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Agenda
► Third Party Liability (TPL) Programs ► Coordination Of Benefits (COB) Process ► Disallowances ► Credit Balances ► Contact Information
West Virginia Bureau for Medical Services TPL/COB Overview Provider - - PowerPoint PPT Presentation
West Virginia Bureau for Medical Services TPL/COB Overview Provider - - PowerPoint PPT Presentation
West Virginia Bureau for Medical Services TPL/COB Overview Provider Outreach & Education Presentation April, 2013 Agenda Third Party Liability (TPL) Programs Coordination Of Benefits (COB) Process Disallowances Credit
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TPL Programs
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Commercial Billings
Medicaid bills directly to carrier
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Cost Avoidance
Enters TPL policy into MMIS system making sure Medicaid does not pay
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Medicare and Commercial Disallowances
Claims sent to providers to bill Medicare or commercial carrier
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Credit Balances
Provider self-disclosure, Desk and Onsite Audits
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Estate Recovery
Recovery of Home waiver service and Nursing home charges for those over 55
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Casualty Recovery
Recovery against third parties when Medicaid pays claims regarding a tort action
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Eligibility Services
Medicaid Work Incentive (MWIN) - Premium Payment collection for Disabled individuals to ‘buy-in” to Medicaid
Health Insurance Premium Program (HIPP) – Paying insurance premiums when cost effective to keep Medicaid recipient on third party insurance
More Information on www.wvrecovery.com and mywvhipp.com ,respectively
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Mary Smith, a Medicaid member, had
- ther insurance
coverage
Is the other coverage currently active?
NO YES
Through HMS, Medicaid made aware
- f other coverage
and avoids paying claims
CO COST AVOIDAN ANCE CE
“CAV” Did Medicaid pay a claim while Mary had other coverage
NO
No Action Needed
YES
Who should have paid Mary’s claims?
Medicare & Commercial Disallowance
PROVIDER RECOUPMENT
“Claims Medicare and Commercial Insurance carriers should have paid before Medicaid
Commercial Insurance (CI) Carrier
MEDICAL RECOVERY
“CI BILLING” Through HMS, Medicaid requests that providers bill the liable program Through HMS, Medicaid bills the carrier that was liable at the date of service
Coordination of Benefits Process
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Medicare and Commercial Disallowances
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CMS does not allow Medicaid agencies to recover monies on claims Medicare paid incorrectly. As a result, provider based recovery services were needed. Medicare and commercial insurance disallowance cycles were created to help correct discrepancies on provider claims
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The identified claim discrepancies are listed and mailed to providers in cycles. A Medicare disallowance cycle is sent out every 60 days. Commercial disallowance cycles are sent out every quarter
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Each cycle length (time given to provider before recovery is made) is typically 90 days.
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The HMS Provider Relations (PR) unit makes an “initial call” to providers to ensure the cycle/project letter and listing was received
The initial call usually takes place 5 business days after the cycle has been mailed, and is completed within 10 business days after the mailing
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A “final call” is then made to providers 10-15 business days prior to the cycle’s close date reminding them of the date the project will close. Final calls are made to providers that have not responded or have outstanding claims
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In between initial and final calls, the HMS Provider Relations team typically receives documentation from providers supporting whether they agree or disagree with HMS’ findings. They also answer calls from providers with various questions regarding the disallowance process
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Once the cycle closes, a recoupment file (which is made up of all the claims in the cycle that the provider has either agreed upon or never answered back to) is then delivered to BMS for processing
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Commercial Disallowance Changes
► Previously Providers were to bill all disallowance claims with dates of service with in 3 years
per Deficit Reduction Act. Providers inability to get claims paid by the primary insurance carrier because of timely filing issues created a need to revise the Commercial Disallowance process.
► Effective January 1, 2013, providers are requested to bill the primary insurance carrier and if
denied for timely filing, send the insurance carriers Explanation Of Benefits or EOB to HMS Provider Relations. HMS will bill the insurance carrier through their CI or Commercial Insurance billing process.
► Once Medicaid received monies from the carriers on these claims, the lesser than calculation
will be applied and an adjusted claim will be issued for any payment due the provider.
► Claims in which no monies have been recovered will be reviewed and any monies owed the
provider will be paid via adjusted claims thru the MMIS.
► Claims recouped in past disallowance cycles; BMS will look at claims going back to cycle
dates during the time period from October to December 2012. Any monies due providers will be applied via an adjusted claim.
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HMS Provider Portal
HMS Provider Portal for Disallowances
► The HMS Provider Portal is a web-enabled, real-time, reliable, and secure application
within HMS’s eCenter platform that is designed specifically to manage third party liability (TPL) and coordination of benefit (COB) activity.
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What are the benefits of the Provider Portal?
- Eliminates paper disallowance listings
- Provides real-time access to disallowance projects
- Expedites provider involvement
- Automates communication with providers
- Ensures current, accurate provider demographic data to HMS
- Provides up-to-date claim status
- Offers on-demand reports for effective management
► There are currently 230 different provider contacts now signed up for HMS Provider
Portal in WV. Access to Provider portal @ https://ecenter.hmsy.com
► For additional information on the HMS Provider Portal, please contact HMS’s eCenter
Help Desk toll-free at 877-828-4839 or by email at ecenterhelp@hms.com
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Credit Balance Audits
► Provider Self Disclosed
- Provide the least amount of assertion
- Reviewed for accuracy
- Does not exclude providers from on-site/remote reviews
► Desk Audits
- Usually conducted as a result of historically low volume of credits or remote geographic
location
- Providers are requested to send patient accounting reports, system screen shots and
copies of RAs, EOBs and adjustment forms
► On-site Audits
- Typically last one to four days
- Primarily inquiries of provider personnel, followed by analytical review of financial
transactions of selected Medicaid recipients
- Including:
Credit Balances Checks Unposted Cash Targeted Claims G/L Reconciliation Other Known
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