Misunderstandings regarding pay and chase still occur from time to time. Here’s some more information. (Our first article on pay and chase appears here – you’ll want to read it first.)
First, the broad overview: There are two prongs to pay-and-chase that affect pediatric offices:
Prong A: TennCare plans may not recoup claims previously paid to you, for the reason of “We found another payer who should have been primary on this date of service,” for patients < 21 years old.
Prong B: TennCare plans may not deny paying EPSDT-related claims when you submit them, even if you and the TennCare plan both know that the child has another insurance at the time.
What pay and chase is and isn’t
Sometimes confusion crops up into what constitutes pay-and-chase recoupment, and what doesn’t. Here are some scenarios to illustrate.
- Volunteer Pediatrics sees Johnny, who has BlueCare, for a sick visit. Johnny’s mom doesn’t tell Volunteer about any other insurance. BlueCare also doesn’t know about any other insurance. Therefore, BlueCare pays the sick visit. Then 9 months later, BlueCare recoups the money it paid to Volunteer Pediatrics, saying that Johnny also had a commercial Cigna plan that day, and Volunteer Peds should bill Cigna. No, BlueCare may not do this. They should “pay” Volunteer Pediatrics and “chase” Cigna.
- Volunteer Pediatrics sees Johnny, who has BlueCare, for a sick visit. Johnny’s mom doesn’t tell Volunteer about any other insurance, but Johnny does have a commercial Anthem policy. BlueCare knows about the Anthem policy. So when Volunteer bills BlueCare, thinking it’s the only insurance Johnny has, BlueCare denies the claim and tells Volunteer to bill Anthem instead. Yes, BlueCare may do this. Cost avoidance is acceptable on sick visit pediatric claims.
- Volunteer Pediatrics sees Johnny, who has commercial United Healthcare, for a sick visit. Johnny’s mom doesn’t tell Volunteer about any other insurance, and United doesn’t know about any other insurance. United pays the claim. As it turns out, Johnny actually does have a commercial BCBS plan through his dad. Using the birthday rule, Johnny’s BCBS plan should be billed first. United Healthcare recoups the claim and tells Volunteer to bill the BCBS plan. Yes, commercial United Healthcare can do this; commercial secondary plans are not governed by pay and chase rules.
- Volunteer Pediatrics sees Judy, who has Amerigroup, for a well visit. Judy’s mom doesn’t tell Volunteer about any other insurance, and Amerigroup doesn’t know about any other insurance. Amerigroup pays the claim. As it turns out, Judy also has a Tricare plan. Amerigroup recoups the claim and says Volunteer should bill Tricare. No, Amerigroup may not do this under both prongs A and B of pay-and-chase rules.
- Volunteer Pediatrics sees Judy, who has both Tricare and Amerigroup, for a well visit. Judy’s mom discloses all insurance to Volunteer. Volunteer knows about both plans. Volunteer sends its claim to Amerigroup first, bypassing Tricare. Amerigroup denies the claim, saying to bill Tricare first. No, Amerigroup must not deny any preventive claims on kids on the first pass. Cost avoidance cannot be used on EPSDT-related claims.
- Volunteer Pediatrics sees Mary, who has United Community TennCare, for a well visit. This is truly the only insurance Mary has. Volunteer bills a preventive claim, which United Community pays. Two years later, United Community recoups the claim because it reportedly overpaid Volunteer Pediatrics. Maybe. This has nothing to do with pay and chase, since there is no third-party liability issue involved. The recoupment may be appropriate, or it may not be appropriate, based on other criteria.
- Volunteer Pediatrics sees 23-year-old Cody, who has special needs and has TennCare Select. Cody’s caregiver discloses only the TennCare Select to Volunteer. Volunteer bills TennCare Select and is paid. 5 months later, TennCare Select recoups the money because it identified that Cody actually had Medicare that day. TennCare Select instructs Volunteer Pediatrics to bill Medicare instead. Yes, this is acceptable, since Cody is 21+ years old and the recoupment request falls within the statutory window.
What is meant by “EPSDT-related” claims under this definition?
Anything that meets the CMS diagnosis criteria as described in CMS’ State Medicaid Manual. There’s both ICD-9 and ICD-10 qualifying codes.
Do I have to accept pay-and-chase?
Not necessarily. You could go along with the recoupment, then bill the alleged primary. This might be a good strategy if the primary insurance would pay you significantly more than the TennCare MCO paid for the same service.
However, our experience has shown that the newly-discovered primary usually tries to deny your claim for timely filing. Timely filing should be waived in this instance, since the timely filing clock should re-start when the TennCare plan takes back its money. However, it usually takes lots of letter-writing with the commercial plan for this to happen, and may cost your practice more in tracking than you would gain by getting the extra payment from the primary.
There can also be a “who’s on first” type of confusion. A primary insurer is likely to be confused if you are trying to get them to pay you, while TennCare’s TPL division is trying to do the same under pay-and-chase.
What if I get a recoup that should have been a pay-and-chase claim?
If your discussion with the MCO does not yield fruit, we recommend filing a state complaint or an independent review with the TennCare Oversight Division. Failure to follow pay-and-chase protocols are sometimes cited in TennCare’s periodic reviews of its MCOs.