August 04, 2016
Area(s) of Interest: Commercial Payors Payor Issues and Reimbursement Practice Management
Under the Affordable Care Act, health plans are required to provide “first dollar” coverage for preventive services. This means that the plan cannot apply patient cost sharing, such as copays, coinsurance or deductibles, to these services. However, in September 2015, the California Medical Association (CMA) was alerted by a physician practice that Blue Shield of California was applying patient cost sharing when it processed HPV9 claims with CPT code 90651.
CMA escalated the issue to Blue Shield and has been working with the payor since then to correct the issue. Blue Shield confirmed it implemented a system fix on May 18, 2016. The payor also confirmed it identified over 14,500 claims dating back to January 1, 2015, that were reprocessed to pay correctly. The reprocessing project was completed at the end of June 2016.
Physicians are encouraged to review their records to ensure all affected claims were reprocessed correctly and to contact Blue Shield if they identify any that are still outstanding.