Wiki 2017-2018 Anthem Blue cross - UDS

Tlantt88

Guest
Messages
2
Best answers
0
HI ALL

i have been fighting with anthem blue cross for months now. CMS rolled out the g0481 82 and 83 codes to bundle all the 8 codes that were previously billed how ever now they have a policy updated on 08/2017 that states they accept the 8 codes again... However they are requesting medical records for ALL samples be sent with the claims meaning now i have to send all on paper attached with medical records. Is any one else having this issue?

Independent lab pos 81- Urine drug testing
 
Not In Network

We don’t accept Anthem of any sort...we are told Anthem is not allowing ANY new Ref Labs in their network, at this time. I’m having a terrible time with Medicaid MCO’s, especially WellCare! WellCare is telling us they will only cover 4 UDS/Year. But list patients in 3 categories, A,B,and C, with C containing Chronic Opiate and Opioid use/Suboxone use. Majority of our PT’s are Group C, so per guidelines, we are allowed more than the allotted 4 UDS/LCMS. But time and again my claims are denied “Maximum Benefit Reached”. We also do LCMS Drug Confirmations G0480-G0483, having same issues with those! I know there is a ton of fraudulent issues with UDS/LCMS, but we are on the up and up! We have proper orders, documentation, and our results are very prompt. Any help or thoughts are much appreciated !
 
2017-2018 Anthem BCBS

As an OON lab you are going to struggle with the Blues and the MCO's. Unless you have a test on your menu that is not offerred by one of the current laboratories that is in-network you will not get credentialed to become in-network. Laboratory Benefit Management systems such as Beacon (United Healthcare) and Avalon (BCBS) are one of the newer methods that payers are trying to manage the over-utilization of presumptive and definitive drug assays and require laboratories to also credential with them. My recommendation would be that your commercial operations team have direct conversations with referring providers on using in-network laboratories when necessitated by the payer contracts. I know that this sounds very counterintuitive to running a laboratory as a business, but if a patient does not have out of network benefits, then their testing should go to an in-network lab.

If they are requesting medical records, then my guess is you are billing out G0482 and G0483 a majority of the time which will trigger edits for medical necessity at most payers. As the previous poster acknowledge, the amount of fraud and abuse in this carve out of lab is staggering and those frequency limits are a response to overutilization and a lack of clinical evidence that supports frequency recommendations beyond a patient's individual history and treatment plan. One suggestion, modify your requisition to capture medical necessity documentation, ensure that you are not listing DX codes on your requisition, make sure you don't offer "panels" and that the ordering provider signs the requisition.

Wish I had better advice, but this area of lab is being pushed to contracted in-network providers.
 
Top