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Let's talk CMS, UnitedHealthcare and Anthem

Keeping up with payers can be exhausting. There's so much to know! But you don't have to figure everything out on your own.

In this post you’ll get key statistics, website details, timely filing requirements, and more information to get you started with CMS, UnitedHealthcare and Anthem.

The Centers for Medicare & Medicaid Services (CMS)

Quick facts

  • CMS is the single largest payer in the U.S. In fact, 40.8% of hospital costs are attributable to Medicare and 18.5% to Medicaid, according to the American Hospital Association from the Center for American Progress. 
  • Medicare is a federal program that serves individuals 65+ years old, younger people with disabilities and dialysis patients. In 2020, there were 61.2 million Medicare beneficiaries (Kaiser Family Foundation).  
  • Medicaid is a state-run program that serves low-income people of any age. As of March 2021, there were 81.7 million individuals enrolled in Medicaid and Children’s Health Insurance Programs (CHIP). 
  • Research from April 2020 shows that private insurers paid an average of 199% of Medicare rates for all hospital services, and 143% of Medicare rates for physician services.

Updates

  • CMS’s rule-making process is rigid, and proposed rules can be publicly commented on before its final rule. All CMS regulations and notices are published on the Federal Register.
  • Medicaid programs are administered by individual states, but you can go to Medicaid.gov for state-by-state overviews. 

Timely filing requirements

  • Medicare timely filing is 12 months after the date of service.
  • Medicaid timely filing varies by state program.

Contact

  • Medicare fee-for-service providers can contact their regional Medicare Administrative Contractors for questions about claims or coverage issues. 
  • Each state Medicaid provider has its own customer service system.

News

UnitedHealthcare (UHC)

Quick facts

  • UnitedHealthcare is the largest payer after CMS by covered lives, with 70 million members.
  • UHC has extensive provider education and training tools, comprising courses in nine different categories. For example, their coding courses are aimed to decrease denied claims caused by coding errors. 

Updates

  • Check the UnitedHealthcare website for provider news and sign up for email updates. 
  • Visit the Network Bulletin website to monitor updates for things such as pharmacy, medical policy, reimbursement and prior authorization. You can also sign up for email updates.

Timely filing requirements

  • No payer-wide policy is in place. Refer to your internal contracts for specific timely filing requirements. 

Contact

  • Visit the provider-dedicated website UHCProvider.com.
  • Providers can also find state-specific information, service, support and detailed contact information on another webpage.

News

  • UnitedHealthcare announced plans to retroactively deny commercial emergency department claims that it considered non-emergent. UHC took a step back after outcry from provider groups such as American Academy of Emergency Medicine and the American Medical Association. Instead, they will “delay the implementation of our emergency department program until at least the end of the national public health emergency period.” Providers argue against this policy in a letter here.

Anthem

Quick facts

  • Anthem serves more than 107 million people.
  • It is an independent licensee of the Blue Cross and Blue Shield Association serving members in California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, New York, Ohio, Virginia, and Wisconsin, as well as specialty plan members in other states.
  • Its companies include Anthem Blue Cross and Blue Shield; Anthem Blue Cross; and Empire BlueCross BlueShield; as well as Anthem Life Insurance Company and several affiliated and specialty companies such as Amerigroup, CareMore, and UniCare.

Updates

Timely filing requirements

  • Anthem claims should generally be filed within 90 days, but you’ll want to check the reimbursement policies for your state.

Contact

  • Anthem uses the Availity portal for provider relations needs and offers assistance through their Provider Experience team. You’ll need to fill out an online form and the Provider Experience team will reach out within two business days.

News

  • After months of negotiations, Anthem in California and Nevada reached a deal with Dignity Health, the largest not-for-profit health system in California, to allow Anthem insured patients to maintain in-network access to Dignity Health services, facilities, and providers.

Comparing your payers 

You probably work with all three of these payers all the time. But did you know that you can store and analyze your payer contracts and fee schedules in Rivet? Model potential changes in your fees to prepare for negotiations and quickly find out where your pain points lie. Want to know how many claims were denied or the total revenue lost from denied claims broken up by payer? What about underpayments? We got you. And you can do it all without opening a spreadsheet! 

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