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Providers and DSS debate billing and attribution issues: ultrasounds, recoupment and MFM taxonomy
Summary
Providers asked whether ultrasounds and other maternity services billed before a case‑rate trigger need recoupment and pressed DSS about how Maternal‑Fetal Medicine services will be identified; MedOps said pre‑trigger ultrasounds remain fee‑for‑service and DSS is assessing taxonomy/TIN issues for MFM attribution and will follow up with practices.
Providers raised practical billing questions during the forum about how the maternity case rate interacts with services billed before or outside a trigger claim and how Maternal‑Fetal Medicine (MFM) services will be identified.
A provider asked whether ultrasounds billed before the case‑rate trigger must be recouped when deliveries are rebilled under the case rate. A MedOps representative responded: "If the ultrasound was performed prior to the trigger visit, the claim should remain fee for service." The representative added that if an ultrasound or other maternity bundle service is billed after the trigger claim, "the claim will 0 pay, and the case will be the payment."
Providers said some practices have mixed billing arrangements (for example, a TIN that contains both routine OB and MFM clinicians), and asked whether MFM would be carved out or better identified through taxonomy codes. DSS said it is assessing MFM data and exploring how taxonomy information could be used to recognize MFM services more reliably, but that the taxonomy data must be corrected at enrollment and that there is no commitment yet to carve MFM out of the case rate.
Multiple providers offered to work with DSS to correct taxonomy entries and to review specific cases (Yale and other systems were discussed as examples) so the team can determine whether a separate approach or adjustment is warranted.
