CaliforniaMedicalBilling.com

Caremore Healthplan of California

admin — Tue, 10 Apr 2012 20:42:54 +0000

For well over a year now, we have been receiving EOBs from Caremore Healthplan of California with numerous under-payments and over-payments errors. Take for example, one check that we received: They processed 31 claims and only 4 of them were processed correctly! :O That’s an 87% margin of error on one check for one doctor!

So I took it upon myself to call the powers that be to see if they could fix their claims processing problems. After 20 minutes on hold, I was routed to their claims manager voicemail. I left an extensive message regarding payments errors. She didn’t call me back. So I called again a few days later and again was put on hold for 25 minutes. Finally, a nice lady from their claims department went to look for the claims manager and put her on the phone.

I explained the problem to her and asked if she could look into the problem and let me know when it is going to be fixed. She got belligerent and escalated in tone as she said that she is ‘looking into this’ but she can only answer to the Dr office or to me but not both. Well, did I say that this problem has been going on for well over a year now?

Now you would think, if somebody brings up a problem that might improve your operations, you would be happy to address it. Well, she was not! Sensing that I wasn’t going nowhere with her, I asked for her supervisor. She promptly transferred me to *guess what* her supervisor’s voicemail.

Well, you can only lead a horse to water… I’ve been in this business long enough to see many managed care companies with this kind of ineptitude have all gone belly up. You can’t lose thousands of dollars due to a poorly constructed system, ignorant staff, and stay in business. So providers watch out and don’t put all your eggs in one basket with Couldn’t CareLess Health Plan of CA!

California chosen by CMS as one of the 12 States For Emergency Psychiatric Care Demonstration

admin — Mon, 02 Apr 2012 13:48:32 +0000

On March 13, 2012, the federal Centers for Medicare and Medicaid Services (CMS) Center for Innovation launched the Medicaid Emergency Psychiatric Demonstration (MEPD) project in 12 states—Alabama, California, Connecticut, Illinois, Maine, Maryland, Missouri, North Carolina, Rhode Island, Washington, and West Virginia, and the District of Columbia.

The three-year MEPD will enable Medicaid to pay for inpatient psychiatric care for adults under age 65 provided by an institution of mental disease (IMD), which is defined as any inpatient psychiatric setting with more than 16 beds. Normally, under the Medicaid IMD exclusion, care provided to adults between the ages of 21 and 64 by an IMD, whether the facility is a private psychiatric hospital or a public facility (such as a state psychiatric hospital), is ineligible for federal Medicaid funding. Each of the participating states will select private psychiatric hospitals with 17 or more beds to participate in the demonstration. CMS anticipates that about 26 IMDs across the 12 states will participate. CMS has not yet provided a date for the implementation of the demonstration project.

The MEPD will pay for inpatient services necessary to stabilize a psychiatric emergency medical condition; these services will be determined by the beneficiary’s medical or psychiatric diagnosis and the physician’s treatment orders. Each participating state will submit a quarterly statement to CMS enumerating all patients cared for under the demonstration at the participating IMDs. The states will submit an operational protocol to provide a summary of the implementation and management of the demonstration. However these applications are not made public because the MEPD applications contain privacy-protected individual and proprietary business information for the states’ private psychiatric hospital partners.

CMS believes that the IMD exclusion has left general hospital emergency departments as the only place where Medicaid enrollees with acute psychiatric needs can seek immediate care although general emergency departments often lack resources or expertise to care for patients in a psychiatric emergency. As a result, patients may experience a delay in treatment or inadequate care. The three-year demonstration will test whether partially eliminating the prohibition against federal Medicaid payments to IMDs improves psychiatric care for people with mental illness and lowers state Medicaid program costs.

Medicare Part B Secondary Payer Deductible Issues

admin — Fri, 19 Aug 2011 15:32:30 +0000

Medicare Part B claims processed after Friday, April 1, 2011, for which the beneficiary has a Medicare deductible remaining and Medicare is the secondary payer, are erroneously issuing payment despite the beneficiary’s deductible not being satisfied or despite the total Medicare Allowed Amount being applied towards the deductible.

The recovery of overpayments made during this time will be performed systematically. The recovery process has not yet been scheduled for implementation.

In addition to these overpayments, Physical Therapy and Occupational Therapy claims processed after Friday, April 1, 2011 where Medicare is the secondary payer and a deductible is not met are being held up by the system and are not being paid.

CMS anticipates both of these issues to be resolved in November 2011.

Medicare physician payment may be reduced by a third

admin — Thu, 09 Dec 2010 18:21:37 +0000

Providers can expect a reduction in Medicare payment of more than 30 percent in 2011 unless Congress grants a reprieve. In the Medicare physician fee schedule (MPFS) final rule that the Centers for Medicare and Medicaid Services has placed on display, providers paid under the MPFS are looking at a 2011 conversion factor of $25.5217, effective January 1, 2011. The current conversion factor is $36.8729.

The reduction is the result of adjustments that must be made under the sustainable growth rate (SGR) formula. Providers should also keep in mind that the current conversion factor is slated to revert to the 2010 SGR level of $28.3868 (a 24.9 percent reduction) for the December 1 through December 31 period.

Other policies within the rule that could affect physician payment include:

* Elimination of the deductible and coinsurance for most preventive services
* Coverage of an “annual wellness visit including a personalized prevention plan”
* Incentive payments for:
o primary care services
o major surgical procedures provided in a health professional shortage area (HPSA)
* Revisions to the practice expense portion of the geographic practice cost indexes (GPCIs)
* Multiple procedure payment reductions specific to physical therapy services

The final rule is due to be published in the Federal Register on November 29. Until that time, it can viewed at: www.federalregister.gov/inspection.aspx#special.

Medicare Egilibility via Palmetto GBA

admin — Tue, 30 Nov 2010 18:35:50 +0000

It used to be that if you need to check patient Medicare eligibility or claim status, you have only two options:

Call the Interactive Voice Response (IVR) system at (866) 931-3903
Use the ANSI 270/271 Beneficiary Eligibility Inquiry transaction at the CMS data center

Anybody who has used the IVR system knows it’s an annoying and time consuming process. As for the other method, providers need to fill out forms and get special software to process. You can also pay a third party monthly fees to access eligibility but it’s not really worth it unless you have large volume.

Most recently, Palmetto GBA has set up a free self service portal also known as Online Provider Services (OPS), that offer information on

Beneficiary Eligibility
Claims Status
Remittances Online
Financial Information (payment floor and last three checks paid)

All you need to participate is a signed electronic data interchange (EDI) Enrollment Agreement on file with Palmetto GBA. And if you are already submitting claims electronically, then you’re good to go

Follow this link and enjoy: https://www5.palmettogba.com/ecx_improvev2/

Los Angeles County Department of Mental Health Electronic Claims

admin — Wed, 27 Oct 2010 20:22:58 +0000

We do a lot of Mental Health Billing! and I mean ALOT! We bill for all credentials from MFT, LCSW, PHD to Psychiatrist and ranging from individuals to group providers all over California. In Los Angeles County, as luck would have it, LACO, also known as LA County Department of Mental Health (DMH) manages the contract for Medicaid.

LACO says they want to get claims electronically but they don’t really mean it. We have tried to get our clearing house to hook up with them. After many failed attempts, unreturned phone calls, and absurd requirements, our clearinghouse finally gave up.
There is a reason why we are all submitting electronic claims in one universal format. It defeats the purpose to require out of the ordinary fields to be programmed. One step forward for electronic claims and two step backwards for LACO.

Until I can get another clearinghouse to brave the attempts, we are having to re-key the claims from our practice management system into their web-based system; both a time-consuming and arduous tasks.

Anybody Home in Palmetto GBA’s Provider Enrollment Dept?

admin — Mon, 25 Oct 2010 18:36:08 +0000

I’ve been trying to get through to Palmetto GBA’s Provider Enrollment Dept for the past 2 days. Here’s a tip to get through. Use two phone lines and alternately redial when the call goes directly to answering machine. The message that says “..you have reached this recording because we are experiencing higher than expected call volume..:

Stay on the line if you hear a ring then message comes on. That means it’s your lucky day and you will be put into the waiting queue with the rest of us. Now, maybe you should hang up and go buy a lotto

On a side note: ARE YOU SERIOUS %$#Expletive$%! PALMETTO? You’ve been at it for over two years and haven’t figured out what the expected call volume should be? GRRRRrrr!!

Can’t get through to Palmetto GBA Provider Enrollment

admin — Wed, 16 Dec 2009 19:26:01 +0000

Things are going from bad to worse. Provider enrollment incorrectly linked one of our provider’s corporate tax id to his personal NPI and deny the entire batch of claims for lacking information. I’m trying to enlighten them on this matter but have been able to get through to Provider Enrollment as ‘all circuits are busy’ for last 3 days!

I called Claims Dept and all they can say is “keep trying – there’s a lot of calls” – I wonder why? *sarcasm intended*

Palmetto Provider Enrollment Wait Time

admin — Tue, 27 Oct 2009 18:50:52 +0000

I called Palmetto Provider Enrollment and was on hold for almost 2 hours today!

Wondering when are they going their act together?

Setting up Medicare Electronic Billing with Palmetto GBA

admin — Thu, 22 Oct 2009 22:09:23 +0000

It used to only take a couple of weeks to set up electronic billing with NHIC now it takes approximately 40 days and that is if you submit your request online. Also, you can only submit online (Electronic Data Interchange Application Online Request Form) if the provider is already billing electronically. Here’s the link: http://www3.palmettogba.com/pgx_ediRequest/index.jsp

Once submitted, be sure to print out your request ID number and follow up with them in 2 weeks to make sure they sent out the Letter of Authorization to the provider. This has to be signed by the provider and send back to Palmetto. From the time they received it, they will take another 20 ‘business’ days to process.

Make sure to follow up with them as soon as the 20 ‘business’ days are up because they are notorious for rejecting the application for any minute missing or incorrect information with no notice.

One good procedure they have implemented is the number ticket system. They will give you a ticket and escalate to 2nd level when you call in after the 20 ‘business’ days.