Wiki Med Advantage plan changing cost share midway through year/due to CMS guidelines?

I bill for MD AND APRN'S who are behavioral health providers. so Psychiatrist and Psych NP's. Anyway one particular MA plan in which we bill E and M codes for follow up medication management started charging copays when their services dates had no copay before earlier in the 2024 Calendar Year. CPT, Place of service everything is the same. So I questioned the Medicare Advantage plan as to why this had changed three to four months into the year. It took them months to answer. 1st response was as follows:

This was reviewed by our Benefits team. There are two pieces to this:
The inconsistency is due to an update to Benefits that did take place around March. The cost share patients are now receiving is correct.
If your providers bill an E&M code (99212-99215), that will take a Specialist co-pay, as the visit is considered a Specialty visit. If the provider bills a psych code (90834, 90837, 90791, 90792) they will not receive a co-pay, as it is considered a Behavioral Health visit.

So then I asked.them f they notified their members or providers in writing of this benefits change and when was the exact date that this change took place. No answer again for weeks. I keep pushing and this is what they sent me.

Hello Lisa,

I have verified that Rachaels guidance previously provided is accurate as to how Cigna Medicare is applying benefits to E&M codes. They have made the change to follow CMS guidelines on 4/3/24. When providers bill an E&M code (99212-99215) for Cigna Medicare members, that will take a Specialist co-pay, as the visit is considered a Specialty visit. If a provider bills a psych code (90834, 90837, 90791, 90792) they will not receive a co-pay, as it is considered a Behavioral Health visit according to CMS guidelines. Cigna Medicare did not send notifications to members or providers as they are following CMS guidelines. If they have any additional questions or concerns regarding this change please contact Cigna Medicare directly
Problem is I called and chatted with Medicare and they can't find any guideline changes that were issued in April of 2024. it is no where to be found. Here is where it gets interesting. they have changed their members cost shares. according to MA plan guidelines

No, Medicare Advantage (MA) organizations are not allowed to make midyear changes to non-prescription drug benefits, premiums, and cost-sharing.
In addition Medicare does not mandate or oversee guidelines for copays with medicare advantage plans.

So I don't think that what this MA PLAN has been telling me is correct and if they are not supposed to make changes midway through the year to members benefits it seems what they are doing is contrary to CMS policy. For example Medicare does not change the deductible amount part of the way through the year
Does anyone know who I should reach out to ? Medicare is unable to find this CMS guideline change that the MA plan bases or uses as the rationale for charging the copay or cost share to patients that they never had before.

Seems fishy to me.

I wonder if what the MA plan really is trying to explain is that they updated the benefit configuration for the specialty visit to apply a copay, which may be the benefit listed in the beneficiary's EOC. I have worked in health insurance for 20+ years and it is not uncommon for a benefit change to be listed in the EOC but the company missed updating their claim adjudication system with the updated benefit prior to the new benefit year starting. Then the issue gets identified and they retroactively update the benefit to match the benefit listed in the EOC.

If you provide the name of the MA plan and verify that it is issued in the state of Tennessee, I would be happy to help figure out the issue since I have insider knowledge working in health insurance, including MA plans.

Thank you so much for taking the time to respond Corinne. CIGNA HEALTHSPRING is the MA plan and it is issued in Tennessee and we also serve Georgia members.
You are the first person to provide a logical explanation of why this might be happening to our claims. What you state above makes sense. That Cigna Hspring was late to the party changing information in their claims adjudication system. However, ..they said CMS guideline change on 4/3/2024 was the reason and no one can produce this guideline and CMS cannot locate it either when I have called and had online chats.
So where or what is EOC Evidence of Coverage in their benefits booklet? Would the following be evidence of coverage ? Our patient Mr. S in his benefits booklet provided a copy of this page for 2024 cal. yr (Psychiatric Services ) Psychiatric Individual 0$ Psychiatric Group 0$ and he has been told by multiple agents that he has no copay and they have reprocessed some of his claims with no copay. this is difficult when they inconsistently process our claims when the info is the same.

I did find out yesterday after pressing... that their plan called Cigna Primary MCR HMO has no specialist copay and Cigna Preferred Medicare HMO does have a specialist copay so I thought maybe I was on to something
The concerning thing is no one can provide a definitive answer and they cannot produce the CMS guideline they base the change on. I need verification that what they are saying is true because in my multiple previous dealings with them they have shown themselves to not provide accurate information and actually put into place a contract for one of our providers that he was never on and started reprocessing previous claims incorrectly as well as future claims incorrectly I had to contact their contracting department to get a list of the Contracts that we had been on. It was a huge mess and issues went on for 3 years and we finally received a settlement that was way too long in coming so I do not find their organization to be reliable or forthcoming with information. They even had to pull in Claims specialists from the Cigna commercial division to assist.
I think one other confusing thing for our patients is this.... They are coming to see a Psychiatrist or a Psychiatric Nurse Practitioner so after years and at the beginning of this year no copay and then all of sudden they have one and in their booklet it says Psychiatric 0$ copay I am just trying to find where it says in writing that Behavioral Providers who bill E and M codes are all of a sudden specialists and that they are not providing behavioral healthcare unless it is a first time visit or if they conduct therapy.

Thanks for any information I really do appreciate it greatly because I have been trying to get an answer from them since May 2024
Lisa

lisaray said:

I am just trying to find where it says in writing that Behavioral Providers who bill E and M codes are all of a sudden specialists and that they are not providing behavioral healthcare unless it is a first time visit or if they conduct therapy.

Click to expand...

The EOC (I linked the EOC I reviewed and cited below) doesn't define what a specialist is, rather they define what a PCP is in Chapter 3 Section 2.1 on page 24, and any specialty not listed as a PCP is considered a specialist provider.

According to Chapter 3 Section 2.3, the patient's PCP selection defines the patient's provider network, are you in-network specifically with the PCP's network?

Maybe the copay is being charged for using a specialist who is Cigna contracted but not specifically contracted with the PCP's Cigna provider network.

Additionally, it appears that prior authorization is required for specialist visits per Chapter 4 Medical Benefits Chart page 50.

Dear Corinne
I finally got an answer from Cigna Healthspring. So apparently they were audited by CMS and CMS is the entity who informed them that they had been processing the claims wrong.
So the guidance was that the Behavioral Benefit is not determined by the type of provider but rather based on the service provided and that the cost share would apply for E&M codes. So for further clarification a specialist copay will apply for office visits CPT codes 99212 99213 99214 these services do not fall under behavioral benefits. She did say that evidence of coverage did not change for the members from 2023 to 2024 and the members were not notified of this change. Providers were not notified either. They did cite an article in the MLN Article A57480 billing and coding for psychiatry and psychology So she said the change occurred due to CMS guidance and that is the reason these people have copays now and why it changed 4 months into the year. Thought you might find this interesting
Thanks so much for your input I appreciate it........
Have a great week!