Medicare/Anthem payments

Medicare/Anthem payments

Jim DeWees

7/6/2009

I have a question about the policies for any of the contracted Medicare companies, like Humana and Anthem.

 

I have done work for several patients who have a Medicare, but have opted for the Humana package. When I have gotten paid from Humana, I get paid the Medicare rates, which is the way it is supposed to be.

 

A few years ago, Indiana Medicaid began outsourcing their work to some for-profit insurance companies to handle the claims and payments, and they were all supposed to pay like Medicaid, allowing all the same codes and fee schedules. I never ran into a problem with that issue, but it was more of a problem when a patient switched policies (or the Medicaid office switched the policies FOR the patient) in the middle of the process. In Indiana, a medicaid beneficiary can switch his/her policy every 15 days, bouncing from one company to another....but what most generally happens is the state sends out a letter to the patient saying they are going to be switched to another company, and the patients don't even know what that really means, other than they are still covered and so it doesn't matter to them. But, what that does is during the time it takes to make the limb and deliver that device, the patient might not be with another company, and this new company might require a precert for the codes, and if there is no precert on file, they don't pay for the claim. And, the lag time between when the patient changes policies and when it is officially documented on their website or their records for us to check at time of service, can be up to 2 weeks. Anyway, I know how to handle that now, and have learned the secrets of how to find out there kinds of issues, the right people to call and ask, and where to check online with Medicaid.

 

But, then Anthem joined in the Indiana Medicaid system. They first wanted all of us to sign the addendum to our commercial contracts in Indiana, which they really didn't tell us anything about why that was happening, other than it was in order for us to get paid.....Well, that was far from the truth. The reason they wanted us to sign that contract was so that we would accept Anthem rates for these medicaid claims. Yes, that's right, Anthem rates are WELL below medicaid rates here in Indiana.

 

So, to put that into perspective....the president of the local university (the largest employer in this area by far) has benefits that pay a lot lower than the person that lives next door in the government housing, who doesn't work or pay anything towards his/her benefits. And, if this president came to my office to have a prosthetic leg made, there is NO way I can afford to make a limb for him using the top components at all. But, I can make a top quality leg for the medicaid patient without any problems. Medicaid in Indiana is not too far below the Medicare rates. (I am not at all making any comments here to the effect that a medicaid patient doesn't deserve the top quality prosthesis, or making any negative comments about medicaid beneficiaries at all). And, to go even a point deeper here, the Indiana Correctional facilities also pay Medicaid rates, and so a convicted felon or any kind of offender (inmate) has better access to quality care than the actual Governor of Indiana has (assuming that he has insurance through the state of Indiana, and not some other source of insurance....since Indiana also contracts with Anthem for their benefits).

 

I did not sign that contract and so if I do any Medicaid work that is an Anthem policy (which I won't....I did that ONCE and learned my lesson) I will get paid Medicaid rates and NOT anthem rates. But, what I do when I have a patient come to my office with this kind of policy is to inform the patient what this means, and how this will affect what I can do for them, and tell the patient to call the medicaid office, and change their policy to any other Medicaid plan besides Anthem.

 

Well, a couple weeks ago, I saw my first Medicare patient that has an Anthem policy (yes, Anthem is into Medicare policies as primary plans....I am NOT talking about a medicare suppliment, but the main policy).

 

Here's the situation: I called to check on benefits and coverage, and for precert information. The person could barely speak English, and basically didn't seem to understand at all what she was doing, except reading something from a computer to me....she was in the Phillipines (I couldn't resist asking her where in the world she was located...meaning where on this globe was she).

 

I then got the number for precerts from her. I called that number, and was on hold for a good while, and then transferred to the nurse to get the codes for precert. After 1 hour and 28 minutes on the phone (hold time and speaking time), this nurse realized that this was a medicare policy and NOT a commercial policy and said, Oh honey, I am so sorry, this is the wrong place for you to be calling.... and gave me the number to call for Medicare policies at Anthem.

 

I was on the phone for a while...again... and got the precert, and 2 days later got the hard copy of the precert and everything in the mail.

 

I made the leg, submitted the claim, and today I got the check for this leg: About $6,500 for an above knee prosthesis, using the Mauch knee, Vari Flex Foot, Iceros liner, Ischial containment, carbon socket, ultralight system, AND the cosmetic covering that I had done in Florida by PRS.

 

Anthem is paying Anthem's rates for this Medicare patient. And to make it worse, they are not paying for the knee, the foot, and 3 other codes because UM1 / 198.....no precert on file, or precert is exceeded. This precert is dated to be good up until Aug 22, 2009, so using MY calendar, it is not exceeded or expired.

 

So, here's my question: Are any of you out there getting paid for Anthem/Medicare policies at Medicare rates or Anthem rates? Just again to point this problem out, if this was a pure Medicare claim, the check would have been between $15,000 - $16,000 or more. But, since Anthem had their way with it, it is well below my cost of the components alone.

 

I have talked to someone at Anthem, who is supposed to be looking at this, but we all know how they work there, and what they are really doing there. I am not holding my breath here.

 

What have you done to get this situation fixed at your offices, or do you just suck it up and take it?

 

As I said in my last post, I am not accepting many Anthem patients at this point at all, because of these problems with no precert on file issues, when in fact I have the precert in my hands. And, then it is a major problem and waste of time trying to get the probems fixed.

 

I am not taking patients with a couple other insurance policies either at this point. I hate having to turn patients away, but I cannot afford to spend that much time and money to make a limb, and then take a huge loss on that. I have plenty of other work to do that I don't need that headache....but, there are patients/amputees that need my services that live here locally, and yet I cannot do it. It is more a matter of principle that I am not going to just keep on taking a loss here, while there insurance companies are handing out million dollar bonus checks to their executives.

 

Somehow we all need to come together on these issues and address these frustrations.

 

I will not re-post any responses with names or any specifics.

 

Thanks

 

Jim DeWees, CP

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