News

Q3 2023 PROVIDER NEWSLETTER

Date: 08/21/23

Payment Integrity Notifications
Optum CPI Payment Edits and Cotiviti Post-Payment Reviews

Optum’s Comprehensive Payment Integrity (CPI) tool:

Ambetter of NC Inc. is committed to continuously evaluating and improving overall Payment Integrity solutions as required by State and Federal governing entities. As a reminder, we have partnered with Optum who is supporting us in performing prepayment claim auditing. The purpose of our review is to verify the extent and nature of the services rendered for the patient’s condition and that the claim is coded correctly for the services billed.

For claims received on or after 11/1/2023, providers may experience a slight increase in written requests for medical record submission prior to payment based on the areas outlined below. These requests will come from Optum and will contain instructions for providing the documentation. Should the requested documents not be returned, the claim(s) will be denied. Providers will have the ability to dispute findings through Optum directly in the event of a disagreement.

Editing Area	Description
Professional Claims for Select Surgical Procedures	Pre-payment medical record review for inappropriate billing of services not documented in the physician clinical notes. There is no medical necessity decision making involved.
Facility NCCI Modifier Override	The algorithm identifies instances in which providers submit claims that utilize the NCCI bypass modifiers with CPT codes that are not allowed to be billed together for the same recipient, on same date of service, based on Medicare NCCI OCE edits.
72 Hour Rule Enhancement	For the 72 Hour Rule criteria, diagnosis codes for the member’s outpatient and inpatient claims will no longer be matched and provider matching will be based on tax ID. These changes are in accordance with CMS guidelines and will apply to outpatient facility claims (lookback and going forward dates of service).
ER Surgical Services without Modifier 54	Requesting medical records to determine if documentation supports services billed for ER surgical services where the follow up was not performed in the ER setting, and the correct modifier (54) was not included with the claim.

Cotiviti Post-Payment Reviews

Commencing 11/01/23, Ambetter of NC Inc. will begin post-payment reviews of inpatient claims to verify payment accuracy of our facilities. Ambetter of NC Inc. has engaged the services of Cotiviti to conduct these claim audits.

Diagnosis-related group (DRG) Review

This program audits the billing appropriateness of the inpatient DRG billed on a claim. Groups of diagnoses and procedures codes on a claim map to specific DRGs. A claim has to be paid on a DRG level in order to qualify for this audit.

Submitting Attachments to Pending Claims

Using the Secure Provider Portal, Ambetter of NC Inc. providers now have the ability to submit attachments to pending claims when additional information is requested. Follow these easy steps!

Locate the claim on the Claims Status Page
Navigate to the Pending claim details and select upload document
Add documents via drag and drop or by selecting a file. Size limit is 5MB per file.
Use trash can to delete upload if needed or click submit.
Confirmation appears at the top of the screen; document is immediately available to view.
Repeat as needed to attach multiple documents to a pended claim.

View, along with additional improvements, in our Portal Enhancement education deck:Provider Portal Enhancement Training

New Provider Guide for ABA Providers

Applied Behavioral Analysis (ABA) providers can reference the Outpatient Treatment Request Checklist for support in request initial and ongoing treatment requests. This guide recommends clinical information that will aid in the timely processing of the request as applicable. Applied Behavioral Analysis Outpatient Treatment Request Checklist

Quarterly Quality Column

Each quarter, Ambetter of NC Inc. will feature a HEDIS® measure (or measures) and share best practices for closing care gaps.

This quarter: Colorectal Cancer Screening (COL)

HEDIS® Colorectal Cancer Screening (COL)

This measure evaluates the percentage of members 45-75 years of age who have had an appropriate screening for colorectal cancer.

Prevalence

“Colorectal cancer (CRC) is the third most commonly diagnosed cancer and the third most common cause of cancer-related death in both men and women in the United States.”- American Cancer Society

Barriers

Common barriers to preventive care in North Carolina include cost/lack of medical coverage, living too far from providers and lack of awareness of recommended preventive services/screenings. A 2021 survey of barriers found that, “the top barriers to FIT/gFOBT and mt-sDNA were lack of provider recommendation (31.6% & 37.5%) and lack of knowledge (24.6% & 25.6%), while for colonoscopy top barriers were psychosocial barriers (31%) and lack of provider recommendation (22.7%).” - Barriers to utilization of three colorectal cancer screening options – Data from a national survey, NIH, National Library of Medicine

How do I improve?

Recommend: Strongly encourage screening. Surveyed patients stated Colorectal screening was not recommended by providers.
- Explain the benefits of preventive visits and screenings. For the COL measure, discuss the different screening methods.
- Advise that early detection of abnormal findings may lead to better outcomes and a longer lifespan.
- Avoid Decision Fatigue. Offer at preventive care visit. Ask patients about their concerns regarding the screening, you might say, “What part of the test are you most worried about?”
Develop a Screening Policy: Establish EMR alerts to indicate a screening. Use organized systems within the practice to reach out to patients who have not had the Colorectal screening. Identify your initial screening rate. Implement a plan to improve screening rates.
Evaluate practice process and measure progress: Track the results of outreach activities. Make sure all providers can view the results of the outreach activities.
Be persistent with reminders: You may need to remind patients several times about the screenings.
Documentation: For HEDIS® COL measure compliance, provider documentation must contain the type of screening, the date the screening was completed, and the screening must be done within the appropriate timeframe. A result is NOT required if the screening documentation is clearly part of the member’s medical history. Acceptable documentation may include a health maintenance report, labs, a standalone Problem List, and Progress Notes indicating type of test and date performed.

Five Screening Tests for Colorectal Cancer

SCREENING	CPT CODES
Fecal occult blood test (gFOBT) - annual	CPT: 82270, 82274 HCPCS: G0328
Flexible Sigmoidoscopy – every 5 years	CPT: 45330-45335, 45337-45338, 45340-45342, 45346-45347, 45349-45350 HCPCS: G0104
Colonoscopy- every 10 years	CPT: 44388-44394, 44401-44408, 45378-45393, 45398 HCPCS: G0105, G0121
sDNA s FIT Lab Test (Cologuard) - every 3 years	CPT: 81528
CT Colonography- every 5 years	CPT: 74261-74263

Resources

New Provider Orientation

During the New Provider Orientation, we will discuss the following:

Ambetter benefits
Verification of Eligibility and benefits
Accessing the public website and secure web portal
Prior Authorizations
Claims
Provider Billing Manual and Provider Tool kit

Ambetter of North Carolina Inc. holds New Provider Orientations monthly on the third Tuesday at 12PM ET.

Register in advance for this meeting
After registering, you will receive a confirmation email containing information about joining the meeting.

Ambetter of North Carolina Inc. also has an on-demand option for your New Provider Orientation.

View the recording

Once you complete an orientation, please submit your attestation.

Provider Manual
Visit Provider Resources for the most up-to-date version of the Ambetter of North Carolina Inc. Provider and Billing Manual:
https://www.ambetterofnorthcarolina.com/provider-resources/manuals-and-forms.html