Tricare and Under Payment of Rotateq

August 5, 2011 in Billing and Collections by brooke  |  Comments Off on Tricare and Under Payment of Rotateq

We have found that Customers are another set of ‘ears and eyes’ on the revenue cycle. We are fortunate to have some customers that share information they hear and see. One of our customers received an article/blog listing related to underpayment for Rotateq in patients with Tricare. Due to this information, we were able to go back an analyze all of our customers whom provided Rotateq to a Tricare patient. Although the occurrence described will not occur in all instances (some customers had no occurrences since January 2010 while others had 15 occurrences in the 18 months since the change). Although the Health Plans have many individuals and usually ‘good’ technology team, some decide to make their own rules outside the norm. Since vaccines are usually the #2 cost in Pediatrics (behind HR costs), optimizing the vaccine payment cycle is a must.

Practices that leverage the PhysicianXpress system can closely monitor the details of their vaccines reimbursements via running a report. In the practice admin section of PhysicianXpress there is a place to enter in the cost for vaccines for a date range by CPT code. If this cost information is entered into the system, there is a report that will show the # of claims per cpt code per insurance company that is paid below cost (can actually ‘drill’ down into the system to view the actual date of Service including reimbursement received). A practice admin user can also click on a different button to view the average payment above the actual cost per vaccine CPT code per insurance company.

The Issue related to reimbursement of Rotateq for Tricare Patients:

You need a Tricare patient whom received Rotateq and for which the resubmission was sent as units (we identified through this process that the unique nature of the claim submission for Rotateq at Tricare causes the resubmission – since this is not a top rejection rate across practices, it is difficult for the issue to appear on the radar as a trend). The number of patients varies for Tricare by Practice – if a resubmission was done with Rotateq as “Package” for a Tricare patient, the total amount would be paid, if resubmission for Rotateq as “Unit” the amount you indicated would be paid.

Interesting that Tricare/Healthnet is aware of this issue but appear not be updating their claim system. We called Tricare and spoke to two different representatives, Tamara (first call) and Robin (second call) to verify the contracted amount for cpt code 90680 and received a reply that Tricare pays $/unit or a $/package (for Rotateq to receive the full reimbursement – needs to be per package).
To differentiate a package vs. unit: first of all, both reps said that it is usually per unit — per 1 vial of vaccine, using 1 dose is = 1 unit; using 2 doses = 2 units and if the whole vial is used then it becomes a package. However, for Rotateq it should be considered package because of the way the Practice buys them. It is usually bought per box of 10 single dose tube (even though the doctor only used 1 single dose of 2ml).

To correct and resubmit the claims, rep advised to list the claim numbers only with patient’s names and date of service. We don’t need to send them corrected claims. It can just be in a spreadsheet and fax it to Tricare at 888-432-7077. According to these representatives, practices are allowed 6 years on corrections because of this NDC codes confusion for most practices.
We also verified of changes/updates on their system because this was not an issue prior to January 2010. The representative from Tricare EDI said there was a change on their system on 1/25/2010.