New Process for Mass Adjustments from Medicare

June 28, 2011

In February 2011, health plans were notified that Medicare would be processing adjustments to claims retroactive to Jan. 1, 2010, due to changes in the Medicare Physician Fee Schedule (MPFS) and certain provisions of the Affordable Care Act (ACA). This notice applied to services performed by physicians, long-term care hospitals, inpatient rehabilitation facilities, home health agencies and any other provider types impacted by select provisions of the ACA and the MPFS changes. Some health plans have elected to receive claims adjustments like this made by Medicare from CMS’s national crossover contractor, the Coordination of Benefits Contractor (COBC), using its “crossover system”. Other plans have elected to receive these adjustments directly from the provider.

BCBSOK is currently receiving these fee schedule adjustments via the Crossover system. The majority of the changes are for very small dollar amounts (plus or minus $.01 - $1.00) and over 50 percent have resulted in no change in our original payment.

The routine processing of these adjustments has resulted in the issuance of thousands of Explanation of Benefits (EOBs) to members for very small dollar amounts. This is creating confusion and frustration for our members. We are also aware of the administrative processing and cost-benefit burdens such small adjustments place on our providers. 

As a result, BCBSOK is implementing the following process:

  • As of July 11, 2011, Medicare mass adjustments will be excluded from crossing over to BCBSOK. We will continue to receive all other routine adjustments and Medicare supplemental claim types via the crossover system. Note: BCBSOK will process all adjustments received through the crossover system prior to July 11, 2011.
  • For these excluded adjustments, the message on your provider notification from Medicare will no longer indicate that the claim has automatically been sent to BCBSOK.  
  • Regardless of the amount, BCBSOK stands ready to process any adjustment at your request. We understand that in many instances, the costs providers incur to process such small adjustments exceed the recovery. Similarly, adjustments may be due from providers, creating the same processing cost concerns. As a result, we are leaving it to your discretion to request processing of these excluded adjustments. If you choose not to request an adjustment, no further steps need to be taken. However, if you wish to receive an adjustment, electronic submission is preferred. Replacement claims submitted electronically will reduce the potential for the claim to deny as a duplicate. To submit a replacement claim, include the required updated EOMB information and indicate that this is a corrected claim with the appropriate bill type, as follows: The first two digits of the bill type indicate the place of service on a professional claim; the third digit indicates the claim frequency. 

Example: Bill type 117 on a professional claim would indicate this is a replacement claim for place of service office. The “11” is for the place of service office and the “7” indicates this is a correction to a previously submitted claim.

Note: The replacement claim will replace the entire previously processed claim. Therefore, when submitting a correction, send the claim with all changes exactly how the claim should be processed.

  • While electronic submission is preferred, you may also submit a paper claim along with a copy of the EOMB from Medicare, using the new Medicare Reconsideration form located in the Education and Reference Forms section of the BCBSOK website.

At this time, we foresee that this process will remain in place for mass Medicare adjustments through mid-2012. We thank you for your cooperation and patience.