Anthem Changes Timely-Filing Deadlines

Anthem has sent out a notice to all providers who have signed non-Medicare or Medicare Advantage contracts with them, stating:
“Effective for all commercial and Medicare Advantage Professional Claims submitted to the plan on or after Oct. 1, 2019, your Anthem Blue Cross and Blue Shield (Anthem) Provider Agreement(s) will be amended to require the submission of all commercial and Medicare Advantage professional claims within ninety (90) days of the date of service. This means all claims submitted on or after October 1, 2019 will be subject to a ninety (90) day timely filing requirement.”
They go on to say in the notice:
“If you object to the enclosed amendment, you must provide us with written notice of your appeal within 30 days of receipt of this letter. If, after 30 days, we are unable to reach an agreement, your contract will terminate on or before October 1, 2019.”

Interpretation

What Anthem is telling you is that practices can “negotiate” with them the terms of their contract before Oct. 1, 2019, if they object to the changed terms. And if an agreement cannot be reached, the practice may terminate their contract with Anthem.
Because contracts are binding on the two parties, Anthem knows they cannot just unilaterally change the terms of the contracts they have with providers. They have to give providers the option to object and renegotiate.
But there is nothing that requires Anthem to renegotiate in good faith and agree to terms other than those which they are handing down in this notice. Anthem is the “800-pound gorilla” in the room and the practice is just a little insect that Anthem can swat and end the contract if the practice refuses the terms which Anthem is handing down.
I thought Medicare Advantage payers had to follow Medicare Guidelines, yet with this notice, Anthem was violating the Medicare timely filing limits quite significantly. The regulations for Medicare Advantage plans are found in the Internet Only Manual, Pub. 100-16.
Medicare’s rule for timely filing is:
“Claims must be filed to the appropriate Medicare claims processing contractor no later than 12 months, or 1 calendar year, after the date the services were furnished.”

Explanation

I reached out to Cyndee Weston, CMRS, CMCS, CPC, the executive director of the American Medical Billing Association, for an explanation.
Although most rules that Medicare Advantage plans must follow are consistent with Medicare Part B, timely filing is tied to the provider’s contract with the payer, Weston explained. Contracted provisions override any Medicare Part B rules. If the practice is not contracted with Anthem, then the practice has other remedies they can rely on, such as those provided by state law (Florida requires at least 6 months timely filing; Virginia requires at least 12 months).
Weston stresses that the practice should ensure they are benefiting from the longer timely filing deadlines, as established by their state laws, when they are not contracted with the payer.
Weston also said that if the practice has passed the timely filing deadline, the Medicare Advantage patient can file a grievance with any Medicare Advantage payer. And the patient, the Medicare beneficiary, may be able to get the full 12 months allowed under Medicare regulations.
For any patient who has Anthem through their employer group plan (that is not a church plan or a government plan), the practice should appeal using the ERISA law, Wetson said. ERISA considers all employer group plans that are not church or government plans to fall under the federal ERISA law. And ERISA provides for a 12-month timely filing for all applicable. So even if you agree to Anthem’s contractual changes, which call for the 90-day timely filing, you can appeal under the ERISA law for all ERISA-covered patients to overturn the 90-day timely filing terms.

Solution

Patient insurance verification and accurate intake is ever important as timely filing periods shrink. Many patients who sign up for Medicare Advantage plans still hand their Medicare cards to the practice thinking they are covered by traditional Medicare. The practice bills Medicare Part B and receives a rejection because the patient had signed up for a Medicare Advantage program. The practice then has to reach out to the patient, who was confused at the time of the visit and will probably still be confused, to find out which Medicare Advantage plan the patient has enrolled in. The practice then must submit the claim to the Medicare Advantage plan so that it meets the timely filing limits.
Performing insurance verification prior to the patient’s appointment will assist in identifying the payer BEFORE the patient sees the doctor and before the claim is generated.

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Barbara Cobuzzi

Barbara J. Cobuzzi, MBA, CPC, COC, CENTC, CPC-P, CPC-I, CPCO, CMCS, is CEO of CRN Healthcare Solutions and formerly owned a medical billing company. Cobuzzi is a subject matter expert in otolaryngology coding. She provides litigation support as an expert witness for providers and payers and often presents for many local and national organizations. She is also a consulting editor for AAPC’s Otolaryngology Coding Alert newsletter. In 1999, Cobuzzi was named AAPC’s Networker of the Year, and she is a past member of the National Advisory Board. She is one of four founding members of the Monmouth/Ocean, N.J., local chapter and is still active with the chapter.

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