Vachette Pathology

In a recent conversation with Tom Scheanwald, Vice President of APS Medical Billing, he noted that claims’ processing for Michigan Medicaid was already cumbersome, even before this budget cut.  In addition, Mr. Scheanwald noted other examples that further delay your Medicaid payments.

There are many examples of denials from Medicaid for valid claims. Denials are done by "line item" and if your biller coded an 88305, 88112 and 88342 for a case, Medicaid may pay for one but reject the other codes as "duplicate” or“ included as part of another service”. Refiled claims and appeals take up to 2-6 months to reprocess, which delays final reconciliation of the account. Furthermore, appeals must be filed by hard copy.

Eligibility for Medicaid runs through Blue Cross of Michigan. This means running a claim through two different systems causing more inaccuracies.

Unlike other states, Michigan Medicaid offers no confirmation when claims are sent by the billing entity.  This omits an important checkpoint that would help to confirm receipt of claims.

Michigan Medicaid offers no Web site on which to check claim status. Instead, a call to a representative on the phone is required.

The biggest obstacle to overcome when processing and following up on Michigan Medicaid claims is obtaining information without a claim number. A claim number is assigned after a claim has been processed by Medicaid. The biller may file a claim but not receive information for 60-90days. When calling to inquire about the claim, the operator will ask for the claim number. You can't give a number if you’ve never received it. This process consumes  ahuge amount of the biller’s time when checking claims.

This Michigan Medicaid cut will not likely be the end of the story.  While Michigan continues to suffer in this economy more severely than other states, it is our opinion at Vachette that we will see this trend follow in other states. For example, Illinois Medicaid routinely runs low on funds and stops processing payments. We are seeing similar situations in California with Medi-Cal and anticipate the same affect in Kansas soon as well.

In summary, pathology groups, laboratories and hospitals already experience difficulty with receiving payment for their services from Medicaid beneficiaries. With these new changes, groups will continue to navigate the bureaucratic nightmare that comes from working with a governmental agency and the final payment will be less rewarding. 

The question that begins to enter a provider’s thoughts here may be: When do you reach a point of diminishing returns? At what point does the hospital based practice go back to the hospital administration and ask for a stipend to cover these patients? When does the private free standing independent laboratory say they simply will not see these patients? How will hospital out reach laboratories cope with this increasing loss of revenue?

The day that these questions need an answer is coming; it is just a matter of time.