Conspiracy to Defraud Pediatricians

[Note the continued updates at the end]

I have avoided blogging for over a week as I tear my hair out dealing with the transition to the 2011 Immunization Administration codes for our clients. I am going to name names below and if anyone representing any of these organizations would like to correct my information, I will give free reign to do so, here.

We knew this would be a problem.  But even in my most cynical moments, I failed to estimate exactly how far this problem would go.

On the SOAPM and PedTalk mailing lists, we received reports of expected payment on the new codes in dribs and drabs, sometimes in interesting bursts.  The AAP did much more than usual to work with payers to find out how they would transition to a new CPT set and SOAPM even tracked the status of some of the major payers.  Internally, at PCC, we were also tracking the various messages we were getting from different payers.

At first, the bad news was limited to local reps from national payers giving out some bad, weird advice.  I helped straighten out a UHC rep in TX who told one of our clients that the new imms codes were not "appropriate for immunizations that require boosters" and, therefore, they shouldn't be used.

Then, a few big payers showed up trying to game the system. BS of California, which should be using RBRVS-based contracts, says it will pay only $2 for the 90461. BC in upstate NY - $11 for the 90460 and $1.50 for the 90461.

And then it got even more interesting

BCBS of Illinois reported the following:

The specific fees are:

90460 = $29 for firsttime billed on claim, $6 each additional
90461 = $16  forfirst time billed on claim, $4 each additional


BlueChoice White
90460 = $25  forfirst time billed on claim, $6 each additional
90461 = $13   forfirst time billed on claim, $4 each additional”

Do you see what they are doing here?  They are literally changing the value of the code based on the the number performed at the visit.  This is in total violation of the HIPAA laws which the physicians are required to follow.  Yet, because of how the rules are written, it's legal for the insurance companies to do this.  As Herschel Lessin put it nicely: "If we break the HIPAA laws, we go to jail.  If they break the HIPAA laws, they go to the bank."

But then it gets more interesting.  And this is where I think the Federal Trade Commission and Department of Justice need to take notice.

Our EDI department, in whom I have a lot of trust and faith, reported to us that many, if not most, of the clearinghouses our clients use were rejecting any claims with a 90460/90461.  That's right.  Even though 100s of CPT codes are changed, deleted, or added every year, the people being paid to manage these things had their programs set on automatic delete.  Here's an example of it happening at the payer level.

One particular clearinghouse had what I'd call a lower quality of service response to the issue. Not only will they not expect the codes to be accepted until mid-January, they do not plan to resubmit any affected claims. To make sure I didn't misunderstand their position - which is, essentially, "It's broken, we'll fix it later, you'll have to redo everything" - here's a copy of the email our crew received:

As I indicated previously, we expect that the update will go in mid-January.

Any rejected claims will need to be re-submitted after the update.  Availity will not be able to manage resubmissions on behalf of our customers.

Did you catch the name of the clearinghouse?  It's Availity.  What makes Availity special?  Availity isn't simply a clearinghouse.  Availity is owned by the insurance companies themselves.  That's right - a combination, I believe, of IL/NM/OK/FL BCBS and Humana.  Maybe some others.

And this clearinghouse, owned by the insurance companies, is rejecting legallly required claims and not resubmitting any affected claims.  Once those claims get through in a few weeks (one presumes), the payers are not following HIPAA/RBRVS rules.

How is this not a conspiracy to defraud physicians?

How can our federal government not understand that this behavior is a huge part of the problem we have with health care funding in this country?

How can these businesses operate with one completely different set of rules from the rest of us?

Someone from BCBS of IL or Availity or somewhere step up and tell me.  I have a few thousand pediatricians listening.

In the meantime, what can we do about it?  Not much.  AFAIK, I there hasn't been a single instance of a payer paying a fine for breaking HIPAA rules.  But if we start complaining, maybe people will listen.  There is a federal complaint form you should complete.  Fill it out.  For every one of the 100s of claims you have a problem with (computers make that easy).

Update #1:

Anthem BCBS, which is significantly larger (BCBS NH, CT, GA, IN, KY, ME, OH, VA, MO, CO, NV, WI, and Blue Cross of CA), has the same problem.


Update #2:

We received the following from Availity (01/07/11, 4:30PM).


HCPCS Issue: Claims with new codes being rejected

Availity is resolving a temporary issue involving the new HCPCS codes that became effective January 1, 2011.

Claims filed using the new 2011 codes were rejected by Availity, beginning January 1, 2011. *Availity is addressing the situation and expects to be able to process incoming claims with the new codes beginning Monday, January 10, 2011.*

We will notify you accordingly on Monday morning to confirm that the new HCPCS  codes have been installed.

Unfortunately, Availity is not able to re-process any previously rejected claims. *Submitters will need to resubmit any rejected claims once the new 2011 codes have been implemented.*

Please monitor your resubmitted claims to ensure they made it all the way through to their respective health plan destinations, since some plans are similarly unable to process new HCPCS codes yet at this point in the year.


- Availity Client Services

Update #3:

According to our EDI folks, the Availity claims are going through now. 11 Days late, but it's working. They won't resubmit anything.

Update #4: Anthem's "solution" to the problem is slick double-speak. Check it:

Upon a little more digging on Anthem’s end it was identified that the denial of codes 90460 & 90461 was occurring at the EDI gateway and not on the Anthem claim adjudication system. Anthem EDI made the corrections over this past weekend and issued the attached statement to all of our Electronic Trading Partners. Now when these codes are (re)submitted they will pass through and pend (not reject) on the Anthem claim system until the codes are loaded. Once loaded the pended claims will be released requiring no further action on the part of the provider.

In other words: they've now just kept the claims from rejecting at the EDI level...but now they'll just hold them until "the codes are loaded." How nice of them!

Update #5: Availity Calls to Apologize

The folks from Availity reached out to our clients, both directly with an electronic message, and indirectly through PCC to apologize for the problems they had with the new codes.  Yes, it's still lame that they couldn't resubmit the claims that were rejected (which creates automatic money savings for their owner/customers), but they did fix the problem and admitted responsibility.

I was also told to pass along the suggestion that ANY time someone has an issue with their service to please pick up the phone and call 1-800-AVAILITY because they want to hear from you.