Town Hall Provider Questions

Questions Asked During September 23, 2021, Town Hall

We have not received our recoupment back after billing correctly from Amerigroup. When we have asked about it, we are constantly told, "It'll be looked into.” We need definite answers as it's a lot of money.

If this is claim that was submitted as a corrected claim, but was past timely filing requirements, Amerigroup encourages the provider to contact their representative for resolution. If this was a recoupment from the Cost Containment Unit, Amerigroup encourages the provider to dispute the recoupment following the instructions on the letter.


How is the provider survey being sent to healthcare facilities? Will it be attention to someone specific within the organization?

The provider survey will be sent out through an Informational Letter to all providers. Each provider organization can decide who will fill out the survey. The survey can be filled out by multiple individuals from the same provider organization. All responses are anonymous.


Other Health Insurance (OHI) is huge ongoing issue. IME sends files that the MCOs blindly load with unverified information. Many, many times these insurances have been termed long ago. Or, that what they show is a Medicare replacement plan. This is such a time-consuming process for all involved. It seems there could be a much better process which would result in a better outcome.

Iowa Medicaid is working on this issue.


Can you please confirm that the expanded telehealth services in effect statewide through at least 60 days after the public health emergency (PHE) declaration is lifted refers to the FEDERAL PHE dates and not Iowa's PHE? It is not specific on the IME website.

Iowa Medicaid’s expanded telehealth services are tied to the FEDERAL PHE.


Reviewing and increasing the Habilitation rates after over a decade of no increase was a 'HUGE positive for providers. Can we expect future reviews and increases for Habilitation services?

Iowa Medicaid is working to setup a process to have annual reviews of all rates. Rate increases are dependent on appropriations from the Legislature.



Iowa Total Care only lists if the patient has primary coverage listed on their site - so instead of being able to rely on the electronic eligibility we must go only to their website to check. Other payors (IME included) pass other insurance information on the electronic eligibility files. Why isn't this required for MCOs?

Iowa Total Care will look into options for including this information in their EDI processes.


We have tried many ways to connect with the contracting area of Iowa Total Care, but no one responds. What do we – a contracted provider – have to do to receive a response to our communications?

There are multiple ways for providers to connect with Iowa Total Care. All providers, contracted or otherwise, can contact Iowa Total Care Provider Services at 1-833-404-1061. Network Development can be reached at NetworkManagement@IowaTotalCare.com, and geographically designated Provider Relations Representatives can be found on Iowa Total Care’s website.


What happens if a provider receives a denial for a FFS claim because there is no prior authorization from IME?

The provider should contact IME Provider Services to verify the services in IoWANS. If the plan is not authorized or does not reflect the services, the worker would need to update these before the provider can resubmit. If the services can be verified, staff can complete verification that will update the authorization. Once updated, the provider can resubmit the claim for processing.
 

 

Questions Asked During August 26, 2021, Town Hall

In terms of the 3.55 percent rate increase for Home- and Community-Based Services (HCBS) providers, there are rates that are not posted on the DHS website. There are providers coming to the association asking if there is a rate increase. Will they be able to bill for services at the new rate, are the rates retroactive? How can providers properly bill?

There are a number of provider rates that aren’t posted on the DHS website because they are individual based rates that the provider contracts with the Managed Care Organizations (MCOs). The MCOs are in the process of increasing those rates in their respective payment systems.

 

I am an orthodontic office. We currently use Ability PC-ACE to submit claims other than to Delta Dental of Iowa. It is very hard to navigate and understand how to enter Primary Insurance information. I have been trying on three claims and have submitted eight times and get a cyclical response – IME's Electronic Data Interchange (EDISS) says Medicaid issue; your team says EDISS issue. I go back to the PC-ACE guide to try to figure out how to enter the claim and have tried about every possible way and I am getting nowhere. Any plans to make a more user-friendly claims submission system?

Iowa Medicaid followed up individually to help troubleshoot the issue.

 

Speaking of reimbursement, when will Iowa Medicaid rates for providers be increased to cover the cost of long acting contraception (IUDs, Nexplanon) so we can prevent unintended pregnancies.

These were increased during the rebase in July 2021. Providers should refer to the new fee schedule.

 

Why are the MCOs allowed to down code our charges? Amerigroup has been doing this and then reprocessing once we protest. This is unnecessary and additional costs for both parties.

Iowa Medicaid needs some more information on this; please send us examples through Provider Services (IMEProviderServices@dhs.state.ia.us).

 

We need to see faster turnaround time on providing the quarterly addendums to the MCOs.

Iowa Medicaid will work on speeding up this process. The delays are due to the publication of the CMS Addendum B, which doesn’t typically happen until a few days before the effective date. Once CMS publishes Addendum B, then Iowa Medicaid staff must take this document and modify it for Medicaid coverage. Iowa Medicaid then shares this with the MCOs to review and comment. The final step in the process is posting it to the website.

 

Will the Federally Qualified Health Centers (FQHCs) get a raise in reimbursement as well? 

For Iowa Medicaid Fee-for-Service (FFS) claims, FQHC interim rates are provider specific and cost based. These rates are set annually based on the review of the provider’s Medicaid Cost Report. Providers receive cost settlement at the higher of their actual cost per encounter or the provider specific Prospective Payment System (PPS) rate as set by the Benefits Improvement and Protection Act of 2000 (BIPA). PPS rates are subject to annual adjustment based on the Medicare Economic Index (MEI). All payments are encounter based.

MCO claims are paid at the minimum of the provider specific PPS rate. Provides can seek the higher, cost based reimbursement, by submitting Managed Care Wraparound Payment Requests to the IME on a quarterly basis. Wraparound payments are subject to cost settlement during the review of the provider’s annual cost report.   

 

We are having many issues with Amerigroup with little support. I would appreciate some details on the best route to address those, as our liaison has been non-responsive.

Please share specific examples with Iowa Medicaid through Provider Services (IMEProviderServices@dhs.state.ia.us).

 

We would like to have the State put some pressure on the MCOs updating retroactive rates by the 60-day deadline. Who do we reach out to when there is significant delays in getting old claims reprocessed and paid at the higher rate?

Please share specific examples with Iowa Medicaid through Provider Services (IMEProviderServices@dhs.state.ia.us) so that we can follow up.

 

What grants are out there for Health Home programs to assist the members that we serve in that program. A general grant that we can use to deal with issues that have come up during this pandemic.

There are a number of resources that are available that are pandemic related. Here are links to several state and federal COVID-19 resources:

 

We understand there is to be another MCO added to the mix starting sometime next year. Please address this, as this is a huge potential additional burden to providers and patients.

Amerigroup’s contract is set to expire in June 2023. Because of this, Iowa Medicaid is going to be submitting a formal Request for Proposal (RFP) for at least one more MCO. We want a minimum of two MCOs to serve Iowa Medicaid, but we're reserving the right for more. The RFP winner or winners would go live in July 2023. We plan to allow a very long runaway prior to go live so there is plenty of time to test and to do all of the necessary ramp up activities prior to go live.

 

Has there been any more information given regarding the behavior procedure-to-procedure (PTP) edit regarding school based Medicaid. In addition, will there be a focus on the school based Medicaid provider manual in regards to clearer requirements and billable services?

Iowa Medicaid continues to evaluate this. We have not decided whether or not we will be waiving the edit for the current school year. Behavior para-professional claims can continue to be billed using the previous codes for the time being.

 

The MCOs not having the same Prior Authorization (PA) requirements for each service is a headache and very time consuming to staff. It was save so much time and money if they were all requiring PAs for the same services.

We have worked with the MCOs to put together a universal prior authorization form, but understand that their requirements can differ. One thing we want to focus on is reducing administrative burden or eliminating processes that aren’t effective. Therefore, if there’s a PA that is getting approved 99% of the time, is it really worth having that step in place anymore – those are the things we want to work on.

 

What can be done to help expedite the handling of MCOs processing and fixing billing that has been put into a "project" we are looking at some bills that have been in a project for months on end.

Please share specific examples with us through Provider Services (IMEProviderServices@dhs.state.ia.us) and we will escalate to MCO leadership, if necessary.

 

Currently, we are treating patients from all over the state of Iowa. Please clarify psychiatric Telehealth requirements post public health emergency (PHE). Will it go back to original guidelines, or will current practice continue?

Telehealth payment parity will continue post PHE for mental health services. In terms of continuing to allow audio only telehealth services, post PHE, that is something that we’re still looking at and we plan to provide advance notice to providers once a final decision is made. We’re looking at telehealth services as a whole post PHE and access statewide will be a consideration in those decisions.

 

We're seeing more issues with J codes being paid. One example is J0702. What is the MCO supposed to go by? The IME Rebatable List, the Data.Medicaid.gov or FDA.gov?

The MCO should use the Data.Medicaid.gov website as indicated in Informational Letter 1897.

 

Can you please confirm that the MCOs only cover CPT/HCPCs listed on the Medicaid Fee Schedule? We are having issues where both Amerigroup and Iowa Total Care representatives are telling patients and our staff via phone procedures/drugs/DME are covered but they are not on the Medicaid Fee Schedule.

Please send specific examples to Iowa Medicaid so that we can review..

 

Are the MCOs saving the state money?  Why do we need to use them?  State Medicaid worked well.

We have looked at costs across the health care market and we are under the average growth in expenditures so yes, they are saving us money, but that is not the only reason we contract with MCOs. We also contract with them because they can provide value-added services, they come with a case management system that helps in coordinating the care of an individual, and they allow us to pay for some services that we’re not able to pay for through FFS.

 

Last year there was discussion about re-credentialing all of the mid-level providers to be Rendering Providers and not just Referring. Any updates on this. 

Physician assistants have the ability to enroll as rendering providers. Provider should reach out to Provider Services Enrollment Department at 1-800-338-7909 option #2 if needing to enroll these providers as such.

 

I have been unable to get clarification from both the MCOs and the State as to whom we can contact to actually negotiate the MCO rates as stated in our contract vs the MCO simply using the cost report to adjust rates down, but not always adjust when costs go up or at least not the full amount.

Send specific examples to Iowa Medicaid through Provider Services (IMEProviderServices@dhs.state.ia.us) and we’ll follow up individually.

 

Does IME have an electronic provider application in the works?  Such as a website we can log into, start, and track our credentialing process?  Along with that, we receive three page letters for each approved provider for each location. The volume of letters we receive per new physician is quite large when they participate at 45 locations. Is there way to streamline the notification process?

This is something Iowa Medicaid will look at as we modernize the systems and processes going forward.

 

Is there a certain amount of time you would like us to try to work with the MCOs on issues? I have a few claims issues I have been working with them on for eight months to a year with no resolution. Are we permitted to reach out after three or four months?

Please reach out to your MCO reps, don’t wait eight months. If you need assistance with escalating an issue, contact Iowa Medicaid.

 

Is there a way to key the town hall meetings into groups--for example, dental, medical, psychological, home care, etc.?  I think we could key in on issues for each area a little better if the town halls would be specialized.

Iowa Medicaid will look into setting up work groups for future meetings.

 

Why does it take so long for Iowa Medicaid to get the addendums out and get them to the MCOs?

Please share specific examples with Iowa Medicaid through Provider Services (IMEProviderServices@dhs.state.ia.us) and we’ll follow up.

 

Wasn't the MCOs supposed to reach out to patients when they are frequent flyers in an Emergency Department (ED)?  We are non-profit and have several that will come here for convenience or because the private clinics will no longer see them. As a non-profit, we cannot advise the patient that they should be seeing their primary care physician and not come to ED.

That is one of the goals of the MCOs, but social determinants of health do play a role in this. Please share specific examples with Iowa Medicaid through Provider Services (IMEProviderServices@dhs.state.ia.us) and we’ll follow up.

 

Our office sent in credentialing paperwork for our office and dentists to become providers to MCNA Dental at the end of May and we have yet to be notified that everything is processed and ready for us to submit claims. In May they said it would take four to six weeks, It’s been 12 weeks today. When I call them, they can never find the information for all three of our doctors or the practice. What do we need to do to become providers?  I have three months of claims waiting to be processed.

Please share more specifics with Iowa Medicaid through Provider Services (IMEProviderServices@dhs.state.ia.us) and we’ll follow up.

 

We understand urgent / emergent obstetric services are to be paid by the MCO regardless of participation with the MCO. We are not contracted with Amerigroup. When a pregnancy patient presents to the emergency room, they are sent to labor and delivery to be evaluated (this claim POS not ER) and Amerigroup will not pay unless we complete a prior authorization the same day patient presents to hospital. A PA should not be required - this is unnecessary administrative burden. What can be done?

Please share more specifics with Iowa Medicaid through Provider Services (IMEProviderServices@dhs.state.ia.us) and we’ll follow up.

 

Do you really believe that Case Managers can advocate fully on behalf of their clients and all clients’ needs when they (the Case Managers) receive their paychecks from the very pay source (MCO) of these services?  Do you see any conflicts of interest?

We have done a lot of work to ensure that there are firewalls in place with the MCOs, however I do see the concern from your end that there is an apparent conflict of interest. Back when Long-Term Services and Supports (LTSS) was under the State, there were the same appearances of conflicts of interested then too. With how the market is today there is always going to be the appearance of conflict of interest and we just have to make sure that we have the appropriate reporting channels so that we can mitigate that conflict and then really keep an eye on how service planning is developed, authorized and delivered. If you have specific concerns about this, please reach out to Iowa Medicaid.

 

What oversight does Iowa Medicaid have over the MCO?  

We do have robust contracts with the MCOs. We want to make sure that the MCOs are operating with the constructs of their contract because ultimately we want companies to be delivering services in the way that the state policy is setup.

 

Is the fee schedule for durable medical equipment (DME) / medical supplies carried over to the MCOs as part of your oversight?

If you have a specific issue with being paid, please reach out to Iowa Medicaid through Provider Services (IMEProviderServices@dhs.state.ia.us) and we will follow up.

 

Does IME, Amerigroup and Iowa Total Care still have the COVID waiver in place for authorizations of swing bed or skilled admission.

Iowa Medicaid has confirmed that this waiver is still in place.