Payer Update, May 2023

Payer Update

Audits – We are here to help!
by Zack Duffy, Director Member & Community Relations

Audits can come to HTCs from a variety of angles. Whether it is a compliance related audit or a payor related audit the Hemophilia Alliance is here to support you through the process. The earlier a center can notify the Hemophilia Alliance, before any legal action is taken, the more we can support HTCs navigating the audit.

Recently we were made aware of a Medicare Targeted Probe and Educate (TPE) audit a member HTC received specifically related to the sale of Hemlibra. The TPE auditors were unfamiliar with how Hemlibra is billed and initially began denying claims related to Hemlibra. The Hemophilia Alliance was able to work in the background with contacts at this specific Medicare MAC (Medicare Administrative Contractor) to ensure that the auditors were educated on how Hemlibra is billed. Without a formal redetermination the auditors reached out and apologized for the confusion and overturned their prior denial. Being able to work through these issues on the front end is always easier before things start moving through the legal process.

The TPE probe also highlighted an important reminder that communication of audits may be sent to the rendering provider on the claim. It is critical that the audit information is forwarded to the person or team that is responsible for responding to the audit as quickly as possible since a timely response is often needed. Also, it is important to ensure that contact information is up to date within the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) If PO Boxes or clinic addresses aren’t up to date it will create delays in communication with Medicare auditors. Find out who your Medicare MAC is here:

While this is an example of a specific type of Medicare audit, we are happy to support you through any type of payor or compliance audit. The earlier we are involved the better. Please reach out to your center’s primary contact at the Alliance and they can loop in all pertinent parties.

Also in this Issue…

Notes from Joe

Notes from the Community
· Announcing: The 4th Annual Innovation Grant
· HTC DSCSA Update
· Not Your Ordinary Mascot!
· VWD Connect Foundation July Conference – Patient Registration Still Available!

Alliance Board Update
· New Board Members

Washington Update
· COVID-19 Public Health Emergency Ends – Impact on Medicare & Medicaid

Alliance Update
· Alliance Member Needs Assessment – Your Participation is Needed
· Upcoming Alliance Meetings

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