I have received multiple texts, calls and emails from several midwives this weekend with concerns about Certified Direct-Entry Midwives being audited by the Alaska Medicaid program. After reviewing the audit information, this is what I have found and what can be done for past and future claims.
Concerns about this audit include:
- Newborn services past one week of age
- Delivery and postpartum care billed separately
- Medically necessary exclusions for care outside of a standardized care schedule
- Medically necessary home visits vs. office visits when coding E/M
I know that a lot of information about coding, billing, reimbursement and insurance management has been passed along from midwife to midwife for decades which can create common misinformation. As it pertains to this audit, Alaska Medicaid has not allowed reimbursement for the following services since 2016 according to the attached Provider Bulletin, Provider Billing Manuals and yet most, if not all of my current midwives, have routinely billed for newborn care past one week, care for gestational diabetes, E/M care after birth, multiple pregnancies, etc according to their state licensing and regulations "because other midwives are being paid". We now know that just because it was paid, does not mean that it should have or it will not be taken back in the future. I have always tried to optimize provider reimbursement and will not tell a provider they can not at least attempt to bill for the services they are licensed to perform when, in their experience, they have always been and should be compensated for it across the state.
I was not aware that Alaska Medicaid did not align with the state's Certified Direct-Entry Midwife scope of practice as it pertains to newborn care and age. I do utilize the posted Alaska Medicaid Fee Schedule code list on my superbills for midwives to file for reimbursement and avoid frequent denials but these superbills can not include all nuances that are clearly explained within the Alaska Medicaid Provider Billing Manuals.
I am asking that all Medicaid superbills be held until I can update the superbills logic over the weekend.
I am going to be working on breaking apart newborn care codes (even though they will be the same as all other home and office codes) and add links, resources and limitations on the superbill based on the selected ICD codes (which signify newborn age).
I will also be limiting the use of 59409 (Labor and Delivery only) for midwives seeing the mother postpartum.
I will be including the verbatim list of Non-Covered Services on the superbill when the midwife indicates that the patient has Alaska Medicaid.
Midwives are required to file a separate superbill for newborns and mothers as they are different patients and will have different limitations within the superbill.
I will be sending a list of claims to everyone that reported newborn care with Medicaid using the ICD-10 codes Z00.111 and Z00.129 (newborns over 8 days of age) since working with me.
Unfortunately, for claims older than 12 months, providers can not file an adjustment to claims that I know of. We can file a VOID request with the attached cover sheet , copy of the claim and remittance for each claim in question. This would alert Medicaid of an overpayment and be processed to come out of future reimbursement unless a check for the overpayment is attached. I am happy to file these adjustment/VOIDs for all claims identified to meet the Non-Covered Service criteria outlined in the attached Medicaid Manuals for Direct-Entry Midwives.
As for medical necessity, this would mean that the patient was not seen "routinely" outside of a standardized care schedule that is established by your licensing or credentialing entity. (ACOG, AAP, NARM, etc). Alaska Medicaid has previously audited providers for seeing patients at home vs. in office questioning the necessity of the home setting based on patient mobility and the ability to meet in the provider's office for routine care. Your medical records would need to clearly identify the need for / medical necessity of such care.
It does seem that this audit started targeting claims in 2020 when the independent provider audits were initiated, meaning providers had to have already audited their claims and cross referenced them with their charts for accuracy before submitting their findings back to the state.
I would highly encourage everyone to thoroughly review the attached manuals and general program guidelines to become familiar with how their limitations may differ from your licensing and regulations.
If you have questions about the audit that has been circulating, please feel free to contact me and I will answer them to the best of my ability.
