MDHHS Addresses Medicaid Attending Physician Claim Edit

The Michigan Department of Health and Human Services (MDHHS) recently issued an L-letter regarding attending physician claim edits that were implemented Jan. 1, 2022. The letter addresses concerns raised by the MHA and hospitals regarding the claim edit that has resulted in denied claims. Existing Medicaid policy stipulates:

  • The attending physician (MD or DO) is responsible for determining medical necessity and appropriateness of service within the scope of current medical practice and Medicaid guidelines.
  • Services must be furnished under the direction of a physician (MD or DO) or dentist.
  • The attending physician must be Medicaid-enrolled for all institutional claims. If the attending physician is not reported on the claim or if the provider is not enrolled in Michigan Medicaid, the claim cannot be paid.

The MDHHS final policy (MSA 21-45), issued Dec. 1, 2021, reflected the above policy and notified providers that the MDHHS would implement edits that would preclude payment for services where the attending provider was a physician assistant, nurse practitioner or podiatrist, resulting in claims denials for dates of service beginning Jan. 1, 2022.  The L-letter modifies policy to mitigate the denial of hospital claims associated with this edit as follows:

  • Outpatient services – The provider types allowed in the attending field prior to Jan. 1, 2022, will be permitted. Also, additional provider types can be reported in the attending physician field for outpatient hospitals.
  • Inpatient services – The provider types allowed in the attending field include physicians (MD/DO), dentists, certified nurse midwives and podiatrists.

The complete listings of permitted attending provider types for inpatient hospitals and outpatient hospital providers are available on the MDHHS website and will be updated as needed.

Affected Medicaid fee-for-service claims for dates of service on and after Jan. 1, 2022, will be reprocessed beginning May 19. Medicaid health plans (MHPs) may begin to reprocess claims and/or resubmit encounters effective immediately. Hospitals are encouraged to contact the MHP for specific instructions. The MDHHS anticipates releasing additional clarification soon. Members with questions should contact Vickie Kunz at the MHA.