Medicaid Committee Chairperson ~ Vacant
The goals of WSOPP on Medicaid Issues have been determined to be the following:
On April 16, 2010 WSOPP held an open forum discussion with representatives from WI Medicaid at the Spring Membership Meeting. Following is a list of questions presented and answered by Pam Hoffman, PA unit.
Q1: How are fees determined for new CMS codes? If CMS established allowables are acceptable, why not use all CMS allowables?
A1: ForwardHealth determines fees for new codes by reviewing a number of resources- product/ manufacturer's info, utilization review and claims review from MMIS, and CMS pricing. I believe there are some Administrative Code restrictions as well, in certain cases.
Q2: What is the relationship between MA and HMO-MA providers: are they required to follow the same policies as MA? Who are they responsible to and with whom do we file a complaint?
A2: When answering this question, we must be mindful of who is asking, a Provider or a Member.
The HMO must cover the same covered services as FFS (sometimes the HMO has stricter PA requirements, sometime the HMO has less strict policies/ guidelines). Bottom line, if a provider appeals (or members grieve), we follow FFS rules.
HMO's can find other treatment (I call it going over and beyond) if other treatment methods may be more appropriate, or result in better outcomes. FYI: This statement is in the HMO contract and we encourage it (e.g. paying for an extended wound vac. Vs staying in hospital).
Keep in mind, we have a contract with the HMOs. Providers have a contact with the HMOs to be a part of their network and follow the HMO rules. We don't per say, have contracts with providers, other than the fact they have to be Medicaid certified in order to be in an HMO network.
Providers should FIRST appeal to the HMO, if still not happy, they appeal to the DHS (via HP's address). This is typically for claims related issues, etc. It usually happens after the service was provided.
Members should grieve to the HMO FIRST, if still unhappy, the appeal to the DHS (vi HP's address). This is typically for a PA related denial like a medical benefit (e.g. gastric bypass was not medically necessary).
Q3: Clarify the policy for coverage of compression hose
A3: The policy for coverage is in the DME handbook. Please explore the handbook using the drop down menu's.
Q4: What is the proper procedure when client coverage changes after a prior is received?
A4: Reimbursement for that service is only available if the member is eligible for that benefit on the date the service is delivered to the member. ForwardHealth recommends providers check eligibility on every DOS.
Q5: Differences exist between CMS and Medicaid with code E1340. We can't bill CMS for that code but MA requires it. The same problem exists with L7510 and L7520, prosthetics parts/labor
A5: MA discontinues code E1340 as of 12/31/09. K0739 is the code used for repairs as of 1/1/10. L7510 is reimbursable by ForwardHealth and includes parts/ labor, L7520 is not and has never been reimbursable by MA as WI Admin Code states reimbursement as labor as a separate service is not reimbursable. This may be different from state to state.
Q6: Life expectancy revisited. Are exceptions allowed for young children/ How can we suggest changes to life expectancy tables? Example: Life of an extended steel shank is 2 years, but it is placed inside a pair of shoes that have an expectancy of 1 year.
A6: Exceptions are not allowed for young children and different policies are not developed for young children as a code (such as L1970) can be used throughout the life span. The policy is written to meet the medical needs of 98% of the population that will need an L1970. Most people who receive a L1970 are not young children in this example. You can suggest changes to life expectancy tables by calling Matt Fanale, Pam Hoffman, or Mary Chuck.
Q7: Are the Core plans to be administered by HMO's? Is this the long term plan?
A7: HMOs have been service Core members since 4/1/09. Keep in mind however that some people stay in FFS, if they receive and exemption or if there aren't 2 or more HMOs serving in that county, therefore making it not a mandated HMO county. A majority of counties ARE mandated HMO counties however.
Q8: Is the State open to changing the PA policy on Therapeutic Shoes to be in line with CMS?
A8: No. Administrative code does not allow ForwardHealth to reimburse MA providers for "Therapeutic Shoe", which is a Medicare program reimbursable by Medicare. Medicare only covers shoes that meet the criteria of the "Therapeutic Shoes" program/ policy. Coverage for "orthopedic shoes" is allowable in ForwardHealth when it meets the criteria clearly described in the DME handbook. Please explore the handbook using the easy to follow drop down menus.
Q9: Please explain why L3020 is not covered when the patient has diabetes and an acceptable primary diagnosis?
A9: L3020 is covered when the patient has diabetes and an acceptable primary diagnosis. We may disagree about what an "acceptable primary diagnosis" is. The DME online handbook has a list of the "acceptable primary diagnoses" that are allowable. Please explore the handbook using the easy to follow drop down menus.
The goals of WSOPP on Medicaid Issues have been determined to be the following:
- Communicate with Medicaid on a unified voice
- Improve the understanding of the Medicaid providers
- Improve knowledge/understanding of Orthotic/Prosthetic/Pedorthic services
- Communicate on regular basis to keep everyone informed of any changes
- Work together with Medicaid to provide the best care possible for the Medicaid recipient
On April 16, 2010 WSOPP held an open forum discussion with representatives from WI Medicaid at the Spring Membership Meeting. Following is a list of questions presented and answered by Pam Hoffman, PA unit.
Q1: How are fees determined for new CMS codes? If CMS established allowables are acceptable, why not use all CMS allowables?
A1: ForwardHealth determines fees for new codes by reviewing a number of resources- product/ manufacturer's info, utilization review and claims review from MMIS, and CMS pricing. I believe there are some Administrative Code restrictions as well, in certain cases.
Q2: What is the relationship between MA and HMO-MA providers: are they required to follow the same policies as MA? Who are they responsible to and with whom do we file a complaint?
A2: When answering this question, we must be mindful of who is asking, a Provider or a Member.
The HMO must cover the same covered services as FFS (sometimes the HMO has stricter PA requirements, sometime the HMO has less strict policies/ guidelines). Bottom line, if a provider appeals (or members grieve), we follow FFS rules.
HMO's can find other treatment (I call it going over and beyond) if other treatment methods may be more appropriate, or result in better outcomes. FYI: This statement is in the HMO contract and we encourage it (e.g. paying for an extended wound vac. Vs staying in hospital).
Keep in mind, we have a contract with the HMOs. Providers have a contact with the HMOs to be a part of their network and follow the HMO rules. We don't per say, have contracts with providers, other than the fact they have to be Medicaid certified in order to be in an HMO network.
Providers should FIRST appeal to the HMO, if still not happy, they appeal to the DHS (via HP's address). This is typically for claims related issues, etc. It usually happens after the service was provided.
Members should grieve to the HMO FIRST, if still unhappy, the appeal to the DHS (vi HP's address). This is typically for a PA related denial like a medical benefit (e.g. gastric bypass was not medically necessary).
Q3: Clarify the policy for coverage of compression hose
A3: The policy for coverage is in the DME handbook. Please explore the handbook using the drop down menu's.
Q4: What is the proper procedure when client coverage changes after a prior is received?
A4: Reimbursement for that service is only available if the member is eligible for that benefit on the date the service is delivered to the member. ForwardHealth recommends providers check eligibility on every DOS.
Q5: Differences exist between CMS and Medicaid with code E1340. We can't bill CMS for that code but MA requires it. The same problem exists with L7510 and L7520, prosthetics parts/labor
A5: MA discontinues code E1340 as of 12/31/09. K0739 is the code used for repairs as of 1/1/10. L7510 is reimbursable by ForwardHealth and includes parts/ labor, L7520 is not and has never been reimbursable by MA as WI Admin Code states reimbursement as labor as a separate service is not reimbursable. This may be different from state to state.
Q6: Life expectancy revisited. Are exceptions allowed for young children/ How can we suggest changes to life expectancy tables? Example: Life of an extended steel shank is 2 years, but it is placed inside a pair of shoes that have an expectancy of 1 year.
A6: Exceptions are not allowed for young children and different policies are not developed for young children as a code (such as L1970) can be used throughout the life span. The policy is written to meet the medical needs of 98% of the population that will need an L1970. Most people who receive a L1970 are not young children in this example. You can suggest changes to life expectancy tables by calling Matt Fanale, Pam Hoffman, or Mary Chuck.
Q7: Are the Core plans to be administered by HMO's? Is this the long term plan?
A7: HMOs have been service Core members since 4/1/09. Keep in mind however that some people stay in FFS, if they receive and exemption or if there aren't 2 or more HMOs serving in that county, therefore making it not a mandated HMO county. A majority of counties ARE mandated HMO counties however.
Q8: Is the State open to changing the PA policy on Therapeutic Shoes to be in line with CMS?
A8: No. Administrative code does not allow ForwardHealth to reimburse MA providers for "Therapeutic Shoe", which is a Medicare program reimbursable by Medicare. Medicare only covers shoes that meet the criteria of the "Therapeutic Shoes" program/ policy. Coverage for "orthopedic shoes" is allowable in ForwardHealth when it meets the criteria clearly described in the DME handbook. Please explore the handbook using the easy to follow drop down menus.
Q9: Please explain why L3020 is not covered when the patient has diabetes and an acceptable primary diagnosis?
A9: L3020 is covered when the patient has diabetes and an acceptable primary diagnosis. We may disagree about what an "acceptable primary diagnosis" is. The DME online handbook has a list of the "acceptable primary diagnoses" that are allowable. Please explore the handbook using the easy to follow drop down menus.
