Insurance/Payors

This page provides a library of communications and resources to help members remain informed, specifically regarding Insurance and Payors.

To contact members of the Clinical Line Committee, please reference their information here:

 

We are happy to announce that we are officially moving forward with the Medicaid fee schedule roll out in a phased approach. We will begin with the Obstetrics and Gynecology specialties and shall continue with Pediatricians and other specialties to follow. This initiative will improve financial efficiency across all practices that service the Medicaid population. Each of the newly-created Medicaid plan codes are tied to the corresponding fee schedule which will reflect the approved amount in the account. It is imperative that all practices select the correct plan code. Here you will find a reference guide detailed by plan with the profile name and the new plan codes. Please ensure that this information is also distributed to the appropriate staff in your practice.

Phase 1 – Effective June 25, 2020

  • United Health Care
  • Aetna Better Health
  • Community Care Plan
  • Miami Children’s Plan

Phase 2 – Effective July 15, 2020

  • Simply Health Care
  • Molina Health Care
  • Sunshine Health Plan

Should you have any further questions, please feel free to contact Jessica Capote, Director of Managed Care, at jecapote@femwell.com or Elizabeth Sanchez, Managed Care Manager, at elsanchez@femwell.com

Florida Medicaid has expanded telemedicine visits to include Well-Child visits for children older than 24 months through 20 years of age. Managed Care MMA plans have also adopted the expansion of these telemedicine services.

CPT codes for Well-Child visits are as follows:

  • New Patient: 99382-99385
  • Established Patient: 99392-99395

Providers must append the GT modifier for live, two-way communication. The Agency and the Medicaid health plans will reimburse the same rate as if the service was delivered face to face. Please refer to the Florida Medicaid Health Care Alert for more detailed information.

As an update to our previous email regarding the AvMed negotiation, we are pleased to inform you that effective July 1, 2020, we have officially executed a path to risk contract for the Medicare line of business for Primary Care Physicians.

Important Items to note:

  • Miami Dade and Broward – Effective July 1, 2020, reimbursement will shift from a fee for service to a capitation payment of $80 per member per month; 25% surplus shared savings.
  • Effective January 1, 2021 – 100% Full risk contract at $150 PMPM.
  • Please continue submitting your encounters/claims with the appropriate level of service and coding to the highest specificity.
  • Please remember to capture all chronic conditions at least twice a year (one between January 1st – June 1st and the second between July 1st – December 31st).
  • There will be a dummy account in Intergy labeled CAP AVMED and all payments will be posted in this account on a monthly basis.
  • You will be able to retrieve the monthly member roster associated with the monthly payment that will be scanned in the DRS folder.
  • The new plan code to be used beginning on July 1st for AvMed Medicare patients is “CAPAVM”.

The Primary Care Clinical Line Director and Program Director will be reaching out to each of the practices individually to discuss your performance and inform you of the resources available to you.

Should you have any further questions, please contact Jessica Capote, Director of Managed Care, at jecapote@femwell.com or Leanne Mascaro, Senior Clinical Program Director, at lmascaro@femwell.com.

As an update on the AvMed contract, we would like to inform you that we have fully executed the written agreement. The effective date of the contract is May 1, 2020. AvMed will begin working on loading the fee schedules in their system. We anticipate that it may take a few weeks for completion. Internally, we will be working on updating fee schedules in all practice management systems. As soon as the fee schedule loads are completed, we will advise all practices accordingly. The contract rate summaries are being provided in this month’s Office Managers’ meetings.

Below are a few highlights of the newly-negotiated contract:

  • Two-year contract
  • 3.5% increase for all specialties including Diagnostic Centers for each year
  • Newly added lab services for MediPath, LLC
  • Newly added surgical carveouts for OB/GYNs in North/Central Florida
  • Newly added carveout for IUDs Nexplanon and Paraguard and Surgical carveout 58561

Please note, a separate notification will be sent to all Primary Care Physicians regarding the value based contract for the Medicare lines of business.

Should you have any questions, please contact Jessica Capote, Director of Managed Care, at jecapote@femwell.com.

As an update to our previous email regarding Florida Blue negotiations, we are pleased to inform you that effective July 1, 2020, we have officially executed a path to risk contract for the HMO Medicare line of business for Primary Care Physicians.

Important Items to note:

  • Miami Dade and Broward – reimbursement will shift from a fee for service to a capitation payment of $100-$150 per member per month based on risk adjustment score.
  • Palm Beach and the rest of Florida – reimbursement from a fee for service will shift to a capitation payment $50-$100 per member per month based on risk adjustment score.
  • Please continue submitting your encounters/claims with the appropriate level of service and coding to the highest specificity.
  • Please remember to capture all chronic conditions at least twice a year (one between January 1st – June 1st and the second between July 1st – December 31st).
  • Florida Blue Medicare PPO will continue to be fee for service; only the HMO product is moving to capitation.
  • There will be a dummy account in Intergy labeled CAP FLORIDA BLUE and all payments will be posted in this account on a monthly basis.
  • You will be able to retrieve the monthly member roster associated with the monthly payment that will be scanned in the DRS folder.
  • The new plan code to be used beginning on July 1st for Florida Blue HMO is “CAPFBL” Florida Blue HMO.
  • Effective immediately, Medicare panels are open and patients are able to choose you as their Primary Care Physician.

The Primary Care Clinical Line Director and Program Director will be reaching out to each of the practices individually to discuss your performance and inform you of the resources available to you.

Should you have any further questions, please contact Jessica Capote, Director of Managed Care, at jecapote@femwell.com or Leanne Mascaro, Senior Clinical Program Director, at lmascaro@femwell.com.

We have been informed by Aetna that some of the telemedicine visits billed with a modifier 95 and GT have been incorrectly underpaid. At this time, there is no action required from the practice as this is not related to the practice billing but rather a configuration error on Aetna’s end that is affecting all practitioners in their network. They are currently working on correcting the issue and will reprocess all affected claims accordingly. Please allow some time for the adjustments to be completed on their end. As soon as we have additional information, we will communicate with all practices.

Should you have any questions, please contact Jessica Capote, Director of Managed Care, at jecapote@femwell.com or Elizabeth Sanchez, Managed Care Manager, at elsanchez@femwell.com.

Florida Blue has informed that some of the telemedicine visits billed with a GT modifier have been incorrectly overpaid for claims with dates of service of April 16th; it is currently in the process of being corrected to pay the in-office visit rate and it’s scheduled to be completed on May 17, 2020. This means you will notice false overpayments on these visits not related to the late fee schedule load. As soon as we have more information on how Florida Blue will reprocess these claims, we will communicate with all practices accordingly.

It is a pleasure to announce that we have reached a verbal agreement with AvMed Health Plans. At this time, you may continue to provide services to AvMed patients with no interruption or need for a continuity of care approval. We are currently awaiting the written agreement. Once the contract is fully executed, we will share the new contract details.

In addition, we will send the template letter below to your patients advising them that you will remain as an in network provider.

We are extremely proud that we were able to avoid a termination and successfully negotiate a contract that will maintain all of VitalMD’s practices in the AvMed network. Should you have any questions, please contact Jessica Capote, Director of Managed Care, via email at jecapote@femwell.com

Resources:

Florida Blue is expanding to allow virtual annual wellness visits for new and established patients. The expansion of the additional services for virtual visits will be in effect for the next 90 days. These visits will be reimbursed at the contracted in-office rates.

Additionally, we would like to inform you that we are monitoring telemedicine claim payments and confirmed that most of all the major payers are reimbursing evaluation and management (E/M) visits at the contracted in-office rates. However, we did notice that for Cigna and United Health Care, some claims were paid at the out-of-office rate when billed with place of service (POS) 02. At one point, Cigna and United Health Care indicated that all claims should be billed with place of service 02, but shortly thereafter, the billing guidelines changed to bill with POS 11.

  • If your practice has claims for Cigna with date of service of March 2, 2020 or thereafter billed with POS 02 and received the reduced rate, please rebill by sending a corrected claim with POS 11 to receive the in-office rates.
  • If your practice has claims for United Health Care with date of service March 18, 2020 or thereafter billed with POS 02 and received the reduced rate, please rebill by sending a corrected claim with POS 11 to receive the in-office rates.

Please note, it is important to verify benefits and eligibility before rendering these services. We noticed that some practices are not collecting patient responsibilities. Many patients continue to be responsible for their portion as if they would have come in for an in-person visit.

The latest changes to telemedicine billing were posted on the COVID-19 Updates for Providers landing page under “4/17/2020 Telemedicine Insurance Plan Guidelines” section. It is very important that all practices check this site periodically to obtain the most updated information.

Should you have any questions, please contact Jessica Capote, Director of Managed Care, at jecapote@femwell.com or Elizabeth Sanchez, Managed Care Manager, at elsanchez@femwell.com.

From the Aetna Bulletin:

In order to reduce viral transmission during the COVID-19 pandemic, the Society for Maternal Fetal Medicine (SMFM) has recommended limiting obstetric ultrasound, including fetal nuchal translucency screening, where possible. In response to this unique situation, noninvasive prenatal testing (NIPT) (CPT codes 81420, 81507) will be covered as a substitute for fetal nuchal translucency screening in all pregnant women, including women at average risk for fetal aneuploidy. Note that this temporary coverage liberalization is not due to a change in the underlying evidence base for NIPT use in average risk women. Rather, it is a response to the lack of availability of other aneuploidy screening technologies in average risk women during this time. This policy will remain in effect until June 4, 2020. Click here for more information and to review the policy in detail.

Please note: this does not apply if a Nuchal Translucency ultrasound is performed.

Many insurance plans have temporarily updated their telehealth policies due to the COVID-19 situation. Below you will find an outline of the information that was provided by each insurance plan on billing and the type of practitioners that can bill for these services. Please ensure that you read the attached payment policies for each of the insurance plans as there may be certain criteria that must be followed dependent on the plan. Also, it’s important to verify benefits and eligibility to ensure the patient has telehealth as part of their benefit plan.

We have also a consent form for patients who do not have the telehealth benefit in their policy and are willing to pay cash. Please note, this consent is only to be used for cash pay patients. As we continue to gather more information on this matter, we will continue to update this document.

  • Aetna Better Health:
    • Applicable to all practitioners listed below:
      • All physician specialties
    • Medicaid and Florida Healthy Kids products:
      • Bill with appropriate E & M codes with a GT modifier. Please ensure to review the policy attached.
      • Please review the policy under resources listed below.
  • AvMed:
    • Applicable practitioners listed below:
      • Internal Medicine
      • Family Medicine
      • Pediatrics
      • Specialist
      • Physician assistant
      • Nurse practitioner
    • The following codes listed below are the only telehealth services that will be payable for AvMed Commercial and Medicare members.
      • Physicians:
        • Telephone Evaluations: 99441 -99443 (PCPs only) or G2012 (All specialties)
        • Online digital evaluations and management services: 99421-99423
        • Appropriate E & M code with place of service 02 and a 95 modifier
      • Mid-levels:
        • Telephone Evaluations: 98966 -98968 or G2012
        • Online digital evaluations and management services: 98970-98972
    • Please review the policy under resources listed below.
  • United Health Care:
    • Applicable to all practitioners listed below:
      • All physician specialties
      • Physician assistant
      • Nurse practitioner
      • Nurse-midwife they did share the attached handout, which states they will pay for it.
    • Telehealth Billing: (You may use audio-video or audio only)
        • Commercial, Medicare & Medicaid
          • Use appropriate office visit E/M using modifier using modifier 95
        • Place of service: 11, 20, 22, 23
    • Electronic Visit (e-visit):
        • Commercial, Medicare & Medicaid
          • Use appropriate CPT code (99421-99423) no modifier required
        • Place of service: 11, 20, 22, 23
    • Virtual Check-In: (Use audio only)
        • Commercial, Medicare & Medicaid
          • Use appropriate CPT code (G2012, G2010) no modifier required
        • Place of service: 11, 20, 22, 23
        • Issue not related to a medical visits within the previous 7 days and not resulting in a medical visit within the next 24 hours (or soonest appointment available)
    • You can find the updated information on the telehealth policy by clicking on the hyperlink
      https://www.uhcprovider.com/en/resource-library/news/provider-telehealth-policies.html 
  • Humana:
    • Applicable to all practitioners listed below:
      • All physician specialties
    • Commercial & Medicare Plan
  • Florida Blue:
    • Applicable to all practitioners listed below:
      • All physician specialties
    •  Commercial Products
      • E/M Office visit: Bill with appropriate E/M code
      • Annual Wellness visits: Bill with standard annual wellness codes (99381-99397)
        • Mainly utilized by Primary Care Physicians
      • Use place of service 02 and modifier 95 or GT
    • Medicare Products
      • E/M Office visit: Bill with appropriate E/M code
      • Annual Wellness visits: Bill with G0402, G0438 or G0439
        • Mainly utilized by Primary Care Physicians
      •  Use place of Service 11 and modifier 95 or GT
    •  Please review the policy under the resources section listed below and the link
      https://www.floridablue.com/providers/covid-19-information
  • Community Care Plan:
    • Applicable to all practitioners listed below:
      • All physician specialties
    • Medicaid and Florida Healthy Kids products:
      • Bill with appropriate E & M codes with a GT modifier.
    • Please review the policy under the resources section listed below.
  • WellCare
    • Applicable to all practitioners listed below:
      • Internal Medicine
      • Family Medicine
      • Pediatrics
    • Medicaid and Medicare products:
      • Bill with appropriate E & M codes with a GT modifier.
      • Telephone conversations, chart review(s), electronic mail messages, or facsimile transmissions will not be reimbursable
      • Please note: Claims for Medicare members will need to go out with Place of Service 02 and the appropriate modifier.
    • Please review the policy under the resources section listed below.
  • Sunshine Health
    • Applicable to all practitioners listed below:
      • All physician specialties
      • Physician assistant
      • Nurse practitioner
      • Nurse-midwife
    • Commercial, Medicaid and Medicare products:
      • Bill with appropriate E & M codes with a GT modifier.
    • For additional information please review the following link: https://www.sunshinehealth.com/providers/coronavirus-information.html
  • Oscar Health Plan
    • Applicable to all practitioners listed below:
      • All physician specialties
      • Physician assistant
      • Nurse practitioner
      • Nurse-midwife
    • Commercial Exchange plan:
      • Bill with appropriate E & M codes with a GT modifier.
    •  Please review the policy under the resources section listed below.
  • Molina Health Plan
    • Applicable to all practitioners listed below:
      • All physician specialties
      • Physician assistant
      • Nurse practitioner
    • Commercial Exchange, Medicaid and Medicare plan:
      • Bill with appropriate E & M code, GT modifier and place of service 02
    •  Please review the policy under the resources section listed below.

Resources:

In response to the operational impacts associated with COVID-19, Florida Blue Provider Services Contact Center is changing the way it currently handles calls regarding claim status inquiries. Effective Wednesday, March 25th, the claim status inquiries option will no longer be available when calling the Provider Contact Center at 800-727-2227. This will remain in effect until further notice.

The Provider Contact Center will focus its calls on eligibility and benefits (E&B), authorizations, referrals and contract inquiries. For inquiries related to claim status, please use the self-service tools on Availity.com . For more information and further instructions, please refer to the document below.

Should you have any other questions, please contact Jessica Capote, Director of Managed Care, at jecapote@femwell.com .

Resources:

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