Medicare Advantage PPO, PFFS high-cost claims process changes coming soon

We’re changing our process so we can better handle high-cost inpatient acute care and long-term care claims for group and individual Medicare Advantage PPO and Medicare Advantage Private Fee-for-Service members that result in diagnosis-related group outlier payments.

Our goal is to:

• Improve payment accuracy.
• Avoid overpayment recoveries.
• Control unnecessary costs.
• Have all claims paid correctly the first time.

To accomplish this, we’ve established a strategic relationship with Equian, an industry leader in prepayment solutions. In March 2018, Equian will begin reviewing inpatient claims to detect and resolve errors before payment. Equian’s service delivery model and advanced analytics allow completion of timely reviews using only an itemized bill.

How the process will work

• Inpatient acute hospitals and long-term care providers will submit their inpatient claims as they do today.
• If the claim includes a DRG outlier payment, submit an itemized bill.
• Submit itemized bills with the applicable cover sheet by fax to 1-844-214-8520 or mail:
  

• Medicare Plus Blue
  Blue Cross Blue Shield of Michigan
  P.O. Box 32593
  Detroit, MI 48232-0593

• A claim that meets the prepay criteria will pend (or freeze) in our claims system.
• We’ll review claims with a DRG outlier payment.

Itemized bill requirements

To complete the review and process the claim, Blue Cross needs your itemized bill. If we haven’t received your itemized bill when the claim is ready for review, we’ll deny the claim. If the itemized bill is received after the claim has denied, we’ll proceed with Equian’s review of the itemized bill and adjust the claim to allow payment. You won’t need to contact us to initiate this process. Also:

• Blue Cross will give the itemized bill to Equian for review.
• Equian’s review will focus on ensuring that you’re billing claims according to Blue Cross guidelines.
• Equian will complete the review within five days and return it to Blue Cross.
• Blue Cross will review Equian’s findings on the claim within five days, determine what changes (if any) will need to be made to the claim and then process the claim.
• Equian will send the results to you through the Forensic Review Report.

What happens next?

After the review is complete, Equian will follow up with you to address any questions they may have or to clarify the findings.

We’ll publish more details about this program in the April Medicare Advantage PPO and PFFS provider manual updates.

Note: To submit a request to update specific contact information for Blue Cross MA members, providers should email MedicareAdvantagePrePayForensicReview@bcbsm.com.