GREAT NEWS! ANY MONIES THAT WERE REQUIRED TO BE WRITTEN OFF FOR MYCARE MEDICAID ONLY MEMBERS (TRADITIONAL MEDICARE OR ANOTHER MEDICARE ADVANTAGE PLAN WAS PRIMARY AND MYCARE MEDICAID ONLY SECONDARY), ARE AT THIS TIME IN THE PROCESS OF BEING PAID!
For the details, please scroll down to my e-mail to Terrilynn Blodgett and Karen Robinson of United Healthcare and beneath that Terillynn's reply to me.
Buckeye (Cenpatico for behavioral health claims) is the ONLY MyCare Plan that has been paying what we deem correctly all along. We are going to be contacting Caresource as they have been processing the same way as UHCP. A portion of the Caresource MyCare contract states
"For the Medicaid portion of a MyCare Member's benefit for Covered Services, Providers shall accept as payment in full the
amounts set forth below, as applicable:
"For Part A, Part B and Part C Covered Services, the Plan will reimburse Providers the lesser of:
(a) the Medicare Member Cost Share, or
(b) 100% of the Medicaid allowable amount based upon the prevailing Ohio Medicaid fee schedule for the Covered Service
minus any payments made to Provider through the MyCare Member's Medicare benefit or any other third party. If the
payments for a specific Covered Service made by Plan through the MyCare Member's Medicare benefit and any other
third party are greater than the Medicaid maximum allowable amount, the Covered Service will be adjudicated at a
zero payment."
We are hopeful we will find that Caresource MyCare Medicaid ONLY had a "systems issue" as did UHCP. They call it a systems issue but it is personally believed UHCP was not following state guidelines and hopefully will find out the same with Caresource.
We shall keep you posted.
Debra Farley
Billing Director
BILLPro Management Systems
12-9-14
From: Debra [mailto:debra@billpro.net]
To: TERRILYNN BLODGETT , Karen Robinson
Sent: Mon, 08 Dec 2014 12:59:53 -0500
Subject: URGENT: System glitch with UHCP and claims processing for Mycare Medicaid only members
Terrilynn and Karen,
In today's ERAs in one of our practices that I am aware of, 6 professional inpatient hospital claims for MyCare Medicaid Only beneficiaries were reprocessed and the FULL traditional Medicare (primary) co-insurance is now being paid, i.e., traditional Medicare paid 80% of the allowed amount and UHCP is now paying the 20% coinsurance. All of these claims previously were denied by UHCP with remark codes:
OA-23 {the impact of prior payer(s) adjudication including payments and/or adjustments}
OA-45 {charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement}
I was absolutely stunned as at least 99.9% of all our clients claims processed by UHCP Mycare Medicaid Only have been denied with these remark codes which has meant thousands and thousands of dollars in write-offs to our clients. Prior to MyCare Medicaid Only, Medicare would pay 80% of the allowed amount (minus deductible) and Ohio Medicaid would pay the 20% coinsurance and, if applicable, the deductible.
I immediately contacted customer service at UHCP and spoke with Tess (reference number 14G005256115) and questioned her about these payments. She said their WAS A GLITCH in UHCP's system and they should have been paying the 20% coinsurance all along. She said I was the first call she received about this. I asked where we can find this announcement. She said she didn't know but I could check the UHCP website. I did and found nothing. She did say UHCP is doing a mass adjustment on all claims so the providers do not have to. That's fantastic but I am requesting from you a UHCP communication explaining this glitch, the reason it happened, and that all claims will be automatically reprocessed. I am sure it will take quite some time for all the claims to be reprocessed.
Page 37 of United HealthCare Community Plan's "United Healthcare Connected for MyCare Ohio Physician, Health Care Professional, Facility and Ancillary Provider Manual," the 2nd paragraph titled "Medicaid Cost-Sharing Policy" states: "UnitedHealthcare Connected members are eligible for both Medicaid and Medicare services. Claims for members will be paid according to the Medicare Cost Sharing Policy. UnitedHealthcare Connected will not be responsible for cost sharing should the payment from the primary payer be equal to or greater than what the provider would have received under Medicaid." Is this now incorrect?
We also request UHCP publish a revised "Medicaid Cost-Sharing Policy" for the MyCare Medicaid Only product.
We couldn't understand from day one why MyCare Medicaid Only was not paying the 20% coinsurance. Providers were taking a huge hit as that 20% was always previously paid by State Medicaid.
We request a prompt response to this e-mail so we may pass it on to our clients.
Thank you
Debra Farley
Billing Director
BILLPro Management Systems, Inc.
***************************************
From: Blodgett, Terrilynn <@uhc.com>
To: Debra <
debra@billpro.net>, Karen Robinson <@uhc.com> Cc: Tosto, Emily <@uhc.com>, Hills, Rhonda M <@uhc.com>, Herget, Michele <
M@uhc.com>
Date: 12/08/2014 02:18 PM
Subject:: URGENT: System glitch with UHCP and claims processing for MyCare Medicaid only members
It was a known system issue from the very start of the MyCare rollout and we informed the state. The system has been corrected and claims are being reprocessed.
For the Lights (UHC Medicaid secondary), we pay up to the Medicare allowable. So if Medicare allows $40.00 and pays 80% which is $32.00 we would pay the $8.00
For the Light members, we do pick up the coinsurance and/or deductible if any
For our duals, we pay the MyCare fee schedule and nothing else, no coinsurance or deductible.
Again, there was a system issue with secondary claims not paying – they were processing at zero and asking the provider to write off the balance. The system has been corrected and a claims project was submitted to reprocess all secondary claims and pay the additional money if applicable.
I have copied my boss, Emily Tosto, and perhaps she can address your request to have UHC publish a new the provider manual.
If you have specific claims, please reach out to the appropriate physician advocate.
Terrilynn Blodgett
Sr. Physician Advocate
UnitedHealthcare
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