Carol Hoppe MedLucid Solutions

ISMA recently met with IU Health Plans to discuss concerns from our members regarding claims that were being processed incorrectly. The issues began in mid-2017 after IU Health Plans began transitioning from outsourced claims processing to processing its own claims. The transition was completed on Jan. 1, 2018. Representatives of IU Health Plans, which covers more than 90,000 people, roughly half of them IU Health employees and their families, acknowledge the transition has been challenging.

Many of the issues that medical practices faced earlier last year have been resolved by putting new policies and processes in place. As problems are identified and solutions implemented, IU Health Plans automatically reprocesses all claims affected by the errors. The following issues have been identified to date.

Patient benefits loaded wrong. One of the major areas where this occurred was with preventive health services, where patients do not typically have to pay their deductible or copay. Additional codes have been added to the system, and IU Health Plans continues to update this information as new preventive codes are identified.

Physician fee schedules loaded wrong. A process has been put in place to review and verify contracts and rates with contracted physicians. Any carve-out codes are now tested to make sure they pay correctly.

Network status of physicians incorrect. Network status is being corrected as identified.

CPT codes were changed from those submitted on claims. This was primarily due to newborn visits being billed with the mother’s date of birth. The system automatically changed the newborn visit code to an age-appropriate preventive visit based on date of birth. This has been corrected to allow newborns to be covered under the mother’s plan for the first 31 days of life under fully insured plans (state law) or until the mother’s date of discharge for self-funded plans (federal law).

Recoupment on explanation of payment (EOPs) without enough information to post the EOP. The current process depends on how payment is received (paper check or electronic funds transfer (EFT). Typically, a notice or “negative explanation of payment (EOP)” is sent requesting a refund with 45 days. If payment is not received in 45 days, the recoupment occurs, but the detail is not on the EOP. The vendor expects to have this fixed by July. In the meantime, you can request to receive an electronic file with the EOP information automatically.

Not paying state-mandated interest on claims paid late. This has been addressed, and IU Health Plans was in the process of paying back all who were owed interest by Dec. 31, 2018. Interest is calculated at 28 days from the date of service to account for processing time. Going forward, interest payments will be linked to the patient on the EOP.

Information on the IU Health Plans website inaccurately reflects information on paper EOPs. This will be addressed by the vendor in a system update between April and July this year.

In some cases, fixes have led to new problems. As errors are brought to IU Health Plans’ attention, it reprocesses all associated claims retroactively. There is no need to appeal or resubmit once you notify IU Health Plans of an error.

IU Health Plans had 70,000 claims on file from March through April of last year. As of Dec. 6, the backlog was about 6,500 claims, with a goal to be within two days (about 4,000 to 5,000 claims) by April.

If you have any concerns with your IU Health Plans claims, please contact your IU Health Plans provider relations representative. Or, call ISMA at (800) 257-4762, and you will be connected with someone who can assist you. IU Health Plans is committed to resolving issues and building strong relationships with the physician community, so please keep ISMA informed if you are not getting the help you need.