Managed Care

Managed Care Payment Delays and Denials in CHOP Situations
Diane Deitz
IOHCA recently has seen an increase in member requests for help with non-payment by MyCare Ohio plans following a change of operator (CHOP) of a SNF or assisted living community that was contracted with the plan. While we are more than willing to intervene with the plans to assist members in these situations, we also recommend filing formal complaints with the Department of Medicaid (ODM) using their official complaint form. We recommend this action because it brings the issue to the attention of the agency responsible for overseeing the MyCare plans. OHCA communicates with ODM about these problems, but receiving them directly from affected providers validates the concerns we report. If you file a complaint, please be as specific as possible about what you have experienced with the plan. Many of the challenges reported to OHCA revolve around delays in issuing a network contract and loading the provider into the plan’s payment system, which requires the provider to enter into non-par, single-case agreements for the plan’s members in the interim. Some specific examples we have heard recently include:

Hospice Room and Board Billing Change: UHC Notice
Erin Begin
IIn March 2019, ODM issued a directive to the MyCare Ohio plans stating that SNFs could no longer directly bill for hospice room and board starting 7/1/019. On May 7th, Aetna Better Health of Ohio issued a statement (https://www.aetnabetterhealth.com/ohio/providers/notices) to its providers confirming that they were no longer accepting hospice room and board claims from SNF providers and providing guidance to hospice agencies on contracting and claims submission. This morning, UHC Community Plan provided the SNF notification confirming that they would also be complying with the ODM directive, stating that “effective 7/1/19 per the new rule from ODM Nursing Facilities (NF) cannot bill for hospice room and board revenue code 0658 or procedure code T2046. ONLY the Hospice provider can bill these services.” They also provided further clarification that the reimbursement will remain at 95% and enhanced payment rates that are available for eligible ventilator patients also apply to hospice. UHC Community Plan has historically been an outlier for hospice room and board, allowing either the SNF or Hospice to bill for room and board.

To date, OHCA has not received any update or notification from Molina, aside from confirmation that they also intend to comply with the change and are working on processes and communications. Please be sure to communicate this change to your hospice providers and correct your billing setups appropriately.

UHC Network Bulletin Summary
Erin Begin

• UHC Medicare Advantage Benefit Exhaust Policy Updated. In the June issue of Network Bulletins for UHC Medicare Advantage plans, there were several changes made to the medical policy for Skilled Nursing Facility Care and Exhaustion of SNF benefits. Most notably was the inclusion of the language referencing a 60 day break in skilled services to begin a new benefit period. Be sure to check benefit period days used with Case Management prior to admitting your resident to ensure benefits are available and accurate copays can be communicated. 
  
  
• UHC Commercial plans delay use of “Always Therapy Codes”. The requirement of therapy services to include the “Always Therapy” Codes (GN, GO and GP) for UHC Commercial plan members has been delayed from July 1, 2019 to September 1, 2019. These modifiers are a CMS requirement, and are already required for all UHC Medicare member claims. Claims submitted with these modifiers prior to 9/1/2019 will be processed as usual. Claim edits and denials for missing modifiers have been delayed.