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INSURANCE NEWS
Multiplan
June 2007, Multiplan has announced acquisition of PHCS health plan. Provider relations department
has sent out letters to all providers’ relationship with Multiplan will be governed by the PHSC agreement. The reimbursement will begin at the current Multiplan contracted rate for service provided for both PHCS and Multiplan members.
Source of information obtained through www.multiplan.com
Oxford
New Oxford’s Radiology policy states that participating Primary Care Physicians and Specialists will be reimbursed for radiology services performed in outpatient setting. The following services can be provided and reimbursement to PCP (Internal medicine / family provider):
71010-71030, 77080- Chest Imaging
77081, 0028T – Bone Densitometry
73620, 73630, 73650, 73660 – Lower extremity imaging
For the full policy description and list of other covered specialist tests, please contact WCH.
Source of information obtained from Oxford policy# RADIOLOGY 013.t0
Neighborhood
Specialty referral policy update:
Effective June 01, 2007, Neighborhood Health Plan will no longer require acquiring a specialty referral ID number in order for service to be reimbursed. The new change requires that referring physician information must specify on the submitted claims. WCH is requesting that all specialists such as physical therapist, podiatrist...etc must provide referring physician full name and NPI. Finally, Neighborhood Health plan conform more closely with specialty referral process.
Source of information obtained from Neighborhood Health Plan June 2007 update
Medicare
Evaluation and Management Documents – Most missed items
During ongoing review performed by Medicare Audit department, the following listed information is not well documented or missed in patients charts. It is important to maintain accurate and well comprehensive record on all E/M services. Here is what Medicare needs to see:
• History
• Physical Exam
• Your Medical Decision Making (provide copy of x-ray, labs and describe complexity of each case)
Choosing correct codes base on the time spent with the patient (provide time spent for consultation and coordination of care Other general information to support the patients condition (hospital record, and any other consultation reports from specialists)
WCH has provided our clients in the past with needed information for E/M services; please review the key elements of E/M service billing.
Source of information obtained from National Government Services file PET1210 (05/07)
Latest Medicare Scams
National Government Services is asking to inform your patients to protect themselves from ongoing
calling scams. Medicare patients are at risk of having their personal information stolen. Here are some of the current phone scams:
Individuals identify themselves as employees of the Social Security Administration. The callers indicate that SSA is sending out replacement Social Security and Medicare cards and they need to verify a beneficiary’s personal information.
Caller states that Medicaid is raising their premiums and offering fewer benefits. Caller states they are offering a National Health Card for one time fee of $89 that would be good for a lifetime. The Medicare member usually agrees and provides bank account information.
Please inform your patients about these frauds in effort to reduce these risks and provide awareness. To report any suspected fraud call State & Federal Workgroup at 877-678-4697
Source of information obtained from Centers for Medicare & Medicaid Services MED 2024 (01/07)
Aetna
Introducing Aetna Health Network Option
Effective January 01, 2008 new open access plan will launch. Aetna Health Network Option and Aetna Health Network are HMO Based plans. For these plans, referrals will not be required for members to access care from participating specialists. PCP selections will not be required as well. In a way, this plan will allow the same flexible benefits as any Aetna’s PPO plans today. Provider reimbursement will be also the same as other Aetna HMO base plans. You can recognize this new plan on the member’s ID cards. The word “Health Network Only” will displayed on cards that are part of this new HMO plan. These plans will be offered to new employers in all current HMO states except California and Washington.
Terminating Provider Agreement:
Aetna is requesting that all providers that are wishing to terminate their provider agreement must inform Aetna immediately. Therefore, Aetna will have enough time to inform the members and assign patients to new providers. At this time, Aetna does not state the termination required period, which means if the provider wishes to leave Aetna they can put in the request any time during their contract period.
Patients Social Security Number:
Effective September 07, 2007 patient’s Social Security numbers will no longer be listed on Explanation of Benefits. The EOB will contain patient account number that will be linked in internal Aetna file to patient profile.
Electronic Statements format of EOB:
In the last week of June, WCH had sent out notices to all of our clients advising to switch back to paper statements. Effective June 01, 2007, all Aetna participating providers have stopped receiving paper statements. Now only Aetna sends out paper statements to credentialing Group providers. All individually credentialing practices must send a letter requesting to reopen their file to paper statements. WCH has sent a sample of this letter to all clients. Some of you have already responded back to Aetna and requested the change. Those that have not yet done this, we are urging you to submit your requests to Aetna. We all benefit from this letter!
Laboratory Update:
Effective July 1, 2007 Quest Diagnostic will provide full laboratory services to all Aetna members. Quest offers a physician portal through which you can transmit lab orders and received results electronically. Effective the same day, LABCORP will no longer service Aetna members.
Source of information obtained from Aetna Office link update June 2007
Atlantis Health Plan
Atlantis is not contracted with Quest Diagnostics. All Atlantis members must be referred to Quentin Medical Labs, Shield Medical Labs, LabCorp, and Bio-Reference Labs. If out of network lab will be used the patient will have financial responsibility to pick up the bill. For more information, please direct your administration staff to www.atlantishp.com
Source of information obtained from www.Atlantishp.com
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