BCBSM Care Management Claims Rejection Study MiPCT Billing and Coding Collaborative Sharing 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 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 to or contact Lori Boctor at or by phone at

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 Example High 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 to You may also send s to Lori Boctor at or contact her by telephone at (313) Please be sure that the s 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, Care Managers were ed invitations to participate 52% completed the survey (N=222) Data cleaning and analysis was performed using SPSS v

12 Web DENIS/PARS Look-up Responsibility Both 16%

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, and S0257, though still small numbers April 2015October 2015Change 5.06%5.55%9.6% increase

Top Five Codes G ,6839,9195,4492,7042,329 Top 5 Codes are the same, though G9002 surpassed 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 Codes4,3749,366 Total75,443141, %6.6%

BCN Total BCN CM code use among billing collaborative members increased by four percentage points April 2015 October 2015 CM Codes6,99220,323 Total93,504267, %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