this edit and allow providers to bill on more than one claim!  Going forward, Priority will continue to recommend the services be billed on the same claim however, they will not deny any services billed on a separate claims going forward.  They stated, "We are recommending that all services be billed on the same claim, as not doing so inflates healthcare cost and confuses members."

As far as dealing with any denials, Priority states: 

  From the time the edit was put in place until now, if a claim was denied, the provider is responsible for resubmitting the claim either;
---As a corrected claim - all on one claim (preferred method)
---On a separate claim form.
     

THANK YOU - to Robin Frey and Margaret Agnone for your help in addressing this issue with Priority Health!! 

NOTE: If you have a payer issue that you believe is a system problem and you do not see it listed above, PLEASE report it to MSHO! 

To report, email the description of your issue, including the ICN Number, date of service, provider number and patient contract number to billing@msho.org.  Do not include the patient’s name.

REMINDER – MSHO’s role is to resolve payer issues that will/can impact all members; we do not address individual claim issues. Unique, patient specific issues should not be reported.