HMS Cost Recovery. HP Provider Relations October 2012

Transcription

1 HMS Cost Recovery HP Provider Relations October 2012

2 Agenda Objectives Health Management Systems (HMS) Roles Credit Balance Worksheet Data Matches Third Party Liability (TPL) Update Procedures Disallowance Project Helpful Tools Question and Answer 2

3 Objectives Clarify who HMS is and understand its function in relation to HP Explain the Credit Balance Worksheet conducted by HMS Understand how HMS conducts data matches Discuss processes used to update TPL information Explain the Medicare Commercial Disallowance Project 3

4 Identify HMS Roles

5 HMS Roles HMS and HP HP contracts with Health Management Systems (HMS) as a cost containment contractor HMS ensures that claims are paid correctly and paid by the responsible insurer HMS conducts the following functions for HP: Cost Avoidance Coordination of Benefits (data matches) Program Integrity 5

6 HMS Roles HMS, Truven Health Analytics, and the OMPP Truven Health Analytics (Truven), formerly the healthcare business of Thomson Reuters, continues its partnership with the Office of Medicaid Policy and Planning (OMPP) supporting: Program Integrity Surveillance and Utilization Review Truven contracts with HMS to perform Medicaid Recovery Audit Contractor (RAC) audits under the Indiana Fraud and Abuse Detection System (FADS) contract 6

7 Learn Credit Balance Worksheet

8 Credit Balance Worksheet Self reporting HMS manages the TPL Project, which uses the Credit Balance Worksheet The Credit Balance Worksheet is used by providers to self-report overpayments to the Indiana Health Coverage Programs (IHCP) Providers can use the credit balance process to return any type of overpayment at any time This process does not require an initial overpayment notification from the IHCP 8

9 Credit Balance Worksheet The Indiana Office of Medicaid Policy and Planning Credit Balance Worksheet and the IHCP Credit Balance Worksheet Instructions are available on the Forms page at indianamedicaid.com 9

10 Credit Balance Worksheet Mailing refund checks If the provider submits repayment via check, checks must be made payable to the IHCP and mailed to the following address: HP Refunds P.O. Box 2303, Dept. 130 Indianapolis, IN

11 Explain Data Matches

12 Data Matches The IHCP contracts with HMS to perform regular data matches between IHCP members and commercial insurance eligibility files This process validates the existence of other payer sources Data matches are performed with all major insurers, including Anthem Blue Cross and Blue Shield, Aetna, Cigna, Prudential, United Healthcare, and many others The primary match key is the Social Security number HMS obtains full information about any identified coverage and transmits it electronically to the IHCP twice each week On the 20 th of each month, HP transmits updated TPL information to each managed care entity for their respective members 12

13 Data Matches If a carrier is identified as a primary payer source for a claim already paid by the IHCP, HMS can submit a claim to the primary carrier to seek reimbursement back to the IHCP Note: Providers are responsible for obtaining all sources of payer information at the time of service 13

14 Know TPL Update Procedures

15 TPL Update Procedures Can a provider update a member s TPL information? Providers can update TPL information via Web interchange From the Eligibility Inquiry screen, click the TPL Update Request link Enter all known information about TPL, including comments HP TPL Unit will verify and update information within 20 business days 15

16 TPL Update Procedures 16

17 TPL Update Procedures Add any known information and submit to the HP TPL Unit 17

18 TPL Update Procedures Can a provider update a member s TPL information? TPL information can also be updated by faxing or calling the TPL Unit Include the member s identification number (RID) and any other pertinent data Send updated TPL information to: HP TPL Unit Third Party Liability Update P.O. Box 7262 Indianapolis, IN Telephone: (317) or Fax: (317)

19 TPL Update Procedures Is there a TPL update form that can be sent in? A Medicaid Third Party Liability Questionnaire is available at the Forms link at indianamedicaid.com The completed questionnaire can be ed to [email protected] 19

20 Describe Disallowance Project

21 Disallowance Project HMS initiates a Disallowance Project based on claims paid that do not list a primary payment Audits focus on inpatient and outpatient claims; however, professional claims are also included in the audit criteria When Medicare or commercial insurance is identified, HMS mails a claim listing instructing the provider to bill the appropriate payer Providers have 60 days to submit documentation to contest any claim included on the listing HMS establishes an accounts receivable to recoup payments that are uncontested by the provider 21

22 Disallowance Project Notification Letter 22

23 Disallowance Project Appeal Process Providers that disagree with the request have the right to appeal under Indiana Code Providers must file an appeal request within 60 days of receipt of the letter Failure to file an appeal request within 60 days from receipt of the letter results in the waiver of any right to appeal The appeal must be mailed to the attention of the supervisor at: Indiana Medicaid Project-HMS Third Party Recovery Unit 5615 High Point Drive, Suite 100 Irving, TX Note: Only in the case of Medicare Exhausted Benefits does HMS accept a Medicare Common Working File screen print as supporting documentation 23

24 Find Help Resources Available

25 Helpful Tools Avenues of resolution IHCP website at indianamedicaid.com IHCP Provider Manual (web, CD, or paper) Chapter 5, Section 1 HMS Medicare Project Unit at HMS Provider Relations at Customer Assistance Local (317) All others Locate area consultant map on: indianamedicaid.com (provider home page> Contact Us> Provider Relations Field Consultants) or Web interchange > Help > Contact Us 25

26 Q&A