Problems with billing MA plans?


I've been heating that sometimes Medicare Advantage plans react strangely to bills and don't pay everything they're supposed to, or have weird interpretations of coverage determinations.

Have any of you had that experience?



Roy Edroso
Part B News


  • edited May 2017
    Yes, Tufts Medicare Preferred is just terrible to deal with. Lots of issues with them.

  • edited May 2017
    What kind of issues, Erica? Are they just refusing charges or do they have weird "rules" about payment?

  • edited May 2017
    We are having issues with certain codes denying for medical necessity.. they claim they follow CMS's LCD/NCD rules but these particular lab codes do not have an LCD or NCD associated with them and no other internal policy to justify the denials.

    Another issue is TCM services. They are denying tons of these stating they have no record of a discharge. We have to appeal with a copy of the discharge summary. My argument is, payment for our claims should not be dependent on what another provider does. If the discharge physician did not submit his claim or whatever the case may be, that shouldn't be our problem. I've asked them why can't they check in their claims history and see that the patient was an inpatient, I mean there must be a facility bill somewhere. It's the strangest thing. Don't have issues with any other insurance, including Medicare, paying our TCM claims.

    Some surgeries have denied for "missing/invalid modifier". They apparently want an LT or RT or other anatomic modifier on certain codes, yet certain other codes they will deny if you DO put the LT or RT (69210 for example we have learned will not pay with the LT or RT). But they don't publish a list of which ones require and which ones don't so it's a guessing game! Medicare never denies for lack of anatomic modifier.

    They don't have clear policy for DME codes. Sometimes they pay with the KX modifier, sometimes they pay with the NU modifier, sometimes they pay with both... I've seen the same code billed the same way on two different claims and one paid and one denied. Absolutely no rhyme or reason.

    I'm sure there are more but these are the current issues that come to mind...And they take FOREVER to resolve issues... e-mails, conference calls, letters.. we are constantly on them and it's very frustrating.


  • edited May 2017
    Wow, thank *you," Erica! That's an eye-opener. I bet a lot of these charges are small enough that they think you won't consider it worthwhile to appeal them. What do you think?

  • edited May 2017
    For the TCM, it is required that the discharge summary be available and proof that the provider has reviewed it prior to the visit is complete and documented within the encounter.
    In our TCM documentation we have a statement in the TCM phone call documentation that confirms that staff has ensured the discharge summary is on the chart or makes the necessary call to get the summary there before the patient face to face visit.

    If you currently do not have a statement confirming that you have reviewed the discharge summary, adding this may help.

    Hope this helps.

    Elizabeth Wineland, RN, MSN, CPHQ
    Coordinator, UnityPoint Clinic Clinical Excellence
    Quality and Payer Metrics/Performance Improvement

    UnityPoint Clinic Methodist|Proctor
    120 NE Glen Oak Avenue, Suite 300
    Peoria, Illinois 61603

    (309) 671-2583 Office
    (309) 636-4129 Fax
    (309) 648-7087 Mobile

  • edited May 2017
    Hi Beth,

    We absolutely have all that documented. We have TCM nurses dedicated to reaching out to each patient discharged in the required timeframe, obtaining discharge paperwork, etc. etc. Our documentation is beautiful, that is not the issue. If TMP wants to do a random audit of our TCM services, that is fine, but to deny every single one because their system is not sophisticated to look at the history to see a discharge was done is just not right. Again, we have to do all this extra work, appeal each one with the discharge summary to prove that the patient was discharged. It's just ridiculous.

    Roy - I don't know what they are thinking! I think they have awful claims scrubbing software.


  • edited May 2017
    The problem with MA plans is that they are only as good as the talent they hire.

    I've had problem with MA plans denying things traditional Medicare would approve - process - and pay (and reported/coded correctly), but always in on appeal.

    The weapon I have is my experience and the tools I use for compliance.

    Karen A. Hurley, BS, CMM, CPC, CNA
    President, HPMSI
    PO Box 409
    Parrish, FL 34219
    Tel: (941) 776-4822
    Fax: (240) 368-0059

Sign In or Register to comment.