What are some strategies for providers to use to figure out their costs?

Work with your CFO or budget team to calculate your staffing, administrative and unit of service costs. For a sample model, utilize the CTAC benchmarking tool.

If someone is denied due to medical necessity or if managed care is refusing to pay, is there an appeals process?

Yes. The first step in the appeals process would be to initiate a discussion with the managed care company. If this is unsuccessful, a formal appeals process can then be instituted. Managed care has created external and internal appeals processes. It's important to recognize that the formal appeals process can be lengthy and time-consuming.

Contact information for a specific plan's appeals department can be found on the MCO matrix at matrix.ctacny.org. 

What should providers do when clean claims differ across payers?

Most times, 80%-90% of claims will be the same. MCTAC has developed a Billing tool and a Chargemaster Webinar to help with this. 

If a field on the claims form is not required and you complete it anyway, what will happen? For example if a field is required for one plan but not others and you set your default to fill it the way it is required for that one plan will the others deny you because you have completed a field that is not required?

Many plans will just ignore it and it will not disrupt the claim, but for some plans, it could lead to a denial. 

Claim testing is a great opportunity to determine the appropriate system set up to reduce denials. 

How will clinicians know which codes to use?

It can be beneficial to create a Chargemaster that everyone at your organization has access to so that they understand which codes are used for which services as well as who (in terms of licensure) can provide and bill for each service.

For more information, view the Creating a Chargemaster webinar.

Where can claims testing contact information be found for each Medicaid Managed Care Plan?

Providers should contact each MMCP to get instructions on claims testing. The MCTAC Matrix below includes a tab for contacts at each MMCP related to billing: https://matrix.ctacny.org/

Are Adult Personalized Recovery Oriented Services (PROS) clients, dual eligible clients, etc. designated as Fee-for-Service (FFS) or managed care?

PROS clients are included in, or carved-in to, Medicaid managed care.

Dual eligible clients are now excluded, or carved out, from Medicaid managed care but have an option for managed Medicare. Dual eligible clients who are not in Fully Integrated Dual Advantage (FIDA) programs will remain in FFS. Agencies should not dismantle FFS as clients are still enrolled in it (e.g. non-FIDA dual eligible clients).

Can providers bill retroactively (i.e., "back bill")?

Plan eligibility is not retroactive. Accordingly, bill Managed Care Organizations (MCOs) fee-for-service (FFS) for 2-3 months. Refer to the guidance found in this presentation.

Are clinicians mandated to code their own sessions?

Yes, clinicians are mandated to code their own sessions.

Can billing departments or billing systems automate codes based on keywords?

No, billing departments or billing systems cannot automate codes based on keywords.

Are we moving towards a Per-Month-Per-Member (PMPM) environment or a Fee-for-Service (FFS) environment?

We are moving towards a PMPM environment. Managed Care Organizations (MCOs) receive a fixed monthly payment for each member which covers a defined set of services, or benefits. Please refer to slide 16, "How Managed Care is Paid," found here.