Hello,
my name is Rene Pulido MD, and I am the owner of Emed Multispecialty Group. I have built this website to try to get some help from my WellCare Medicare Advantage Partners who have performed a recent audit which has left me with many questions and concerns.
The purpose of this website is not to complain or place WellCare in a negative state. The purpose of this website is to obtain answers to questions so that I can learn to be a better provider and so the process can hopefully make communication better so that we can strengthen our work relationship.
Timeline
- 3/24/2023: Received a refund request letter from WellCare dated 3/13/23 for 795 claims in the amount of $21,449.12. The amount was due in full within 45 days of the date of the letter or they would start recouping the money from future claims.
- 3/27/2023: Attempted to call number provided on letter to get more information, but it was strictly an automated system that does not allow you to speak to a person. Contacted provider services and was told that there is no way to contact them directly other than through fax or USPS. Sent letter via fax asking for them to contact us so that we could get more detailed information.
- 3/27/2023: Started audit review of all claims based on the information that was provided. The only reason stated was that WellCare paid at the incorrect rate. After research I deduced that they wanted to pay us at a facility rate, not the non-facility rate.
- 3/28/2023: Dr. Pulido emailed Sunshine Health Provider Relations, Margaret O’Bar (contracting), Sherri Baker (Medicare Advantage Rep), and Tekia McGriff (Medicare Advantage Rep) asking for assistance. The only response received was from Tekia McGriff. She stated that she had sent the information up to their leadership for review. Never received a further response.
- 4/6/2023: After no response from faxed letter, resent via fax and then sent the letter via USPS certified mail. Still received no response.
- 4/26/2023: Completed audit and sent results letter to WellCare via fax and USPS certified mail.
- 5/16/2023: Received WellCare’s response upholding their decision. The letter was dated 5/9/23.
WellCare’s Reasoning Behind Request
According to WellCare, they follow CMS guidelines and in their response, letter dated 5/9/2023, cited the chapter and section of the guidelines where this information could be located. It does state that POS 02 (used for telehealth services for patients that are at an originating site other than their home) are to be paid at the facility rate, not the non-facility (private practice) rate.
My View
Insurance companies in general have made it nearly impossible to keep up with the ever-changing guidelines surrounding telehealth during the public health emergency during the pandemic. Guidelines and regulations changed sometimes daily, and the insurance companies did a very poor job in communicating if their own rules followed CMS guidelines or not. As a payer that provides services for Medicare Part C, WellCare is not required to follow CMS guidelines.
The reason stated on the request letter for the recoupment was a “processing error-pd incorrect rate.” The letter provided no further information. We attempted to contact anyone that could provide us with a better explanation. There was no direct line to the recovery department and the phone number provided on the letter went directly to an automated response line only. We contacted three different representatives in different departments that we already have relationships with, in hopes that they could point us in the direction of someone who could help. Only one representative responded saying that they would forward the information to leadership. We also contacted the provider services phone number that we use when needing information about eligibility and claims. They confirmed that the only way to contact that department is through the mailing address on the letter or through a fax number that they provided.
We sent two separate letters requesting to be contacted for further explanation that were sent by fax. The second letter was also sent via certified mail. We received no response from WellCare at all. We completed the audit of 795 claims within the 45-day time limit and, based on the limited information that we had, sent our results again both by fax and certified mail. A letter dated 5/9/23 was received on 5/17/23 with WellCare’s finding of the review. They stated that the recovery was deemed as valid and cited section 20.4.2 of chapter 12 of CMS regulations stating that they were correct.
Although CMS guidelines do support WellCare’s findings, the problem that I have with this is the lack of communication from WellCare. We never received notification from them concerning any changes or updates pertaining to their policies surrounding this or any other issue. This is true going back several years. With regulations and guidelines undergoing constant governmental changes and each insurance company molding those into what fits best for them, it is impossible for the small private practices like Emed Multispecialty group to be expected to keep up with the constant changes by insurance companies with no notification from them.
Conclusion
My practice values our relationship with WellCare. You can call me old fashioned, but I feel like the best relationships are built on trust and communication. If I had been told, we were doing something wrong we would have immediately changed it. WellCare is such a large company that I don’t what to judge all of management on what could have been the decision of a few people who just require more training. I am hoping that the information noted here will help communication not only with providers but also internally in WellCare.
If you are from WellCare and want to communicate with me directly please use the contact me link.
Thanks
Rene Pulido MD.
If you are a provider with similar questions and concerns you can leave a comment below
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