Commonwealth Coordinated Care Updates

Commonwealth Coordinated Care (CCC) Plans Beginning Recoupment of Patient Pay Overpayment:  As you know, the three Medicare Medicaid Plans (MMPs) participating in the CCC program were unable initially to properly apply the payment pay amounts to Medicaid nursing facility claims.  In many cases, the MMPs paid the full Medicaid rate despite the reported patient pay obligation.  This resulted in overpayments on accounts that accrued for some time until each of the MMPs corrected their systems to properly apply the patient pay amount to payment.  The MMPs have also subsequently asserted that there are/were technical issues with the DMAS patient pay files and discrepancies between that file and the facility-reported information.

Additionally, overpayments have occurred as a result of other processing issues by the MMPs.  For example, one MMP applied incorrect rates to claims for a period of time and one MMP double paid some amount of claims as they bounced between the MMP and their third party vender for Medicaid claims processing.  Finally, there remain discrepancies in payment related to authorization issues and bad debt that have also produced some overpayment of accounts.

Last week, Humana announced that it was recouping the overpayments related to the patient pay issue via negative balance on current claiming.  In other words, the MMP is applying the credit toward current claim payments thereby netting the current payment total against the credit balance (reducing the amount of the transaction).  Humana indicated that they are providing account level detail to reconcile the recoupment.  While we thought we had agreement that this reconciliation would take place prior to the actual recoupment, apparently that agreement was not communicated within Humana.  Nonetheless, facility staffs are anxious to get all CCC accounts reconciled, so to the extent the information from Humana agrees with facility accounts, this will speed up that process on the credit balance side.   Given the past criticism of Humana (ILS) remittance detail, we are concerned that the data provided will not reconcile with facility accounts, but we await your input as to whether or not they have created another accounting mess.

Regarding the other MMPs, Anthem has announced that they will soon be conducting a data integrity check of their account overage data related to the patient pay issue with two nursing facility chains.  Assuming the data reconciles with those two chains, Anthem will be issuing letters and account detail to all facilities impacted by the patient pay overage issue.  Anthem will give nursing facilities the option of refunding the overages to Anthem via separate transaction, or applying to overage to current claims payments.  Anthem intends to issue two reminders subsequent to the initial letter; provider inaction after the second reminder will result in Anthem initiating recovery against current claims.

Virginia Premier is not yet as close to initiating their recovery, but has announced a process essentially identical to that described by Anthem, beginning within the next few months.

The attached document created by the MMPs provides some additional detail.

Any feedback as this MMP recovery effort proceeds is appreciated, as we need to make sure these accounts are cleared correctly.  If you have any feedback, please e-mail Steve Ford directly.

VHCA Issues Public Comment on DMAS-Announced Managed Long Term Care Expansions:  As we had previously reported, DMAS sought public comment on its announced plans to expand the managed care program to the remaining long term care population, again including nursing facility residents in that expansion.  You will recall that DMAAS announced two phases, the first making the Medicaid side of CCC mandatory within the current CCC demonstration area; the second creating a statewide Medicaid-only managed care program for Medicaid recipients of long term care services and supports.  While we anticipate many more conversations and opportunities for input, the attached are our initial comments as solicited by DMAS.

Northern Virginia Coverage under CCC Effective July 1:  As reported previously, four localities in Northern Virginia (Loudoun, Arlington, Alexandria, and Falls Church) are set to go live for coverage under CCC effective July 1 (additionally, Wytheville and Staunton also are set to go live July 1).  Residents in your facilities should have received their enrollment information, including their insurance cards with primary care physicians listed.  To the extent you are aware of issues with primary care physician assignment or other ancillary providers, we would encourage you to work with the MMP to correct those issues as soon as possible.  While CCC includes a “continuity of care” provision for existing beneficiaries whereby service authorizations and provider relationships are honored, this period is only for 180 days and based on the current care plan.  Experience in other regions has been that it can take some time to correct these concerns, so we recommend you not wait until the 180 day period expires to work on the issues with the MMPs.