On May 24, 2012, Michigan Medicaid released an alert noting that the Michigan Medicaid Provider Manual includes Reimbursement Limitations under its laboratory services section. According to this policy, “Medicaid limits laboratory payments when rendered by the same provider, for the same beneficiary, on a single date of service.”
Furthermore, the alert noted that “a processing error was allowing all laboratory services to be reimbursed beyond the stated MDCH Policy Guidelines. The issue has been resolved and current claims are now being processed according to policy guidelines.” The Michigan Department of Community Health also indicated, “Please be aware that MDCH will be reprocessing incorrectly processed claims and doing take backs on overpayments in the near future.”
Of great concern is the fact that this policy does NOT exempt Surgical Pathology CPT codes; whereas they did exempt CPT codes associated with Cytopathology, Cytogenetics, and Pathology Consult codes (historically these types of limitations, if they have been imposed, are exclusively applied to clinical lab tests).
With this precedent being set, of even greater concern would be if the Commercial Insurance Carriers apply this Reimbursement Limitation to their Medicaid Replacement Plans.
APS Medical Billing has expressed disdain to Michigan Medicaid on behalf of all of our impacted clients. Medicaid has indicated that perhaps the guidelines may have been misappropriated and have suggested APS begin an official Policy Appeals process. APS is actively attempting to reverse this policy to essentially have the CPT codes associated with Surgical Pathology be EXEMPT from the Reimbursement Limitations.
In the interim, APS’ Insurance Specialists along with our proprietary Contract Management system have begun segregating the under payments for surgical pathology codes traced back to this payment rule until the appeal process can be carried through to completion.
APS stepped in and took control of the transition and generated normal collections in our second month, improving billing, which is a huge accomplishment for our business.