Capitation Accounts

[kayfly]

I bill for a low vision clinic and since I have not gone to school to learn coding (I am in the process of doing that though) I get confused when capitation denials come in. I received two last week from Medicare: denied due to capitation.  How do we get paid for our service or do we? I get so confused with these and I just don't know what to do. Thank you for any help!

[Michele]

IS the patient enrolled in a Medicare Advantage Plan?

[kayfly]

Hi, the first one is a Medicare/Medicaid so it went to Medicare and came back with that message. The second one is Humana Gold who I billed first and it said it was unprocessable THEY sent it to Medicare and I got the denial from Medicare for the capitation reason.

[Michele]

Have you looked the patient's up on Connex to see what CMS shows they have?  It sounds like they have an Advantage plan and you are just billing the wrong one.

Weird on the Humana one.   I've never seen them forward information to Medicare.   

[kayfly]

I have no idea what Connex is but I will look it up today and check it out, thank you! Medicare/Medicaid...no advantage plan there! The Humana sending to Medicare IS weird for sure it just sounds as though I need to make some calls. I get confused with these capitation issues. Thank you for the suggestion though and I will do that today!

[Michele]

Connex is the online system to look up Medicare beneficiaries and claims data.

[kayfly]

I looked it up and it is not available for Idaho! Thank you though, I have a call in to Medicare...on hold now!

[kristin]

Each MAC has their own system/application for looking up what insurance a patient has. Mine is Connex, but other places I work for use Novitasphere, FCSO, etc,. You need to get set up with the portal for your particular MAC.

It seems that while the patient(s) is saying they have standard Medicare, they may actually be enrolled in a Medicare Advantage plan. This is not uncommon. You can also use Availity to find out if they have an MA plan instead of standard Medicare.

[kayfly]

Thank you Kristin, I hate Availity but I will try it! These capitation issues throw me for a loop

[kristin]

Availity is great for certain things, and this is one of them. Other things, not so much.

Generally speaking, whenever you see a denial for a Medicare patient stating it is a capitation issue, that means they have a Medicare Advantage plan which needs to be billed instead.

[Sriram_Sub]

As you may know, for the state of Idaho it would be Noridian healthcare solutions. Their provider portal can be accessed via https://www.noridianmedicareportal.com/

You will have to register for a user account and also for an administrator account if none set up already. You will be able to find out if the patient has an advantage plan.