We’re enhancing our process for MA PPO, PFFS high-cost claims

Editor’s note: An August Record article detailed enhancements to our process for handling high-cost claims. This article looks specifically at high-cost claims for members with Blue Cross Blue Shield of Michigan Medicare Advantage PPO and Private Fee-for-Service plans.

Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO and PFFS plans are implementing an enhancement to their handling of high-cost inpatient claims that result in a DRG outlier payment.

On behalf of our group and individual Medicare Advantage PPO and PFFS customers, we’re seeking prepay solutions as a way to improve payment accuracy, avoid overpayment recoveries and control unnecessary costs.

To help us address this, we have established a strategic relationship with Equian, an industry leader in prepay solutions. In December 2017, Equian will begin 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 its reviews are completed timely, using only an itemized bill for input.

The result we hope to achieve by this change is that all claims will be paid right the first time.

More details of this program will be published in the October Medicare Advantage PPO and PFFS manual updates.