Forget All the 'Medicaid Only' Clients or Anyone Having Medicaid as Secondary Without Medicare: THIS Should Finally Deal Some Kind of Death Blow to the Medicare Advantage Companies due to Management Nightmares

Well, let's start off with the good news, shall we?  The blasted LME's are not managing the Medicare primary/ Medicaid secondary funds for those clients.  Those are most of my clients. 

They ARE managing the Medicaid for people who ignorantly sign onto some other Medicare Advantage Plan, it appears.  So, if you have clients who have Humana as their Medicare, w/ a wrap-around to Medicaid, you'll have to have the Medicaid dollars managed by the LME. 

AND, there's now no longer any 365 days to submit Medicaid billing.  There's 90 days under the Medicaid Waiver. 

So,that makes it simple: I simple advertise myself as a Medicare/ Medicaid provider but not Medicaid alone. And no Medicare Advantage plans clients. 

So, just as I have been telling my clients for years: DON'T GO OFF YOUR MEDICARE PLAN.

So, to add tothe list of problems with the oxymoronic Medicare Advantage companies:

1. you commonly have to get authorizations somewhere along the way to continue to see the patients.

2. you not uncommonly have to send in all your notes in order to get paid (I had to do this many times w/ Humana but they stopped that about a year ago but who knows they could start again)

3. they have a 15% administrative cost whileas Medicare has about a 5% administrative cost (in other words, some fat cat is not earning a sky is the limit salary which is what is being proposed by the bill which was to be voted on yesterday by the NC State Legislature turning the LME-MCO's into mini-hospital authorities wherein they could create their own salaries and avoid having any consumers on their boards and not report to the county commissioners).

4. there is no wrap-around in terms of billing, to Medicaid, as this administration has to go through the LME whileas w/ a client with primary Medicare and secondary Medicaid, there continues to be a wrap-around.

This is sheer idiocy.  How many pieces are we trying to carve this mental health care into, anyway?

Here is my e mail to Donna at Western Highlands Network LME and below it is her reply. She's a helpful woman working in a blown-up system.

*************************************************************
Marsha Hammond,PhD


Jun 14 (6 days ago)
to Donna

thanks for your reply, Donna.

I have several questions as associated with it and a comment: there
was an automatic wrap around from Medicare to medicaid previously.

Now, I have, or my biller has, the additional step of turning in the
EOB from Medicare to WHN, so that WHN can figure out how much is to be
paid as associated with the client's Medicaid account. Correct?

I want to make sure that I understand this correctly: there is now no
samless way to have an automatic wrap around to Medicaid for dually
eligible clients utilizing this Medicaid waiver. Correct?

If so, I find this exasperating. It just adds work for me or for the
biller and is ludicrous. Is there any plan to CREATE a seamless way
to do this -----like it has always been done before?

You indicated that there is '90 days', I assume, from date of service.

That was not associated with Medicaid in the past. I believe it was
a year. I would have to check on that but it certainly was not 90
days. Is this as associated with the Medicaid waiver? If so, where
are the rules/ regulations associated with the Medicaid waiver? Please
don't tell me to go wander around in the DHHS/ DMA web pages. Surely,
the guidelines must be in a discrete place and I would so much
appreciate it if you could simply give me the URL.

Thirdly, I do not understand your sentence below: "Mcare/Mcaid does
not enter a managed period."

thanks for your hard work.

                                            ****************************
Donna Baker Oliver donnaba@westernhighlands.org

3:58 PM (23 hours ago)
to me

Yes there used to be what is known as the "crossover" from Mcare to Mcaid. In the current Waiver system through out the State there is not a "crossover" process. From what I understand it would be very complicated to achieve with a federal system like Mcare. Other providers have been frustrated by this as well. Regarding the managed question: when a consumer has third party insurance like BCBS, Aetna etc plus Mcaid, the Mcaid is managed by WHN UM once the session limit has been used or the provider goes to managed. ********Mcare/Mcaid is the exception in that the secondary Mcaid is not managed by UM.

You are correct the "90 days to bill" is associated with the Waiver. Previously providers who have since come under Waiver sites had 365 days to bill the Mcaid vendor. Providers not yet under Waiver sites (ie. not seeing consumers whose Mcaid are under Waiver sites) still have 365 days from what I understand.

Most importantly, providers can only receive reimbursement for services provided to WHN consumers (whose Mcaid is with our counties) when they have a fully executed contract with WHN.

Thank you,