Getting Your Tricare Underpayments Back

We’ve talked extensively about how practices have been overpaid for some vaccines by Tricare.  However, you may also have been underpaid on other vaccines during the same period.

If you were underpaid, it was likely on the following vaccines:

  • 90468 (Hib) – which should pay “about $25-35”
  • 90707 (MMR) – which should pay “about $60-70”
  • 90716 (Varivax) – which should pay “about $100-120”
  • 90698 (Pediarix) – which should pay “around $90”
  • 90680 (Rotavirus) – which should pay “between $80 and $90)

(Please review our caveats on “should pay” in our previous posts.)

We encourage you to calculate your underpayments and have Tricare reprocess these as well.  Strategies on how to do this in a future post.

Managing Your Tricare Recoupment Requests

Many practices throughout Tricare’s South region are reporting several thousand dollars (or more) in Tricare recoupment requests.   Here are some helpful tips for evaluating the recoupment requests:

Getting the total owed

Some practices who are receiving several recoupment requests are having trouble tracking what the total recoupment amount should be.  You can see all your practice’s pending Tricare recoupments on the Tricare website.

  • Go to mytricare.com.  If your practice has an active account, click “Secure Sign-In.”  If not, click “Register Now.”
  • After logging in, mouse over Claim Information, then click on Recoupments.
  • In Search criteria, click Provider location then select the name of your office.
  • Scroll down to see your list of open recoupments.  The total still owed is in the bottom right.:

recoups

Are the recoupment amounts correct?

Make sure the recoupment amounts are correct.  You’ll need to compare what the claim originally paid against your Tricare fee schedule.  (Don’t have a fee schedule?  We can’t post the exact fee schedule here, since yours might vary from another practice’s fee schedule, but we can give some estimates — see below.)

  • From the Recoupments screen above, click on the Refund Control Number (above, redacted) for the recoupment you want to look at.
  • You will then see all the claims attached to that recoupment amount listed by claim number:

claim line items

  • To see the line item information for that claim, click the claim number (redacted here), then the View claim details button.
  • Near the top of the next screen, on the right, there is a PDF icon with a link that says “View the remit for this claim.”   You can then see what you charged and what Tricare paid you.
  • Click the Back to Recoupments button in the upper right to return to the Recoupments screen.

But how do I know which line item they’re recouping against?

Tricare doesn’t tell you (shame on them), only that they overpaid a vaccine line item.  However, here are some tips:

  • The overpayment is on the serum code, NOT the admin (9046x, 9047x) code.
  • Tricare overpayments were most likely to occur on the following vaccines:
    • Hep A (90633)
    • Gardasil (90649)
    • DTaP (90700)
    • IPV (90713)
    • Menactra (90734)
    • Rotavirus (90680) – which is also likely to have been underpaid
  • The correct payment for each of these vaccines during 2012 (assuming your practice does not discount vaccines significantly beyond CMAC prices) was approximately:
    • Hep A:  “between $30 and $36”
    • Gardasil: “between $150 and $170”
    • DTaP: “between $25 and $30”
    • IPV: “between $30 and $36”
    • Menactra: “between $125 and $135”
    • Rotavirus: “between $80 and $90”
  • Look at what you were paid on your claim line item for these vaccine CPTs.  If you were paid significantly above any of the above amounts, you were truly overpaid.
  • Typically, we have seen one of two types of overpayments:
    • Tricare paid exactly DOUBLE the proper fee;
    • Tricare paid your whole charge (which was less than double the proper fee)

For example, in the above refund request list, we can see that (highlighted in yellow) there are 5 identical recoupment amounts for $34.48.  We see that all those claims had a vaccine that paid exactly 68.96, or twice the proper payment for that particular vaccine.   Since the correct payment is half that, each of those claims was truly overpaid by $34.48.

Similarly, we see another claim that lists a recoupment amount of $28.40.   We see that, on the EOB, one vaccine line item that was supposed to pay $28.40 actually paid $56.80.  Thus $28.40 is truly due back to Tricare.

 

 

 

 

Free AAP Webinar: APM Success for Rural Practices

Sponsored by the American Academy of Pediatrics’ Digital Navigator Program, this FREE webinar will update participants on the current types of alternative physician payment methodologies in place and the issues they present to pediatricians in primary and specialty care within small & rural practice settings.

How Small & Rural Practices Can Thrive Under The New Alternative Payment Models

Presented by Suzanne Berman, MD, FAAP.

February 24, 2016 at 12:00 Noon Central Time.

To register click on:  How Small & Rural Practices Can Thrive Under New Alternative Payment Models

PURPOSE

Practices are experiencing the impact as payment models evolve, particularly in value based payment and risk sharing models to more adeptly manage expected utilization and related practice expenses for treatment. Practice viability will be dependent on how well quality, cost, and efficiency are managed. Success is based on the practice’s ability to control the health care expenses of the patient population so that they do not exceed the budgeted amount. Learn strategies for pediatric practices to utilize and to assess practice readiness so as to effectively transition to value-based payment systems.

INTENDED AUDIENCE

Physicians, clinic administrators, clinic managers, and business office managers

OBJECTIVES:

  1. How might APMs actually increase health disparities, and how can I mitigate these unintended consequences?
  2. How can I do data analysis on a shoestring budget?
  3. What free/low cost options are available to small/rural practices for practice transformation support?
  4. What workflow changes in a small/rural practice are most impactful under an APM?

Pay and Chase: A Refresher

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.

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.

Tricare Vaccine Payments: What (We Think) Works

Since most of us are sending electronic claims, you want to check your 837 EDI files (electronic claims transmission files) to see that you are actually sending what you think you’re sending.

We’ve become aware that some practices THINK they may be sending a certain NDC number or NDC suffix, but their claims software actually sends something different.  Check with your vendor!  Also note that if you are sending paper claims, Tricare has different requirements.

For electronic claims: Tricare wants most vaccine NDCs to have a 1 UN NDC suffix, but a few vaccine NDCs should have a 0.5 ML NDC suffix.

What’s an NDC suffix?

Vaccine claim lines should look something like this:

vaccine EDI

  • Yellow highlight = CPT code (90734, here Menactra)
  • Green blob = our practice’s charge for Menactra (obfuscated for anti-trust reasons)
  • Blue underline = date of service (2016/01/05, January 5, 2016)
  • Red underline = 11-digit NDC number (notice how right before it is the NDC prefix “N4”)
  • Black underline = “NDC Suffix” = .5 and ML, separated by an asterisk *

So when  we say “0.5 ML” NDC suffix, we mean that the last part of your vaccine charge (the segment that starts with CTP**) should go out looking like this:

90633 - Yes

Or the CTP segment might have a leading zero:

90744 - Yes

When we say “1 UN” NDC suffix, we mean that the claim should look like this.  Look particularly at the CTP*** segment:

90707 - Yes

Note that BOTH the 0.5 ML NDC suffix claims and the 1 UN NDC suffix claim all have UN*1 in the top of the line item (yellow highlight).  That’s number of billed units (like if you do two 96110, you bill 2 units of it) which is different than the NDC suffix (pink highlight).

90707 - Yes hilit 90744 - Yes hilit

So, which vaccines should be billed which way?

As best we can tell, Tricare pays vaccines according to the contracted rate if the following vaccines are submitted as follows:

 

1 UN NDC suffix 0.5 ML NDC suffix Either one seems to work
90648 (Hib)

90698 (DTaP-Hib-IPV)

90707 (MMR)

90716 (Varicella)

 90633 (Hep A)

90649 (Gardasil)

90700 (DTaP)

90713 (IPV)

90734 (Menactra)

 

90670 (Prevnar 13)

90744 (Hep B)

90715 (Tdap)

All flu vaccine codes

Once again, Rotavirus vaccine is an exception:

90680 - Yes

It will pay properly using the modifier F2 and the NDC suffix “2 ML.”

It will also pay properly like this:

  • SV1*HC:90680*[bla]*UN*1***1~
  • DTP
  • REF
  • LIN**N4*00006404701~
  • CTP****1*F2~

…using the NDC suffix “1 F2.”

Who Owes You Money?

From time to time, payments owed to your practice go astray.  If (for whatever reason), someone tries to pay your practice but is unsuccessful, the payer is supposed  to turn the money over to the State of Tennessee.

Enter the Tennessee Unclaimed Property service, part of TN’s Department of the Treasury.  You can look for your practice name and/or individual physician name(s) to find and claim mislaid insurance payments, vendor rebates, utility deposits, and so on.

If your practice has changed names or locations, you’ll want to do a search periodically to find your unclaimed property.

A quick search today shows lots of TNAAP member practices (and some children’s hospitals!) are owed money — in some cases, over $1000.

Submitting a claim is easy and can be done on the TN Unclaimed Property portal.   It takes a few months to process your claim.

Tricare Vaccine Recoups

We’ve become aware that Tricare is doing a large-scale project to recoup overpayments on vaccines from as far back as 2012.   Here are some things to know:

Can Tricare do this? 

Yes, if you were genuinely overpaid.   Tricare is a federal government program and is not subject to the 18-month limited lookback period of commercial insurance programs in Tennessee.

How do I know if I was overpaid?

Your recoupment request should include an itemized list of patients with DOS, the alleged paid amount and the overpayment amount:

recoupreq

Once you have identified the claim in question, look at the vaccine(s) paid on that claim.  Compared to your fee schedule, one or more of your vaccines was probably overpaid.  The common patterns we’re identifying are:

  1. At least one was either paid double the contracted rate
  2. Your entire fee was paid (i.e. a $0 adjustment on that line item.)

Examples:

Vaccine X:  Tricare pays $35.  Practice charges $100.

   -Tricare paid $70 (2x the contracted rate.)

Vaccine X:  Tricare pays $35.  Practice charges $50.

    -Tricare paid all $50 (the entire charge.)

I don’t have a Tricare fee schedule.  Where can I get one?

Your Tricare rep should be able to help you with this.  Alternatively, you can call the Tricare claims 800 number (800-403-3950) and ask for your fee schedule.  You will be asked for a list of CPT codes and matching NDC numbers that you want the fees for, so have those handy.

Note: fee schedules change over time.   Your current fee schedule for vaccine X might be $35, but in 2012 (during the recoup period) it may have been $32.50.

In general, unless Tricare has negotiated deeply discounted rates with your practice, Tricare pays at least the CDC private list price on most vaccines.

You can also get a partial list of vaccine prices at http://www.tricare.mil/CMAC.

Tricare Vaccine Claims

Tricare, the government payer for families of active duty military, has some very peculiar rules about how it wants vaccine claims sent.   Your practice may be getting overpaid or underpaid (or both!) if it is not following the Tricare rules.

When you submit a CPT code for a vaccine to Tricare, you must also include an NDC number with the appropriate NDC suffix.

In general, Tricare wants you to use the individual (not bulk) vaccine NDC code, along with the suffix “UN1.”

Rotavirus vaccine is an exception — for these, use the individual NDC code, the suffix “ML2,” and the modifier F2.  (The modifier goes in the same place as you would normally put a modifier -25 or -59.)

Update: There are some vaccines that Tricare wants you to submit using the NDC suffix “0.5 ML” instead.

What’s the difference between individual and bulk vaccine NDC codes?  Most vaccines come in packages of 5 or 10 vaccines.  That multi-dose “package” has an NDC number, which is different than the “unit dose” NDC of a vaccine that’s administered.   The unit dose NDC may be printed on the individual vaccine vial syringe — or maybe not.

If you use the bulk vaccine NDC code, Tricare’s computers will sometimes assume that you are claiming you gave all 5-10 doses to that one patient (yes, that’s crazy) and will pay you up to 5x or 10x the usual amount.  (Typically, this is capped out at whatever your charge is.)

You can look up whether your vaccine NDC is an “individual” or “bulk” NDC code here:

http://www.hipaaspace.com/Medical_Billing/Coding/National_Drug_Code/NDC_Number_Lookup.aspx

In this example, the tan line indicates the bulk/package NDC code and the blue line indicates the individual/unit dose NDC code.

ndcs

How can I tell if I’ve been overpaid, underpaid, or neither for a particular vaccine dose?

Compare your total payments to Tricare’s fee schedule.   At a minimum, you should be paid above your cost for vaccines.    You may see a pattern of many doses of a particular vaccine being paid at or slightly above the CDC private reference price, but with other doses being paid at 25%, 50%, 200%, or 400% of that amount.