Naturopathy, Medicare, and our local blue

[ste]

This topic tends to ruffle feathers and cause people to get distracted and dart off in all sorts of directions. Let’s try to stay focused on the technical issue and avoid larger theoretical or legal entanglements. I could have commented or reopened previous post but somehow they strayed from the topic and became unpleasant.
I bill for twenty some naturopaths. It’s a good specialty and one that I did not choose. It chose me and happened just like Linda said it would. Thank you Linda.
Now on to the controversial stuff. I learned early on that when Medicare is the primary insurance one simply writes a letter, drops the claim to paper, and mails to two items to the secondary insurance. With a little nudge here and there the secondary always paid and everybody was happy.
In October of last year our local blue stopped accepting paper claims and suddenly the easy fix that made everyone happy was gone. I’ve been working with two competent provider reps trying to overcome this obstacle but after 3 months of trial and error the solution remains elusive. The provider reps continue to be helpful, energetic, and optimistic whereas I’ve added up the time spent on the project, compared it with any possible financial outcome, and become ornery.
The GY modifier looks promising but at what point does a biller say enough is enough and let’s take it to the insurance commissioner or some other higher power?

[RichardP]

We are in California.  Your State rules may be different.

Every so often, we get notice that a carrier is going to stop accepting paper claims.  Or they are going to stop sending paper EOB's and we will have to go on-line and print them out ourselves.  Anything to pass their costs along to the provider without increasing what they pay him.  There is a form letter that we fill out and have the relevant provider sign stating that he is a small practice with fewer than X number of employees (may have to attach a recent payroll printout) and is not set up to do electronic billing.  They get the letter, say OK, and continue accepting paper claims and sending us paper EOBs.  The next year, we go through the same drill for everybody, for a number of different carriers, all over again.

Somewhere in the bowels of your Blues, there is an office that accepts such letters and OKs the continuation of paper billing.  Your job, should you choose to accept it, is to figure out the mailing address of that office and get the specifics that they require in your letter to them.  The most important part will probably be that the provider has fewer than X number of employees and is not set up to do electronic billing.

If you are not in California, your mileage may vary.

[PMRNC]

In October of last year our local blue stopped accepting paper claims and suddenly the easy fix that made everyone happy was gone. I’ve been working with two competent provider reps trying to overcome this obstacle but after 3 months of trial and error the solution remains elusive.

Is this happening just for MSP (Medicare Secondary payor)?  or is for all claims for your local BCBS? What state? If it's isolated to just your Medicare Secondaries I would think someone over at Medicare can advise you on these. The GY/GX modifiers are supposed to identify those non covered Medicare services right?

The GY modifier looks promising but at what point does a biller say enough is enough and let’s take it to the insurance commissioner or some other higher power?

IF this is "commercial" and is JUST a BCBS thing it will depend on the payor's plan. ERISA plans for example don't involve the state dept of insurance, those are governed by the labor dept.
That's why I'm thinking we need to know if this is JUST a problem with your MSP claims or not.

[ste]

This is a group of 8 providers who bill under one Tax ID submitting 300 claims per month of which 60% are electronic (they treat a lot of MVA patients). 7 of the providers are employees, plus an office staff of 3 or 4, and I submit most of their claims electronically. I doubt a small practice exclusion is an option.
I have been told by two provider reps and several others within Regence that all BCBS claims (regardless of plan or State) from Oregon Practitioners must be submitted electronically. This particular claim in question is BCBS of North Dakota insurance and like all Blue card plans these claims get submitted to our local which is Regence. All Washington Practitioners will be given until sometime towards the end of this year before they get cut off and can no longer submit paper claims to Regence. The exact date has not been announced. WA and OR are under the same Regence umbrella. The only exemptions that I am aware of are patients submitting their own claims. They can still mail their paper claims in to the same Regence address in Salt Lake City.
Yes, the GY modifier identifies a service as not being not covered by Medicare. The idea being that the claim processor will somehow associate "not covered by Medicare" with "not able to submit to Medicare" and therefore come to the conclusion that asking for an EOB from Medicare is futile. It sounds like a pretty big stretch to me but if it works I won’t complain.
The insurance type is commercial. The Product/Network is MED016007 – MED SUPP which means this is a Medicare Supplement Plan which means it follows Medicare guidelines. Oops. This might be where things begin to fall apart.
Actually the provider is a chiropractor who is not a Medicare Provider. Essentially it’s the same as a naturopath claim because a letter stating:
“This chiropractor is not a Medicare provider and therefore the secondary insurance should process the claim as if they were primary”
has always resulted in the claims getting paid.
Hopefully, I have backtracked enough to recover credibility but not too far to cloud my reasoning. Anyway, I was trying to follow Linda’s line of thinking and say this is an ERISA plan and as such is governed by the Labor Department.     
 

[Michele]

Just another thought, submit electronically and then file appeal with appropriate attachments.  I know this is not ideal but it may be a quick fix.  And at this point there is no other option clearly visible.

[ste]

Update:
Placing the GY modifier on each line item works.