bcbsm care management claims rejection study mipct billing and coding collaborative sharing the...
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Percent of Rejected BCBSM Care Management Claims Over TimeTRANSCRIPT
BCBSM Care Management Claims Rejection StudyMiPCT Billing and Coding CollaborativeSharing the Learning and Growing Stronger Together!
Recap and Goal• Collaborative members were asked about their
top billing and coding issues
• Claims rejections identified as a concern
• POs were asked to submit five examples of rejected care management claims
• BCBSM partners explored each claim and are following up with submitting POs
• Summary tabulations of results are shown here
Percent of Rejected BCBSM Care Management Claims Over Time
2015 Collaborative Special Study on Claims Rejection Findings
Number and % of Claims Rejections are shown in each colored segment
6 POs submitted a total of 21 claim rejections
BCBSM Hints on Special Issues•Obesity•Mental Health•HDHP with HSA•The Importance of Checking
Eligibility Near the Point of Service
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Denied Obesity/Mental Health Diagnosis Claims
Claims for eligible PDCM/MiPCT members that deny due to the diagnosis billed (obesity/mental health) are eligible for reimbursement. There are two options of how reimbursement can be issued:
1.If there is another diagnosis that can be billed in the “first/primary” diagnosis position on the claim form, please status those claims with a new relevant diagnosis in the first/primary position and still include the original diagnosis in positions 2-9. 2.However, if there is no other diagnosis that can be billed, BCBSM will need to be notified of that denied claim. You can open an issue on the Collaboration site (if you have access to it), or send an email to [email protected] or contact Lori Boctor at [email protected] or by phone at 313-448-3341.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
High Deductible Health Plan w/HSA
• There is no cost share for members enrolled in PDCM unless that member has a HDHP w/HSA.
• HDHP Qualifications:– All covered benefits (except preventative services) including medical and prescription drugs
must be subject to the deductible.– The entire family deductible must be met before reimbursement is issued.
• Members who are not Eligible:– Members who are enrolled in Medicare A and/or B are not eligible to participate in a HSA.
They are however, eligible to enroll in an HDHP without the HSA.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
What you will see for MOS Web Denis Groups• Once you determine that any of the PDCM codes are payable, scroll down to “Maximums”, “Dollar
Assignment Rules” to determine if the deductible will apply. If it applies like this example, the member has a HDHP with an HSA.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Web-DENIS-NASCO ExampleHigh Deductible Health Plan with HSA Reference
When the member is enrolled in a High Deductible Health Plan with an HSA
9
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
Where to Send Questions
• For BCBSM practices, please submit an issue through the PGIP Collaboration Site (if you have access) or you can send an email to [email protected]. You may also send emails to Lori Boctor at [email protected] or contact her by telephone at (313) 448-3341. Please be sure that the emails are secured when sending PHI information.
• BCN practices with questions should contact their provider consultants. For the PO’s with questions, please contact your PO Consultant.
• Data were collected via Survey Monkey ® July 1– August 3, 2015
• 431 Care Managers were emailed invitations to participate
• 52% completed the survey (N=222)
• Data cleaning and analysis was performed using SPSS v19.0
11
12
Web DENIS/PARS Look-up Responsibility
Both16%
Checking BCBSM Eligibility Near the Point of Service•For half of the rejections submitted, the PO or
practice reported that they did not check eligibility at or near the time of service
•There are practices who incorporate eligibility verification near the point of service (preferable by staff other than the Care Manager)
Example of Integrating Front Office Eligibility Checking from Our Last In-Person Billing and Coding Collaborative(Dr Peddireddy’s Practice, CIPA)• HOW:
▫The Care Manager checks the schedule the day before and identifies members who would benefit from care management and gives them to the office manager.
▫The Office Manager checks Web DENIS for the PDCM benefit and apprises the Care Manager
• HINTS FOR OTHERS:▫Work as a team – let the clinicians focus on the
clinical and the operational experts focus on eligibility, etc.
▫Adopt a process. Start with something. Improve over time.
▫Checking the day before is practical, doesn't slow the patient intake process down, and helps the practice to prepare for the next day's care schedule
Care Management G and CPT Codes are Key to Sustainability• Important for attracting more self-insured
groups (who want to see that their members benefit from care management services)
• National payment trends indicate the growth of coding for care management (new proposed CMS codes for 2016; potential for 2017 introduction of a monthly code; etc.)
• POs and practices that develop robust eligibility, billing and coding processes will have an advantage over the rest of the nation
Overall•9.6% increase in G and CPT code billing
•Increase in billing commercial payers•The size of the billing collaborative has
doubled, so we must compare % G-codes billed/population
•Significant increases in billing of 98961, 98962, 99489 and S0257, though still small numbers
April 2015 October 2015 Change5.06% 5.55% 9.6% increase
Top Five CodesG9002 98966 98967 99496 99495
11,683 9,919 5,449 2,704 2,329
• Top 5 Codes are the same, though G9002 surpassed 98966 during this time period
BCBSM• Total BCBSM CM code use
among billing collaborative members increased by an entire percentage point
April 2015
October 2015
CM Codes
4,374 9,366
Total 75,443 141,088
5.8% 6.6%
BCN• Total BCN CM code use
among billing collaborative members increased by four percentage points
April 2015
October 2015
CM Codes
6,992 20,323
Total 93,504 267,5673.4% 7.6%
Polling Questions•This webinar was helpful and provided
information that can help us to reduce rejection rates
▫Very much agree▫Somewhat agree▫Disagree▫Strongly disagree)
Polling Questions
• We have made an active effort in our PO or practice to use the billing and coding MiPCT collaboratives to improve our practice or PO’s care management coding performance (see scale above)
▫Very much agree▫Somewhat agree▫Disagree▫Strongly disagree)
•
Polling Questions•We have actually improved our
performance on G and CPT code submission as a result of the MiPCT billing and coding collaborative (same scale as above)▫Very much agree▫Somewhat agree▫Disagree▫Strongly disagree)
Polling Questions•What topics would you recommend for
additional billing and coding collaborative sessions