Virginia Premier and Anthem, two of the managed care organizations which participated in the predecessor program to CCC Plus, known as Commonwealth Coordinated Care (CCC) or the Dual Demonstration Program, are still working to resolve issues related to that program. The CCC/Dual Demonstration Program ran from the summer of 2014 through the end of 2017 and included both Medicaid and Medicare benefits. Virginia Premier and Anthem have provided us with information on how members can resolve outstanding CCC issues. 

Virginia Premier

Virginia Premier has been conducting audits of claims paid under the (CCC) program through a contractor, SCIO. SCIO is examining documentation relative to the MDS and subsequent RUG assignment. In some instances, the auditor was finding that the RUG was overstated and should have been a less-intense RUG. Providers have notified VHCA-VCAL that in many instances, SCIO was not properly interpreting the MDS data. Providers then appealed the findings. Some of the appeals overturned the down-coding recommended by SCIO. In other cases, the providers agreed that due to poor documentation, the file did not support the billed RUG determination.

In instances where the provider did not formally acquiesce nor appeal the audit findings (or pieces of it), Virginia Premier’s policy had been to retract the full payment. If the provider acknowledged the findings, Virginia Premier would retract the difference in payment based on the billed RUG verses the SCIO-determined RUG. After concerns were raised, Virginia Premier agreed to modify its policy to retract the difference in RUG as opposed to the full amount even for providers who do not acknowledge the audit.

Virginia Premier provided the following statement on this policy:

We have vetted our policy and made a change based on the feedback we received from you and your members. For audit letters for which we have not received a response, we will begin reprocessing the claim(s) at the adjusted RUGS rate, instead of fully retracting the claim(s). This change is effective immediately. Furthermore, for any claims that we have fully retracted prior to this change, we will reprocess them at the adjusted RUGS rate. We expect to complete reprocessing by May 17.

We are updating the letter that SCIO sends out as part of these audits this week. They will not send any further letters until the change has been made. Additionally, we will be sending a letter to impacted facilities to advise them of our updated policy and next steps related to letters they have received.  We’re targeting to send this letter out by Thursday, May 2.

As it stands, this was the only known global issue with Virginia Premier and claims through the Dual Demonstration. There are providers working directly with Virginia Premier on one-off issues. If you still have issues with Virginia Premier for claims during the Dual Demonstration that you have not made contact about, please notify Steve Ford so he can assist in facilitating your conversation with Virginia Premier.

Anthem

Anthem has stated that it believes the bulk of claims issues under the Dual Demonstration have been addressed or are known and are in the process of being addressed. It is our understanding that the bulk of remaining issues were in the area of secondary claims (similar to current experience under CCC Plus).

Anthem has recommended that providers with any remaining Dual Demonstration claims issues provide spreadsheets with the affected claims to Marvin Brown and Stephanie Labus by July 1, 2019 so that Anthem can work the claims and reach resolution with the goal of “closing the books” on the Dual Demonstration in the near future. If you are not certain that your previously communicated issues are actively being worked, we would suggest you resubmit them under this request.

Of note, if any of your claims issues are related to the patient pay, the provider will need to send to Anthem, along with the claims, whatever documentation of the correct amount that exists in the file, as Anthem does not have the ability to look at the system for patient pay amounts older than 12 months, which all of these will be.

If you have any questions or concerns about the Anthem process, please let Steve Ford know.

As a reminder, Humana, which did not opt to participate in CCC Plus, went through a closeout of claims issues last summer.