What to Expect with WellCare CMS (UPDATED-60 days in)

This article is a follow-up to our previous article about preparing for the CMS/Wellcare transition in Florida. We’ve learned a lot over the past 60 days and we wanted to post an update since some of the information has changed. We’re not going to re-visit items that were discussed in the first article so please review it (here) if you haven’t already read it. It contains a lot of useful information about setting up your accounts, EFTs, and steps to take for efficient operations under WellCare.

First of all, what has changed since our previous article?

CMS patients (ONLY) do not require prior authorization from WellCare for ST/OT/PT services at this time. If you do try to submit an authorization, it will be sent back informing you as much. WellCare will conduct a review of the program after the first 6 months (right around 8/1/19) to see if they will change that decision.

However, be sure to obtain physician’s signatures for your evaluations and POCs before you begin treatments, not only is it a legal requirement but you don’t want to get caught without them if WellCare reverses this decision in the near future.

How is the transition going?

So far, there is good and bad with an overall positive outlook for the future. Let’s start with the bad news.

  1. Many claims for CMS patients have been paid at rates below the 100% Medicaid rate due to some errors in the contracting department of WellCare. This is a known issue and, for affected providers, WellCare is pulling weekly reports and fixing claims as they discover them. They’re working on a long-term solution to ensure this no longer happens but in the meantime check your EOBs to make sure this isn’t happening to your practice.

  2. There is another claims processing error that is causing multiple therapies rendered on the same day to be denied; you may have seen IH147 (denied – inconsistent ICD-10/modifier or mutually exclusive diagnosis). UPDATE: WellCare has researched this issue and discovered that claims denied for IH147 are valid denials and must be re-billed as corrected claims. The denial is due to multiple “Mutually Exclusive” diagnosis codes being billed on the same claim. For example, F80.2 (Mixed receptive-expressive language disorder) cannot be billed on the same claim as F84.0 (Autism Disorder) since ICD-10’s Coding Manual views them as mutually exclusive dx codes. For more information on which codes are considered “Mutually Exclusive”, see the “ICD-10 2019 The Complete Official Codebook.” Stay tuned for our upcoming article which will highlight commonly used codes that should not be used together on claims.

  3. Although many providers blamed WellCare, there was an issue with the Optum clearinghouse that caused two weeks’ worth of claims to be bottlenecked at Optum. Again, not WellCare’s fault at all; just poor timing since it occurred the week after transition. Those claims should have processed by now however there was a batch of claims on February 25th and 26th that were completely lost by Optum. Check your records to ensure you were paid for claims sent on those dates. I’ve had to re-bill all claims sent on those two dates.

Ok, hopefully that didn’t put you in a foul mood because we think the good news outweighs the bad news in the long term.

  1. Payments are coming in faster than the previous CMS payor. We are seeing payments in as little as 7 business days. Once the claims issues discussed above are ironed out, this should be a huge positive for providers.

  2. No Auths required for ST/OT/PT!!!! That is a massive administrative burden that we don’t have to deal with at the moment. This will likely change in the future but take a moment and relax in the present. They didn’t have to do this for us, it communicates that they’re really trying to make the transition as smooth as possible.

  3. New Providers are being credentialed at a rapid pace. From start to finish, we’ve seen entire practices contracted and credentialed in under 60 days. And the process for adding new providers/therapists to your practice is quick (45 days or less) and easy (CAQH and a short credentialing letter to your provider rep).

The good news addresses most of what providers hated about the old CMS. The claims issues are being dealt with and are always expected with transition to an entirely new system. WellCare management teams are responding to concerns quickly and ACTUALLY addressing issues unlike some other payors. We must do our part by looking at the payments and informing our reps early and often when issues occur. We have our share of frustration just like you but we’ve found the WellCare team to be responsive to our issues and to act to resolve the root problems; all the while keeping us informed of their progress.

As always, feel free to reach out with comments or feedback.

Thanks!


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