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August 2017
Here’s a closer look at enhancements to our process for handling high-cost claims
Blue Cross Blue Shield of Michigan has implemented several enhancements to our current process for handling high-cost claims to better meet the needs of our provider partners and customers. Enhancements include expediting prospective payments and expanding prepayment high-dollar reviews.
Health care providers have told us they’re dissatisfied with the timeliness of the prospective payment process for high-cost claims and the disruption caused by post-pay audits. Our group customers are also seeking prepay solutions as a way to improve payment accuracy, avoid overpayment recoveries and control unnecessary costs.
To help address these challenges, Blue Cross has established a strategic relationship with Equian, an industry leader in prepay solutions. On May 1, 2017, Equian began reviewing certain types of high-cost inpatient claims to detect and resolve errors before payment. Equian’s advanced analytics and service delivery model helps ensure the reviews are completed within five days, using only an itemized bill for input.
Blue Cross has already made several enhancements to the process. For example, the process of identifying outliers for review now occurs weekly versus monthly, since mid-April 2017. And many of the internal processes have been streamlined as well as high-dollar claim approvals. These changes are expected to accelerate the prospective payments by at least four weeks.
The result we hope to achieve by these changes is that all claims will be paid right the first time. This will reduce administrative costs and the need for multiple adjustments, speed up claims payments and help us build trust with our provider partners about the integrity of our payment process.
The enhanced high dollar process:
- Providers will submit their claims as they do today.
- A claim that meets the prepay criteria will pend in our systems.
- The claims we’ll review are those greater than $25,000, Percent of Charge or DRG Outlier
- To complete the review and processing of the claim, Blue Cross will request an itemized bill from the provider.
- The provider has 10 days to provide the itemized bill to Blue Cross.
- If the provider doesn’t respond, the Blue Cross Payment Integrity Unit will follow up with the provider after 10 days.
- If the provider doesn’t respond within 21 days, they will be contacted by their Blue Cross provider consultant.
- The itemized bill received from the provider is given to Equian for review — the claim is still pending.
- Equian’s review will focus on ensuring claims are billed according to Blue Cross guidelines.
- Equian’s review will be completed within five days and returned to Blue Cross.
- Blue Cross will review Equian’s findings on the claim within five days and determine what, if any, changes will need to be made to the claim and process the claim.
- Equian will send the results to the provider, which is referred to as the Forensic Review Report.
What happens next?
Within 10 days after the review is complete, Equian will follow up with the provider to inquire if they have questions or need clarification on the findings. Equian will also provide contact information. Equian will work to resolve and provide status on items that require further clarification.
Providers have 60 days from the date of claim payment to discuss any questions with Equian. To do this, providers should submit written explanations that substantiate the charges in question, medical record excerpts and any other supporting documentation to Equian in one of two ways:
Equian will reply to the reconsideration request within 30 days from the date the request is received.
If there is no resolution between the provider and Equian, the provider can submit a second reconsideration request directly to Blue Cross. The second request must be submitted within 30 days of receipt of Equian’s response to the original reconsideration request.
The provider should submit documentation on the questioned charges, written explanations, medical records and other supporting documentation to Blue Cross by email at BCBSMPre-PayForensicReview@bcbsm.com.
The Blue Cross Payment Integrity Unit will review and respond to the request within 30 days of receipt from the provider.
Where can I get more detail?
On web-DENIS, a detailed look at the entire process will be available. The site contains a list of frequently asked questions, presentations and much more information. To access the documentation:
- Log in as a provider at bcbsm.com.
- Click BCBSM Provider Publications and Resources on the lower right of the page.
- Click Newsletters & Resources in the left navigation.
- Click Provider Training in the left navigation.
- Scroll down to the High-cost claims review process section to find the documents.
You can also read the previous articles in April Record and the March/April issue of Hospital and Physician Update.
If you have any questions, contact your provider consultant.
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