Volume 4 | Issue 1 | Fall 2008 | 335 East Big Beaver; Troy, MI 48083 | www.advomas.com | 248.989.4200
Medicaid EZ Link With the Thanksgiving
Nursing Home Transfers holiday soon upon
MC Authentication us, it’s that time of
Requirements year again when we give thanks for
all that we have and are able to do. As you will see inside this
2009 Medicare edition, we recently took the opportunity to acknowledge our Advomas staff and thank
Copay-Deductibles each one of them for all of their hard work and effort put forth to service those less
Blues Redesigns Card fortunate than us. Practically everyday we receive some form of positive feedback from
the people we have assisted – they are most thankful to us for helping them resolve a
Seasonal Effective Disorder medical debt that they would otherwise have been unable to pay. It is in those moments
that we recognize what a positive impact we can have on other people’s lives.
More recently Advomas acknowledged National Patient Accounting Week by recognizing
the staff at each of our client hospitals to let them know their efforts throughout the year
are very much appreciated as well. And now, we’d like to take this opportunity to express
our thanks to all of you for your continued support of our organization! We truly appreciate
your business and enjoy the relationships we have established over the years with each of
you. We thank the Department of Human Services and all other community organizations
that assist us in establishing medical coverage for the uninsured. There are many
involved, who just do their job without ever expecting anything in return, other than the
satisfaction of knowing they helped someone in their community get to a better place.
Oakland County IHP We believe that in concert we have truly helped reduce the number of uninsured in
Michigan and we will continue to work together in that effort.
As we celebrate our 3rd year anniversary of the Advomas Advocate, we’d like to take
a moment to especially thank Ellen Spagnuolo and Christie Ribant for their focus,
commitment and dedication to producing this newsletter for us! We think they do a
wonderful job pulling together important information for you to know and apply to the
work that you do. We hope you enjoy reading it and find it to be a helpful reference tool.
Remember to take the time to count your blessings this Thanksgiving. In spite of these
poor economic times, we are certain we can all find things for which to be thankful.
Have a wonderful and blessed holiday season!
Above & Beyond At Advomas, it is not the effort of one individual that allows us to be so successful; it is do to a team
of staff members working together for one common goal. In one recent case involving a disabled
veteran, the Medicaid approval was an end result of both diligence and team effort.
The patient was in-house at a nearby hospital for 34 days and Advocates, drove to the patient’s home in Harrison, only to find
then transferred to the rehabilitation unit for another nine days. that he was no longer living there. Coincidentally, we then
Charges incurred exceeded $200,000 dollars. During our received returned mail with a forwarding address in Prudenville
bedside interview, we were able to determine that he may in Roscommon County. From this, we were able to secure a
be eligible for the VA Millennium Bill, as well as Medicaid. new phone number and reestablish contact with our applicant.
Unfortunately the Mill Bill program will not pay for a rehab Patients moving while a Medicaid application is pending can be
stay when beds are available at a VA Hospital. Therefore, very problematic. Not only can it cause the case to be transferred
it was essential to secure full Medicaid coverage. but it can also make it more difficult for the patient to get to the
A disability Medicaid application was submitted to Clare DHS ordered appointment. Attempts made to reschedule the
County DHS, which was later denied for “lack of verification.” appointment for our patient were unsuccessful. Therefore, our
This denial was made in error as all verifications were submitted Field Assistant, Reed Hillman, transported the patient to his
timely to the worker. Since it was too late to reapply, our appointment, more than one hour away. I would like to say that
Appeals Specialist, Mike Bowman, appealed to DHS and won. things went smoothly from there but that was not the case.
The case was then sent to the Medical Review Team (MRT), for DHS mixed up the location of the appointment and the patient
a disability determination. MRT deferred the case, requesting was not able to be seen. DHS did reschedule the appointment
that the patient see a specialist chosen by DHS. The patient for Gaylord! I guess we’re lucky they didn’t send us to the
was required to travel to Mt. Pleasant for the appointment. Upper Peninsula!
Meanwhile, to make matters worse, the patient’s phone had This case is a good example of the kind of perseverance, tenacity,
been disconnected, making it difficult to ensure that he attends and team work it takes to be successful. We would like to thank
his appointment. We sent a contact letter to the patient with no the entire group that worked this account and had a part in
response. So, Brandon Bird, one of our Flint office Patient securing the healthcare coverage.
At Advomas, In honor of our employees, the Management Team barbecued and
we feel we have served the staff lunch. Even the owner, Bruce Knight, was tossing
a great staff and serving up the salad! Each employee received a goody bag
of dedicated and a certificate citing the many reasons they are appreciated.
individuals. We would like to share some photos and some of the things that
make our staff great!
You’re innovative, compassionate and effective. You believe in “we.” You are helping the
indigent at a time when they really need it. You’re willing to help out in a crunch no matter how busy
you are. You make work fun. You add a tremendous amount of value to our success. You expect the
unexpected and adjust accordingly. You exemplify the true meaning of family in times of need. Your
knowledge and willingness to teach is what makes our company great. Your willingness
to just jump in and do is extraordinary. You go the extra mile. You are always willing to take
time to answer questions from patients, clients and coworkers. You do your best
every day. You turn in the apps you think are a long shot and then get an approval. You take on
all the extra work given and do it with a smile. Your diligence when trying to reach patients. You
never say, “It’s not my job.” Your perseverance in pursuing an account results in success for the
company. Your ability to communicate in different languages so there is no barrier to
our success. Your willingness to go outside expectations to help a client, co-worker or
patient. Your sense of humor. You make our company shine!
“ Your services are just smart business!
— COBRA Administrator
The Macomb County Department of
Human Services has been diligently
working on filling positions to meet
their staffing needs. Since January,
2008 Macomb County has hired a
total of 56 new workers along with
filling many positions in other areas.
As we have all experienced, the
Every year, as the winter months approach, it is estimated shortage of staff causes a delay
that 10 MILLION AMERICANS within the northern in eligibility, payments to the hospital
and sometimes lost revenue.
regions of the U.S. experience Seasonal Affective Disorder
Things are looking better for Macomb
(SAD), also known as Seasonal Depression. County and the residents it serves.
More staff means better and faster
SAD can severely and profoundly affect many aspects of our personal and social lives, families, services for clients, hospitals and
and work environments. outside agencies.
Many scientists believe that the onset of colder weather, combined with decreasing daylight,
only 9-10 hours a day, causes our Serotonin levels to drop and Melatonin levels to increase,
resulting in a reaction comparable to hibernation. Our bodies begin to slow down, our minds
become less sharp in processing information, and we crave more sleep.
In many cases, SAD triggers moods of depression. Some of the major symptoms include:
loss of energy, social withdrawal, increased anxiety and irritability, oversleeping, poor memory
and lack of interest.
Though we are unable to change the seasons, here are some easy ways
to combat the effects of Seasonal Affective Disorder:
Be sure to exercise. Avoid heavy meals and Get a massage to help
Get outdoors! eat a balanced diet. stimulate blood flow.
Turn on all the lights in Take your vitamins. Try aromatherapy in
the morning and change Listen to uplifting music. your home.
to natural light bulbs. Make a point of laughing
Other options include home light boxes or light therapy treatment by a professional.
If symptoms are severe, see your doctor who may be able to assist with prescription
Hopefully, the above suggestions will help bring a healthy balance to our minds
and bodies during the ever changing seasons.
Volume 4 | Issue 1 | Fall 2008
335 East Big Beaver; Troy, MI 48083
www.advomas.com | 248.989.4200
If you are not using the EZ Link system for sending
medical documentation to MDCH, you will soon
We all struggle with the never ending saga of patient pay amounts being
experience an increased rejection rate for your deducted from the inpatient hospital bill when the patient was transferred from
electronic Medicaid claims. MDCH announced
they would no longer accept paper documentation
If you find that the patient pay
a nursing home.
via mail effective October 1, 2008 for claims that was deducted in error on an inpatient
have been submitted electronically. Providers are bill, it may be due to a coding issue.
required to use EZ Link in order to submit medical We are suggesting that hospitals check the admission source code to ensure
records for claims processing. This program is an proper payment. When a nursing home resident was admitted through the
internet based tool which allows providers to submit emergency room, the claim should show source code 5 instead of 7. The 5
claim attachments through a secure web portal. indicates that the patient was transferred from a nursing home. This will trigger
To connect an electronic claim with documentation MDCH to review and determine where the appropriate deduction should occur.
submitted through the EZ Link system, the following The determination is made based on which facility the patient was in on the first
notation must be included within the NTE02 day of the month. If you bill with source code 7 the patient pay will automatically
Segment of Loop 2300: “required documentation be deducted from the facility claim. If this is not watched closely, the hospital
was sent via EZ Link.” The note reference code of will experience a loss of revenue for the hospital admission.
“ADD” should be reported in the NTE01 segment
More information on EZ Link can be found on
the Michigan Department of Community Health
Blues to End NPI Contingency
website at http://www.michigan.gov/mdch Period for Facility Claims
For a step by step instructional guide at visit: Blue Cross Blue Shield of Michigan and Blue Care Network will end the contingency
http://www.michigan.gov/documents/mdch/ period for reporting the National Provider Identifier (NPI) for facility claims effective
Documentation_EZ_Link_StepByStep_ February 1, 2009, as reported in the October issue of The Record.
All electronic facility claims submitted on or after February 1, 2009 must contain only
the NPI in all applicable provider identifier elements. Claims received after this date
using legacy numbers will be rejected. Blue Cross does urge providers to move forward
with only reporting the NPI number as quickly as possible. It is recommended that
providers contact their software vendor or clearinghouse to ensure this change has
been made on their end.
MEDICARE MATTERS CMS INSTITUTES
New Provider Authentication
The Centers for Medicare & Medicaid Services (CMS) issued notice that effective March 1, 2009,
providers will be required to authenticate their provider number when contacting CMS before CMS
is able to disclose protected health information.
Beginning on March 1, 2009, when you call the
Interactive Voice Response System or a Customer For more information
Service Representative, CMS will require you to If you would like more information regarding the
provide three data elements for authentication. Those authentication requirements for Medicare inquiries,
include your National Provider Number (NPI), your you can locate the information on the CMS website at:
Provider Transaction Access Number (PTAN), and
the last 5 digits of your tax ID number. You will only
be allowed three attempts to correctly supply this Written inquiries, such as email, fax, and mail, are no
information before the call is terminated. different and should contain the three data elements
Once the caller has met the authentication requirements, for provider authenticating. The exception to this rule
they will then be asked to supply the following is written inquiries on provider letterhead. However,
beneficiary information: the provider’s name and address on the letterhead
Last Name must match the contractor’s file for this provider.
Medicare contractors may use discretion when the
First Name or Initial file doesn’t exactly match. Providers will still need
Health Insurance Claim Number to include either the NPI, PTAN or the last 5 digits
Date of Birth or Date of Service for the TIN.
2009 Medicare Deductible
and Premium Amounts
Part A deductible: $ 1,068.00
Part B deductible: $ 135.00
Part A co-ins: $ 267.00 per day
Part A life time reserve: $ 534.00 per day
Part A premium: $ 443.00 (or less depending on work quarters)
Part B premium: $ 96.40 (or more depending on income)
Redesign of the Blues Card Underway
The next time you receive a new Blue Cross Blue Shield insurance card, it may have a whole new look. In an effort to increase
worldwide recognition, Blue Cross announced that it will require all Blues plans to issue similar cards to its members by January 1,
2011. The redesign will feature a magnetic strip that contains the insurer and enrollee ID number as well as the subscriber’s name
and date of birth. The Blues is hoping that this addition to the card will help to ensure a more efficient billing process in the future.
Some of the other changes made to the card include: It was also reported that the group and plan code have been
• The subscriber’s name will be referred to as enrollee removed from the card. I don’t know about you, but I often
• The contract number will be referred to as enrollee ID find myself using the group number to establish the origin
• The insurer’s number will identify the state of coverage of coverage or employer. This assists us in determining a
potentially eligible COBRA patient when coverage has been
terminated. I wonder if the carriers ever evaluate the cost to
a provider when making what seems to be a simple change.
Volume 4 | Issue 1 | Fall 2008
335 East Big Beaver; Troy, MI 48083
www.advomas.com | 248.989.4200
ON THE Some personal observations and commentary
by Bruce Knight, Founder of Advomas and Chief Counsel
W. Bruce Knight, Founder and CFO
The political climate and the economy must have had an effect on the Michigan Courts
because they too have been kind of non productive. Below is about as good as I can do
with the cases coming down last quarter:
In Bonkowski v. Allstate Ins. Co. (Michigan Court of Appeals) (Lawyers Weekly No. 07-67889 - 16 pages) (published opinion)
(Zahra, J., joined by Talbot and Cavanagh, JJ.), on appeal from the Oakland County Circuit Court; the jury awarded 1.7
million dollars to the father of a paralyzed son for attendant care services rendered by the father. The award was upheld
in the Court of Appeals so don’t forget that a no-fault carrier is responsible for attendant care for an injured party even
if those services are provided by a relative. Holy Mackerel…1.7 million!!!
In - Berkeypile v. Westfield Ins. Co. (Michigan Court of Appeals) (Lawyers Weekly No. 07-67373 - 18 pages) (published
opinion) (Murphy, J., joined by Davis and White, JJ.), on appeal from the Jackson County Circuit Court; Nelson, J., the
court allowed an injured party to collect from his uninsured/underinsured policy even though he collected more than the
limit in his policy from the drivers who were responsible. Although this doesn’t really pertain to a patient’s PIP policy,
it does point out that a person injured in an automobile accident has several targets from which to recover for his
damages over and above the payment of medical bills.
In - Woodman v. Kera, LLC. (Michigan Court of Appeals) (Lawyers Weekly No. 07-67374 - 33 pages) (published opinion)
(Talbot, J.) (Bandstra, J., concurring) (Schuette, J., concurring), on appeal from the Kent County Circuit Court; Johnston,
J., the court reasserted the old common law rule that a parent cannot waive a negligence claim of his/her child through
contract. In this case, the parents signed a release excusing a business owner from liability if the child played on and
was injured on the business’s slides. The child was injured and the release signed by the parents was declared invalid.
This is really old law (No! I don’t remember when it was first proclaimed) and it’s based on the premise that one cannot
contract himself out of a claim for negligence. The thinking behind this is that if one could, you wouldn’t have to make
anything safe. There are inroads being made into this axiom but for now, a parent can’t forgive negligence of a business
which harms his/her child. This is something you put in your back pocket if you are making a claim for anyone injured
outside his own home when the injury was caused by the property owner. I should add that there are some specific
exclusion for things like ski areas, etc. where the participant is assuming a risk, so I guess to be absolutely sure, you
have to ask a lawyer…..I hate it when that happens.
There really wasn’t much new in the PIP-Crime Victims-Cobra world so this is about as much as
I can do for this quarter. I will say one thing of interest lately is that the court rulings are starting
to swing back in the direction of the injured party which may be a needed change in light of what
the Supreme Court has done but I do think there is a new trend. We’ll see.
Program (IHP) 17 Years of
The Oakland County Indigent Hospitalization Program (IHP) recently completed
its 17th year of operation. The program was designed back in 1991 by Advomas
to assist Oakland County and its hospitals with a way to provide hospitalization
benefits to residents of the county who were otherwise uninsured and not eligible
for any other government assistance. Advomas continues to administer this for the
county and is proud to report that in fiscal year 2007 the program once again
assisted about 1500 Oakland County residents with their inpatient hospital claims. This represents approximately 27 million dollars in
charges for hospital services – an increase of 7 million over last year. In addition, Advomas was able to secure coverage through another
payer source, other than IHP, for 224 Oakland County resident totaling more than 11 million dollars in charges.
The IHP program would not exist if it were not for the cooperation of Oakland County government and all Oakland County hospitals. Their
efforts need to be commended in that the success of this program has enabled many uninsured Oakland County citizens to receive help
with their hospital bills, thus avoiding severe financial difficulties or possible bankruptcy.