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WCH BULLETINWCH BULLETIN
WCH Service Bureau is a proud member of the following professional organizations:
December 2012VOLUME 3
ISSUE 10
Welcome to the December issue of WCH bulletin!
WCH is 2012-2013 Compliant with OMIG http://omig.ny.gov/data
WCH Service Bureau, Inc. would like to take this
time to wish you and your family a happy holiday
season. It gives us great gratitude and pleasure to
express to you our season's greetings and best
wishes for the New Year.
Thank you for giving us the opportunity for having your
trust in our services. May your holiday season and the
New Year be filled with much joy, happiness and
success.
We look forward to working with you in the coming
year and hope our business relationship continues for
many years to come.
WCH would like to consolidate in wishing you
health, comfort, and a prosperous New Year ahead!
We are always here for you!
INSIDE THIS ISSUE:
4 WCH CORNER 23
10
CREDENTIALING NEWS11
14
HEALTHCARE UPDATES15 28 NEWS BY SPECIALTY
29 STATES UPDATES15 30 QUESTIONS AND ANSWERS
32 FEEDBACK
16
18
19
20
20
21
22
Attention Health Professionals: Information Regarding the 2013 Medicare Physician Fee Schedule
Important Changes Effective January 7, 2013 - Correction
Medical Necessity Top Reason for RACDenials
Use of Q6 Modifier for Locum Tenens byProviding Performing Provider NPI - Analysis Only CR
Office of Inspector General CMS Fact Sheet: Draft HHS Notice ofWork Plan FY 2013 Benefit and Payment Parameters for 2014
Credentialing Live Webinar Three Steps in Order to Receive EHR Incentive Payment
Electronic Funds Transfer (EFT)
Oxford Fined for Failure to Explain Coverage
There is no Such Thing as a 10-minute Office Visit
Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program
Avoid Untimely Claim Denials
Magellan Outpatient Behavioral HealthNew Model
Improper Payments to Providers forIncarcerated Beneficiaries
Payments for Alien Beneficiaries UnlawfullyPresent in the United States on the Dates ofService
23
24
25
WCH CORNERWCH YEAR RECAP
The 2012 year has been extremely busy for WCH, we would like to let our clients know what results we had achieved this past year.
WCH IS 5010 COMPLIANT! We are officially registered with Medicare program as 5010 compliant vendor, as well as with other insurance companies.Once again, we want to make sure that you know, that WCH is 5010 compliant and your claims are in good hands!
Clients will find Registration form on WCH WCH PUBLICATION RECEIVED website to receive CEU credit. CEU CREDITS
WCH Bulletin and WCH Times have been each approved for 1 CEU credit by AMBA - American Medical Billing Association.
WCH is proud to offer numerous opportunities for professional growth and certification/licence maintenance.We offer a fast and convenient way to earn CEU credit. Each publication gives you 1 CEU credit.
From January 1, 2013 all WCH publications will be under package subscription.
On your online profile you can review your CEU credits and maintaing full credit list.
New CFPC,CPC coder in WCH! WCH Service Bureau, Inc has announced in April edition, that Liz Bannova (Vice-Manager) become CFPC (Certified Family Professional Coder)She showed great determination, knowledge and achieved her goal, WCH is very proud to have first CFPC coder on staff.
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WCH RELEASED NEW PROGRAM - WEBINAR SERVICE WCH has released program - Webinar service. This program helps our clients with web-conference, online-meeting, seminars and presentations via Internet in real-time mode. Participants can access to the service in the web-browser without long and tiring downloading of software.Service has very convenient, simple and intuitive measuring interface. Service provides possibility of recording webinar for the future downloading and later viewing by webinar users. Webinar is the perfect tool for corporate education.
WCH CONTEST THE WINNER WAS ANNOUNCED! WCH contest finished and winner was announced.The competition was fierce, and it was great to see such amazing, interesting, exciting designs of potential virtual assistant. In
nearest future our clients and website visitors can see new virtual assistant with new tools.
We have started selling our software product Time Management on Amazon.This product received a good attention frombuyers. We invite you to visit our Amazon store: http://www.amazon.com/gp/product/B005AKPJA6
WCH ONLINE STORE AT
NEW CREDENTIALING DEPARTMENT MANAGERFrom July 1, 2012 WCH has new credentialing department manager Mr. Osipyants. We are confident that with Mr. Osipyants experience incredentialing arena and well established relationship with insurancesvendors will streamline all credentialing processes and hopefully relieveour clients from their enrollment headaches.
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WCH Go Green Initiative WCH support Go Green Initiative programWe recommend that our clients follow us on this initiative, you can start with simple things first:
Think Green and Go Paperless!
џ Use Gmail or Hotmail on your mobile device for reminders
џ Accept our invitation to receive your Electronic remittances by email
WCH will continue to update about our џ Upgrade to E-Faxinternal Go Green processes every issue. If you џ Set up for electronic funds transfer need a more personal assistance with the (EFT) for your insurance paymentsprocess, please contact us for help.џ Set your staff's payroll for direct deposit
џ Communicate with everyone via email џ Stop printing or copying- purchasing
scanner is priority for every office
WCH WEBSITE NEW DESIGN! We are launched our WEBSITE new design. The site has undergone a fresh lick of paint and some radical new changes. From here you will be able to keep up to date with all the latest news, releases and more. The new site is fully compatible with your mobile devices too! So you can check us out whilst you are on the go! Don't forget to check out WCH new blog where WCH updating and sharing important news from healthcare industry. So head on over to now!
ICD-10 CODE CONVERSION ON WCH WEBSITE WCH have placed on WCH website new ICD-10 Code Conversion just might make your job a little easier. The ICD-10 code translator tool allows you to compare ICD-9 to ICD-10 codes. ICD-9 is being expanded from 17,000 to approximately 141,000 ICD-10 codes, and this online tool can help you map that expansion.
WCH BLOG! In our blog you may find interesting news and fascinating views, interesting news of health care industries.The new Blog section of our website is an exciting new outreach project for us. Our blog focus on a variety of topics related to medical industry. Do not miss interesting news in our blog. We are sure you will be happy to list through our blog. Who wants be a writer, please send your text to us.
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WCH offers free website for clients, don't miss a chance
For clients that do not have a website, we are offering to create one to three page website with information about your practice.
You may ask Why you need to create a website?Because of your potential patients use online to find their doctors, laboratories and imaging centers.
Several months ago we offered free-websites for our clients. Now we continue this program Free Websites for Doctors.
97%
WCH became a proud member of RAMA Russian American Medical Association On June 1 WCH became a RAMA member. Russian American Medical Association was founded and incorporated in 2002. It was created to facilitate and enable Russian American physicians and other health care professionals to excel in patient care,
teaching and research, and to pursue their aspirations in professional, humanitarian and community affairs. RAMA is not a political organization. The main office of RAMA is located in Cleveland (Ohio) and has regional offices in several U.S. states.
CHANGES IN THE BILLING DEPARTMENT WCH is continuing to grow and expand our departments! The billing department has reached over fifty employees. Our department updated staff is below.
Oksana Pokoyeva, CPC, CPMA, Billing Department Manager
Elizaveta Bannova, CMRS, CFPC, CPC, Vice Manager
Zukhra Kasimova,CPC, [email protected]
Victoria Uzakova,[email protected]
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SOCIAL MEDIA DEPARTMENT
Social Media Department promotes WCH services through different channels of marketing:
We Invite You To Join Us! Please Visit .
Department pushes the WCH into new social media spaces, drives innovation and online communication programming in this arena, provides platform for real-time conversation, collaboration and idea sharing. Plus we can do it all for you! If you want to promote your services, please contact us:
wchsb.com
Valeriya Designer M
Aksyonova, Olesya Petrenko, arketing Manager
WCH PANTHERS-RACE FOR CURE 2012On September 9, 2012, WCH has taken part in 2012 Komen New York City Race for the Cure in Central Park.We were honored and privileged to take part of such an extraordinary event that not only benefited the foundation by helping them reach the goal of $6 million, but also to promote awareness of local breast cancer screening, education and outreach programs.
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Refer WCH to Your Colleagues and Friends for billing service!
Only happy clients refer others, and we want to make sure we exceed the expectations of every client who passes through our doors.
We understand that, we only grow if you are happy with our service.If you know anyone who needs billing service, WCH is here to help.
We are grateful for referrals that come our way and pleased to offer a Referral Reward Program.
WCH will provide you with , the deal is worth
For any questions please, contact Olga Khabinskay
2 complimentary insurances for credentialing$800, for every client that will sign with us.
WCH Referral Program for our clients
General Manager888-924-3973 (x 1201), 718-934-6714
skype: [email protected]
AMA: LAST-MINUTE ACTION TO AVERT CUTS TO PHYSICIANS SHOWS THE NEED FOR MEANINGFUL MEDICARE CHANGES“Congress averted a drastic cut of 26.5 percent from hitting physicians who care for Medicare patients on January 1. This patch temporarily alleviates the problem, but Congress’ work is not complete; it has simply delayed this massive, unsustainable cut for one year. Over the next months, it must act to eliminate this ongoing problem once and for all.“This last-minute action on the part of Congress is a clear example of how the Medicare program is increasingly unreliable for physicians and patients. This instability stalls progress in moving Medicare toward new health care delivery models that can improve value for patients through better care coordination. Physicians want to work with Congress to move past this ongoing crisis and toward a Medicare program that ensures access to care and the best health outcomes for patients and a stable, rewarding practice environment for physicians.”
Source: Jeremy A. Lazarus, MD President, American Medical Association
WCH will hold All Medicare claims 2013 claims approximately for 2 weeks till Medicare will
update fee schedule
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CREDENTIALING NEWSfound that 33 percent of medical equipment OFFICE OF INSPECTOR GENERALsuppliers in South Florida did not maintain WORK PLAN FY 2013 physical facilities, a vulnerability that might be
In an effort to promote efficiency and reduced by confirming legitimacy of location
eliminate waste, fraud, and abuse, the Office with onsite visits conducted during the
of Inspector General (OIG) takes a look at enrollment process. (OEI; 00-00-00000;
Medicare and Medicaid programs every year. expected issue date: FY 2014; new start.
In doing so, it provides an annual work plan Affordable Care Act.)
stipulating areas of these programs that require monitoring and investigation by
Program Integrity—Improper Use of components of the OIG (Office of Audit
Commercial Mailboxes (New) Services, Office of Evaluation and Inspections,
We will determine the extent to which Office of Investigations, and Office of Counsel
Medicare Part B providers and suppliers had to the Inspector General). During the fiscal
practice locations that matched commercial year, these offices typically audit and review
mailbox addresses in 2011. Medicare Medicare Part A and B claims to determine
providers and suppliers are required to whether providers billed appropriately for
establish physical business facilities of services they furnished.
adequate size and with permanent, visible WCHSB credentialing department staff
signs and must provide CMS with specific reviewed the 2013 work plan and identified
street addresses (not mailboxes) recognized by key areas of focus:
the U. S. Postal Service. Recent evidence suggests that individuals attempting to
Onsite Visits for Medicare Provider and defraud Medicare may be using mailbox rental
Supplier Enrollment and Reenrollment (New)services to evade enforcement of this
We will determine how often onsite visits requirement, as commercial mailbox services
occur as part of the Medicare enrollment or provide a recognized street address without a
reenrollment process. CMS reserves the right, mailbox number. (OEI; 00-00-00000; expected
when deemed necessary, to perform onsite issue date: FY 2014; new start)
inspections of a provider or supplier to verify enrollment information submitted to CMS.
Independent Therapists—High Utilization of (42 CFR § 424.510(d)(8).) Moreover, CMS is
Outpatient Physical Therapy Services authorized to expand the role of unannounced
We will review outpatient physical therapy preenrollment site visits. (Affordable Care Act,
services provided by independent therapists § 6401(a)(3).) CMS implemented the
to determine whether they were in Affordable Care Act provider and enrollment
compliance with Medicare reimbursement provisions by requiring onsite visits for
regulations. Prior OIG work found that claims provider and supplier types identified by CMS
for therapy services provided by independent as moderate risk or high risk. (76 Fed. Reg.
physical therapists were not reasonable, 5862 (February 2, 2011).) A prior OIG review
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medically necessary, or properly documented. Medicaid program integrity reviews by CMS's Our focus is on independent therapists who Medicaid Integrity Group have identified have a high utilization provider enrollment, including the rate for outpatient physical therapy services. employment of excluded providers, as one of Medicare will not pay for items or services the most common vulnerabilities. (OEI; 07-09-that are not “reasonable and necessary.” 00632; expected issue date: FY 2013; work in (Social Security Act, § 1862(a)(1)(A).) progress)Documentation requirements for therapy services are in CMS's Medicare Benefit Policy First Level of the Medicare Appeals Process Manual, Pub. 100-02, ch. 15, § 220.3. (OAS; W- We will describe redeterminations (the first 00-11-35220;W-00-12-35220; W-00-13-35220; level of Medicare appeals) processed in 2008-various reviews; expected issue date: FY 2013; 2011 for Medicare Parts A and B. A Medicare work in progress and new start) contractor has 60 days to conclude a
redetermination regarding a denied claim. We Program Integrity—Excluded Individuals will also assess the processing of Employed by Managed Care Networks redeterminations by Medicare contractors and We will determine the extent to which OIG- CMS's monitoring of redeterminations excluded individuals were employed by processing. (Social Security Act, § entities that provide services through MCE 1869(a)(3)(C)(ii).) (OEI; 01-12-00150; expected provider networks in 2009. We will also issue date: FY 2013; work in progress)determine the extent to which safeguards are in place to prevent excluded individuals and Part B Imaging Services—Payments for entities from participating in Medicaid Practice Expenses managed care provider networks. The We will review Medicare payments for Part B Department of Health and Human Services imaging services to determine whether they (HHS) and OIG have authority to exclude reflect the expenses incurred and whether the individuals and entities from all Federal health utilization rates reflect industry practices. For care programs pursuant to the Social selected imaging services, we will focus on the Security Act, §§ 1128, 1156, and 1892. practice expense components, including the Medicaid and any other Federal health care equipment utilization rate. programs are precluded from paying for any Practice expenses are those such as office items or services furnished, ordered, or rent, wages, and equipment. Physicians are prescribed by an excluded individual or entity, paid for services pursuant to the Medicare except under specific limited circumstances. physician fee schedule, which covers the major (Social Security Act, § 1862(e)(1), and 42 CFR § categories of costs, including the physician 1001.1901(b).) The payment prohibition professional cost component, malpractice applies to the excluded individual or entity, costs, and practice expenses. (Social Security anyone who employs or contracts with the Act, § 1848(c)(1)(B).) (OAS; W-00-12-35219; excluded individual or entity, and any hospital W-00-13-35219; various reviews; expected or other provider issue date: FY 2013; work in progress and new through which the excluded individual or start) entity provides services. Recent State
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Diagnostic Radiology—Medical Necessity of High-Cost Tests We will review Medicare payments for high-cost diagnostic radiology tests to determine whether they were medically necessary and the extent to which the same diagnostic tests are ordered for a beneficiary by primary care physicians and physician specialists for the same treatment. Medicare will not pay for items or services that are not “reasonable and necessary.” (Social Security Act, § 1862 (a)(1)(A).) (OAS; W-00-12-35454; W-00-13-35454; various reviews; expected issue date: FY 2013; work in progress and new start)
For more detailed information please visit the OIG website at www.oig.hhs.gov
Dora Mirkhasilova,Credentialing Specialist
Phone: 718-934-6714 1102 or [email protected]
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HEALTHCARE UPDATESrather than printing and mailing a paper check. EFT payments are especially advantageous because payee receives payment faster than with a paper check, and there is no risk of a check getting lost in the mail.EFT is Fast- no making a trip to the bank, Safe- no paper check to lose or damage, and less expensive than paper check payments and collections, that means that your money will be confirmed in your bank account quicker ELECTRONIC FUNDS TRANSFER than if you have to wait for the mail, deposit
(EFT) your check, and wait for the funds to become available. Electronic Funds Transfer, or EFT, allows to
send payments to payees electronically,
What You Need to Know
The therapy caps for 2013 will be $1900 for physical therapy and speech-language therapy combined and
$1900 for occupational therapy
reasons for not providing reimbursement for OXFORD FINED FOR FAILURE TO the amount claimed. The two Oxford EXPLAIN COVERAGE: The NYS companies fined are Oxford Health Plans NY,
Department of Financial Services (DFS) has Inc., and Oxford Health Insurance, Inc. Oxford
announced that Oxford Health has been fined responded that the violations were not the
$665,000 for failing to explain coverage to its result of any conscious policy to evade the
health plan members. Oxford was cited for requirements of the Insurance law or
approximately 300,000 instances of failing to regulations. Oxford must submit a corrective
provide explanation of benefit statements action plan to DFS within 60 days of the
(EOBs). State law requires that the EOB approval of the Stipulation it agreed to with
explain what services the plan covers and how DFS.
consumers can appeal when they believe See: .
claims are improperly denied. The violations are cited in an Examination Report undertaken
Governor Vetoes Bill Amending Self-referral by the NYS Department of Insurance (the
Law: predecessor to DFS) for the period October 1,
Governor Cuomo has vetoed legislation that 2001 through December 31, 2008. Oxford
would have brought New York's law on the failed to send EOBs for certain claims, and in
prohibition of financial arrangements and certain instances failed to provide specific
referrals into conformance with the federal explanation of any denial, reduction or other
http://ow.ly/exLFd
WCH Times | 15
Stark Self-Referral Statute. The legislation State Law covers referrals of designated included certain exceptions to the self-referral health services regardless of payment source, prohibition adopted under the federal law but meaning remuneration from private insurers not currently part of New York's law. and managed care plans are covered by the
statute. In addition, the Stark Law contains This bill would amend the Public Health Law exceptions for the following additional types which prohibits, subject to certain exceptions, of arrangements that are not in the State Law, health care practitioners from referring which make it more permissive:patients to providers of health care services
џ community-wide health information with whom the practitioner or an immediate systems and e- prescribing items and family member has a financial relationship. services and electronic health record This bill could weaken those Public Health items and services (in contrast, the Law prohibitions by, among other things, State Law only includes a limited creating additional exceptions to what allowance for the provision of constitutes a financial relationship, albeit in computers and related equipment and conformity with federal law. Given the supplies by a clinical laboratory to a concern with real and apparent conflicts of health services purveyor),interest that this change would engender.
џ bona fide charitable donations,
Generally, the Stark Law prohibits physicians џ fair market value compensation from referring Medicare patients for certain arrangements, anddesignated health services (e.g., clinical lab,
џ a “temporary non-compliance” grace imaging, radiation therapy, and physician
period for arrangements that, but for a therapy services, among others) to an entity
ministerial error, otherwise comply with with which the physician (or a member of the
a Stark Law exception. physician's immediate family) has a financial relationship, unless an exception applies. The State Law by and large mimics the Stark Law, but there are certain distinctions that make the State Law more restrictive. Notably, the
Regarding self-referral:
An insured patient that I checked out was THERE IS NO SUCH THING AS A 10-shocked when I said the charge for her visit MINUTE OFFICE VISITwas $100. She said, “But he was only in the
I will never forget something a patient told room for ten minutes!“ I was briefly at a loss me several years ago when I was covering the for words. I recovered, we agreed on a front desk in a practice I was managing. If you payment plan for her co-pay, I made a note on manage a practice and haven't worked at your her encounter form for the billing office and check-in and check-out desks recently, I highly she left.recommend it.
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I've been thinking about our conversation, and 6. He marked the encounter form with the thinking about what that $100 – actually the level of service and her diagnoses and payer would probably only pay about $35 and gave her the form to take to the check-with her co-pay, the grand total would be $55 out desk.– and what that $55 is supposed to cover… 7. He refiled the medication
1. First, we scheduled the appointment, reconciliation in the chart, finished which was a work-in, so it took several documenting the visit, and placed the people to take the message, pull the chart in the bin to be refiled. The chart medical record (paper charts), call the was filed, and the encounter form was patient to assess the problem, sent to the billing office.determine the need for the 8. At the billing office the charges and any appointment and schedule it. payment was posted and the claim was
2. When the patient arrived, we checked filed. If there was no problem with the to make sure her address and phone claim, it electronically passed through were the same, quickly checked her two scrubs and a final one at the payer.eligibility to make sure the insurance on 9. If payment was not denied for any of a file was still in force, and asked for a dozen reasons, the payment would photo ID. An encounter form was arrive at the billing office and would be generated at the nurse's station to posted.notify her of the patient's arrival.
10.Since the patient did not pay her co-pay 3. The nurse called her from the reception at the check-out desk, the patient
area, weighed her, and took her into an balance is billed to the patient. If the exam room to take her vitals, take a patient pays on the very first statement, brief Chief Complaint and History of it has taken the practice from 45 to 60 Present Illness, review the medications days to receive the complete payment she is taking and check to see if she of $55.needed any chronic medication refills
I know that patients often say “But he only while she was therespent 10 minutes with me.” Checking back
4. The physician came in to see her, asked with the provider, I find it was typically longer.
about any changes since she'd last been Patients tend to underestimate the time as it
seen, reviewed her History of Present goes very fast.
Illness and examined her. He talked to The total visit encompassed the work of the her about her illness and described a phone operator, the medical records clerk, the treatment plan for her upper triage nurse, the check-in person, the nurse, respiratory infection given her chronic the doctor, the check-out person and the health problems.biller. It took 8 people, and at least 45 minutes
5. He prescribed a medication for her of work to make that appointment happen.
problem, updated her medication list Plus, that visit had to help pay the expenses
and made a copy for her to take with for the rent, the utilities malpractice
her.
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insurance, medical supplies, computers, grasp of what actually goes into the services phones and janitorial services. they receive. They see very little of the
behind-the-scenes efforts. I don't think the The practice, the patients and the overseers of
patient visit is necessarily the perfect time to healthcare want each visit to be non-rationed,
educate patients on what goes into an office safe, high-quality, error-free, holistic, pleasant,
visit, but maybe each of us should be clean, accurate, efficient and reimbursable.
prepared to offer a meaningful answer when It's what we all want. And it isn't cheap.
the patient says “But he only spent 10 Even though healthcare and healthcare minutes with me.”reimbursement have been sizzling hot topics in the past few years, most patients – already
Source: www.managemypractice.comanxious and often sick – do not have a strong
contain one iteration of loop 2320 with an REMINDER - IMPORTANT AMT01 equal to "D" (primary payer paid CHANGES EFFECTIVE JANUARY 7, amount). Claims containing more than one
2013 - CORRECTION iteration will be rejected on the 999. Medicare Secondary claims must only • Line adjudication information, paid units of contain one iteration of loop 2320 with an service in loop 2430 SVD05 must be greater AMT01 equal to "D" (primary payer paid than or equal to 0 and less than 9,999.9. amount). Claims containing more than one Claims reporting paid units of service less iteration will be rejected on the 999, not the than 0 or greater than 9,999.9 will be rejected 277CA as previously indicated. on the 277CA. CMS issued Change Request (CR) 7880 edit Attention PC-ACE Pro32 users: Your next spreadsheet changes for institutional and quarterly update will be available January 7, professional claims. The edit changes below 2013. This update will address necessary will be implemented January 7, 2013. changes in regards to these edits. Users who do not upgrade will receive errors due to new New editing that may require changes to how edits effective January 7, 2013you submit your claims:• Subscriber policy or group number in loop 2000B SBR03 must not be present. If this information is reported you will receive a 999E (acknowledgement with errors) and a claim rejection on the 277CA.• Medicare Secondary claims must only
Source: cms.gov
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reports may contribute to CMS's oversight EARLY ASSESSMENT FINDS THAT obstacles.CMS FACES OBSTACLES IN
OVERSEEING THE MEDICARE EHR WHAT RECOMMEND
INCENTIVE PROGRAM We recommend that CMS: (1) obtain and review supporting documentation from WHY DID THIS STUDYselected professionals and hospitals prior to This study is an early assessment of CMS's payment to verify the accuracy of their self oversight of the Medicare electronic health reported information and (2) issue guidance record (EHR) incentive program, for which with specific examples of documentation that CMS estimates it will pay $6.6 billion in professionals and hospitals should maintain to incentive payments between 2011 and 2016. support their compliance. CMS did not concur Because professionals and hospitals self-with our first recommendation, stating that report data to demonstrate that they meet prepayment reviews would increase the program requirements, CMS's efforts to verify burden on practitioners and hospitals and these data will help ensure the integrity of could delay incentive payments. We continue Medicare EHR incentive payments.to recommend that CMS conduct prepayment reviews to improve program oversight. CMS HOW DID THIS STUDYconcurred with our second recommendation.This study reviewed CMS's oversight of
professionals' and hospitals' self-reported We recommend that ONC: (1) require that meaningful use of certified EHR technology in certified EHR technology be capable of 2011, the first year of the program. To address producing reports for yes/no meaningful use our objective, we analyzed self-reported measures where possible and (2) improve the information to ensure it met program certification process for EHR technology to requirements. We also reviewed CMS's audit ensure accurate EHR reports. ONC concurred planning documents, regulations, and with both recommendations.guidance for the program and conducted structured interviews with CMS staff Source: https://oig.hhs.govregarding CMS's oversight.
WHAT CMS FOUNDCMS faces obstacles to overseeing the Medicare EHR incentive program that leave the program vulnerable to paying incentives to professionals and hospitals that do not fully meet the meaningful use requirements. Currently, CMS has not implemented strong prepayment safeguards, and its ability to safeguard incentive payments postpayment is also limited. The ONC requirements for EHR
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accepted by Novitas Solutions, Inc after your AVOID UNTIMELY CLAIM DENIALSend of day processing time on Monday, An important message from Novitas December 31, 2012, will not be considered Solutions, Inc. (formerly Highmark Medicare received until our next business day of Services) Wednesday, January 2, 2013, due to standard All claims for services furnished on January 1, system operating hours. We recommend you 2010 and after, must be filed with Novitas submit these claims at least 2-3 business Solutions, Inc no later than one calendar year days prior to December 31, 2012, to allow (12 months) from the date of service or the time for potential report error resolutions claim will be denied as being past the timely and claim resubmissions.filing deadline. Please remember the holiday
on the first of the year and submit your claims Source: Novitas Solutions, Incbefore one year from the date of service for timely processing.
To avoid receiving an untimely claim denial for services, Novitas Solutions, Inc must receive these claims prior to your end of day processing time on Monday, December 31, 2012. Once received electronically, they must also be accepted on the initial acknowledgment report Office will be closed on Tuesday, January 1, 2013, in observance of the New Year's Day holiday. Therefore, any electronic claims that are received and
takes effect in January 2013:- Reduces provider administrative tasks- Expedites direct access to care- Identifies and addresses gaps in behavioral health services and coordinationMAGELLAN OUTPATIENT
BEHAVIORAL HEALTH NEW MODEL Key Components of the Outpatient Care Magellan Behavioral Health's new Model:outpatient care management model, which џ The model works through:
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џ The model works through: џ A decrease in the time you spend on the - Removal of administrative processes often phone or online with Magellan to obtain perceived as access barriers, such as authorization for routine outpatient care preauthorization and treatment request that meets criteria for continuation.forms џ Reduction of your administrative burden, - Use of proprietary evidence-based, clinically providing more time for you to spend with driven claims algorithms to identify only those your patients and your practice.cases needing care management support or other intervention Services Still Requiring Preauthorization- Review of all submitted claims against the High-risk cases and higher levels of care such clinical algorithms as inpatient, residential, and partial
hospitalization services.What Does it Mean for Providers? Specialty care such as intensive outpatient џ You can initiate routine outpatient services, treatment, psychological testing, outpatient
including counseling and medication ECT, transcranial magnetic stimulation (rTMS), management visits, for members without hypnotherapy, applied behavior analysis, and calling Magellan or obtaining biofeedback.preauthorization through our website.
the dates of service on the claim overlap. (The IMPROPER PAYMENTS TO Centers for Medicare & Medicaid Services PROVIDERS FOR INCARCERATED (CMS) Internet-Only Manual, Medicare Claims
BENEFICIARIES Processing Manual (100-04), Chapter 1, § 10.4.) In addition, the Medicare Claims The Office of Inspector General (OIG) of the Processing Manual provides instructions for Department of Health and Human Services providers who render services to incarcerated advised in the 2013 OIG Work Plan that they beneficiaries who meet the criteria for would be reviewing Medicare payments for exception.Incarcerated Beneficiaries. Medicare, in
general, does not pay for services rendered to Audits conducted by the OIG have resulted in incarcerated beneficiaries; however, the overpayments to providers across the country, regulation does permit Medicare payment including those serviced by National where an incarcerated beneficiary has an Government Services. As a result, CMS has obligation for the cost of care. (Social Security charged National Government Services to Act, § 1862, and 42 CFR § 411.4.) The begin the process of recouping identified Common Working File will reject claims on overpayments. The first series of which the dates of incarceration (as obtained overpayment adjustments have generated. from the Social Security Administration) and
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Overpayment letters will begin to be mailed contain the guidelines for applying for an on Monday, December 10. The listing of the extended repayment plan so that you may claims impacted by this action that you will research that option if necessary. receive with your letter will indicate that; "This claim adjustment was due to a mass Source: OIG.com adjustment." The detailed description of the adjustment can be found on the Fiscal Intermediary Standard System. The letters will
OIG have resulted in overpayments to PAYMENTS FOR ALIEN providers across the country, including the BENEFICIARIES UNLAWFULLY National Government Services states of
PRESENT IN THE UNITED STATES business being identified. As a result of these audit findings, the OIG and the CMS have ON THE DATES OF SERVICE charged National Government Services to
The Office of Inspector General (OIG) of the begin the process of recouping those
Department of Health and Human Services overpayments. The first tier of this process
advised in the 2013 OIG Work Plan that they has now begun and we have generated the
would be reviewing payments for Alien first round of those overpayment
Beneficiaries Unlawfully present in the United adjustments. As with any overpayment
States. The OIG will determine whether situation letters have also been generated.
Medicare payments were made on behalf of These letters will begin to be mailed on
beneficiaries who were unlawfully present in Monday, December 10. The listing of the
the United States on the dates of services. claims impacted by this action that you will
Medicare payment may not be made for receive with your letter will indicate that;
items and services furnished to alien "This claim adjustment was due to a mass
beneficiaries who were not lawfully present in adjustment." The detailed description of the
the United States. (The Centers for Medicare adjustment can be found on Fiscal
& Medicaid Services (CMS) Internet-Only Intermediary Standard System. The letters will
Manual, Medicare Claims Processing Manual contain the guidelines for applying for an
(100-04), Chapter 1, § 10.1.4.8.) Medicare extended repayment plan so that you may
prohibits payment for services rendered to research that option if necessary.
individuals who are not "qualified aliens." (Personal Responsibility and Work
Source: OIG.com Opportunity Reconciliation Act of 1996, § 401.) These audits that have been conducted by the
WCH Times | 22
administrative time on RAC activity. Medical MEDICAL NECESSITY TOP REASON record requests jumped by a fifth (21 percent) FOR RAC DENIALSthis quarter.
Recovery auditors (better known as RACs) Medical necessity is the most common reason denied 23 percent more Medicare claims in for denials and has been since the first the third quarter of this year, compared to the quarter of 2010, according to the more than previous quarter, according to the American 2,300 surveyed hospitals since AHA started Hospital Association. monitoring denials.The RACTrac results signal not only more Sixty-one percent of hospitals said the RAC denials but also more associated costs. claimed treatment took place in the wrong Denials cost providers 26 percent more this setting and not that the care was medically quarter. More than half of hospitals (58 unnecessary. Forty percent of them are percent) said they are spending more than appealing the decisions at a 74 percent $10,000 for managing the RAC process, while success rate.41 percent spent more than $25,000. Twelve percent said they spent more than $100,000. Source: CMS. Gov
Hospitals say they also are spending more
only be validated through medical record USE OF Q6 MODIFIER FOR LOCUM review; the locum tenens physician does not TENENS BY PROVIDING appear on claims and is not required to be
PERFORMING PROVIDER NPI - formally enrolled in Medicare. Professional practices may also bill locum tenens for ANALYSIS ONLY CR“regular physicians” who have left the Locum tenens policy states that “Physicians practice with no intention of returning. may retain substitute physicians to take over During any circumstance when the locum their professional practices when the regular tenens physician is billing under the NPI of the physicians are absent for reasons such as regular physician the locum tenens physician's illness, pregnancy, vacation or continuing NPI shall also be on submitted claims to allow medical education, and for the regular transparency into the identities of these physician to bill and receive payment for the physicians. This is a statutory requirement substitute physician's services as though he under SSA section 1842: “the claim form performed them himself … These substitute submitted to the carrier for such services physicians are generally called 'locum tenens' includes the second physician's unique physicians.” Substitute services are indicated identifier.”with the HCPCS Q6 modifier. The locum
tenens physician is not allowed to substitute Source: CMS. Govfor more than 60 days, which currently can
WCH Times | 23
ensure that those who are sick have access CMS FACT SHEET: DRAFT HHS to the coverage that they need. CMS NOTICE OF BENEFIT AND PAYMENT proposes a risk adjustment methodology to
PARAMETERS FOR 2014 use when operating risk adjustment on Earlier this year, CMS published the Patient behalf of a State. CMS also outlines the Protection and Affordable Care Act: Standards agency's proposed approach to validating Related to Reinsurance, Risk Corridors and risk adjustment data to instill confidence in Risk Adjustment Final Rule (Premium the program. States that are running an Stabilization Rule) (77 FR 17220) and the Exchange and their own risk adjustment Establishment of Exchanges and Qualified program can propose a different Health Plans; Exchange Standards for methodology.Employers Final Rule (77 FR 18310). These
џ Stabilizing premiums in the individual rules implement standards for Affordable
market for health insurance: The Insurance Exchanges (Exchanges), States, and
transitional reinsurance program is a three-health insurance issuers related to the
year program designed to reduce medical reinsurance, risk adjustment, and risk
risk for issuers and thereby reduce corridors programs established by the
premiums for enrollees in the individual Affordable Care Act and the establishment of
market to ensure market stability with the Exchanges and qualified health plans. These
implementation of new consumer programs are designed to provide consumers
protections in 2014. The statute sets a with affordable health insurance coverage, to
fixed, national amount for the reinsurance reduce incentives for health insurance issuers
program. To improve efficiency and reduce to avoid enrolling sicker people, and to
administrative burden, CMS proposes stabilize premiums in the individual and small
uniform reinsurance payment parameters group health insurance markets inside and
for this program. CMS proposes that a outside Exchanges.
State may supplement the HHS reinsurance The draft HHS Notice of Benefit and Payment payment parameters, but must pay for Parameters is a proposed rule released today those supplementary parameters with that expands upon the standards set forth in additional State reinsurance collections or these earlier rules, and provides further State funds (instead of funds collected by information related to policies such as the risk HHS under the national contribution rate). adjustment, reinsurance and risk corridors CMS also proposes: a per capita rate under programs, advance payments of the premium which contributions would be collected tax credit, and cost-sharing reductions. Key annually by HHS from all applicable health proposals include: insurance issuers and group health plans;
exclusion of certain types of plans from the џ Reducing the incentives for health reinsurance contribution requirement; and insurance issuers to avoid enrolling people standards governing the calculation of with pre-existing conditions: The contributions.permanent risk adjustment program will
assist health plans that cover individuals џ Protecting health insurance issuers against with higher health care costs and will help uncertainty in setting premium rates:
WCH Times | 24
The temporary risk corridors program low- and middle-income individuals, and protects qualified health plans from Indians. CMS is proposing that issuers uncertainty in rate setting from 2014 to 2016 provide cost sharing reductions at the point by having the Federal government share risk of service for eligible individuals and that in losses and gains. CMS proposes to account CMS directly reimburse issuers for these for profits and taxes in the calculations and to payments.align this program with the MLR program.
џ Exchange User Fees: Under the Affordable Care Act, Exchanges are self-sustaining
џ Assisting low and moderate-income entities. CMS proposes a user fee for Americans in affording health insurance on health insurance issuers participating in a Exchanges: CMS proposes further Federally-facilitated Exchange that would clarification regarding the administration of be commensurate with fees charged by advance payments of the premium tax State-based Exchanges.credit and cost-sharing reductions. To help Source: CMS. Gov eligible individuals pay their premiums and make coverage purchased through an Exchange affordable for low- and middle-income consumers, CMS is proposing to make advance payments of the premium tax credit to issuers on behalf of certain individuals. The cost-sharing reduction program will further reduce the out-of-pocket spending for health services for
the maximum incentive under the Medicare THREE STEPS IN ORDER TO EHR Incentive Program by starting in 2011 or RECEIVE EHR INCENTIVE PAYMENT2012, if eligible professional don't start by
The EHR Incentive Programs are available 2014, he/she is not eligible to receive any
for Medicare and Medicaid eligible incentive payment. Under the Medicaid EHR
professionals. These programs started to work Incentive Program eligible professional can
in 2011 year. The total maximum incentive receive the maximum incentive by starting in
amount that can be paid under the Medicare 2016. Under the Medicare EHR incentive
EHR Incentive Program is $44,000 over five program payment adjustments will take place
consecutive years of program participation in 2015 for providers who are eligible but
and under the Medicaid EHR Incentive decide not to participate. Adjustments to
Program is $63,750 over six years of program Medicare reimbursements will start at 1% per
participation. Eligible professional can receive year, up to a maximum 5% annual
WCH Times | 25
adjustment. No payment adjustments under As an option provider can check eligibility the Medicaid EHR Incentive Program. through web site
Three steps in order To receive EHR incentive payment:
1) Provider must be eligible. Incentive There are specific Eligibility Requirements payments are made to individual for Hospitals. providers, not to practices or medical To learn which hospitals are eligible to groups. Provider can be eligible for both participate in the program, visit Medicare and Medicaid EHR Incentive Programs but can participate in one only.
The following are considered “eligible professionals” who can participate in the 2)To get an incentive payment, provider Medicaid EHR Incentive Program: Physicians must use an EHR that is certified (primarily doctors of medicine and doctors of specifically for the EHR Incentive osteopathy); Nurse practitioners; Certified Programs. You can find a complete list of nurse-midwives; Dentists; Physician assistants certified EHR technology at the Certified who furnish services in a federally qualified Health IT Product List (CHPL) website, Health Center or Rural Health Clinic that is led .by a physician assistant. To qualify for participation in the Medicaid 3) To receive an EHR incentive payment, EHR Incentive Program, an eligible providers have to show that they are professional must also meet one of the “meaningfully using” their EHRs by following criteria: meeting thresholds for a number of • Have a minimum 30% Medicaid patient objectives. CMS has established the volume objectives for “meaningful use” that • Have a minimum 20% Medicaid patient everyone must meet to receive an volume, and be a pediatrician incentive payment. All required • Practice predominantly in a Federally objectives that should be reported are Qualified Health Center (FQHC) or Rural the same for both Medicare and Health Clinic (RHC) and have a minimum 30% Medicaid EHR Incentive Programs. For patient volume attributable to needy the first year of participating, eligible individuals professionals have to meet the
requirements for and report data on a The following are considered “eligible continuous 90-day period during the professionals” who can participate in the calendar year (any 90 days from January Medicare EHR Incentive Program: Doctors of 1st to December 31st). For the medicine or osteopathy; Doctors of dental remaining years of participating, eligible surgery or dental medicine; Doctors of professionals have to meet the podiatry; Doctors of optometry; requirements for the entire calendar Chiropractors. year. For the first year of participating
https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Eligibility.html
http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Eligible_Hospital_Information.html
http://healthit.hhs.gov/CHPL
WCH Times | 26
under Medicaid EHR Incentive Program, eligible professionals have the option to report adopting, implementing, or upgrading For Medicaid eligible professionals CMS will to a certified EHR system and not to report then send information to the individual state. meaningful use objects. Twenty-four hours after successfully “Meaningful use” is reporting thorough web registering through the CMS website, eligible site. professional will need to log in to his/her state The EHR Incentive Program consists of 3 program's website to verify registration and stages. Each stage has own requirements. We provide additional eligibility information. are currently in Stage 1. Medicare EHR Incentive Program runs by CMS How do you register? Use Registration User and Medicaid EHR Incentive Program runs by Guide that will give you step-by-step state. To see if your state's program has directions on how to register online. launched go to the Medicaid State For Medicaid EHR Incentive Program Information section of the EHR website state. To see if your state's program has launched go to the Medicaid State Information section of the EHR website Medicare EHR Incentive Program
.You can also look at the State EHR Incentive Program Milestones and Web Resources
, which provides individual websites for each state's Medicaid EHR Incentive Program.
If you eligible professional and you have decided to participate in the Medicare/Medicaid EHR Incentive Program you can register online at:
https://ehrincentives.cms.gov/hitech/login.action
https://www.cms.gov/EHRIncentivePrograms/Downloads/EHRMedicaidEP_RegistrationUserGuide.pdf
https://www.cms.gov/Regulations-and- https://www.cms.gov/EHRIncentivePrograms/Guidance/Legislation/EHRIncentivePrograms/ Downloads/EHRMedicareEP_RegistrationUserMedicaidStateInfo.html Guide.pdf
https://www.cms.gov/apps/files/statecontacts.pdf
.
WCH Times | 27
78320 (bone imaging; SPECT).
Cardiology џ The technical component (TC) and TC Rubidium is used with the following portion of global services for certain cardiac PET scan diagnostic cardiovascular and
78491 Myocardial imaging, positron emission ophthalmology procedures will be tomography (PET), perfusion; single study at reduced when the service is furnished by rest or stress the same physician (or same physicians in 78492 multiple studies at rest and/or stress the same group practice) to the same
patient in the same session on the same The level II cod e for rubidium is A9555 day.(rubidium 82Rb, diagnostic, per study dose, up For diagnostic ophthalmology services, a 20-to 60 millicuries). If “supervision, interpretation percent reduction will apply. For diagnostic and report” also is performed, one or more cardiovascular services, a 25-percent reduction codes from the 93015–93018 range would be will apply. For codes affected by the new appropriate. Note that, the American Medical multiple procedure payment reduction (MPPR), Association revised codes 93015 and 93016 in see Tables 10–15 in the in the Medicare the 2013 CPT manual to eliminate the word physician fee schedule final rule at “physician” when connected to supervision. Changes are shown below.93015 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with supervision, interpretation and report93016 supervision only, without interpretation and report.
RadiologyFor 2013, effective January 1, the Centers for Medicare & Medicaid Services (CMS) will implement two
other primary changes related to the multiple procedure payment reduction (MPPR) policy.
џ CMS has added the following to the list of nuclear medicine codes covered by the MPPR policy: CPT code 78306 (bone imaging; whole body) when followed by
http://www.gpo.gov/fdsys/pkg/FR-2012-11-15/pdf/2012-26902.pdf
Some Medicare payers will allow code V71.1, especially for PET for the initial treatment strategy. According to the Medicare national coverage determination (NCD) for PET for oncologic indications, this scan may be allowed for tumors that are “strongly suspected” based on diagnostic tests and clinical history. If the PET is done with negative results, V71.1 could be used to indicate that the physician suspected a malignant neoplasm.Some payers also allow V71.1 for subsequent treatment strategy when the physician suspects a recurrence or metastasis that is subsequently disproven by PET.The bottom line then: Check your payer’s local coverage determination (LCD) to see whether V71.1 is allowed.
NEWS BY SPECIALTY
Source: panaceahealthsolutions.com
WCH Times | 28
Anthem Blue Cross announced it was expanding Aetna aims for accountable its ACO network via care-coordination programs cancer care in Michiganwith providers in Southern California, and it Aetna, Hartford is introducing a launched a new primary-care initiative with six program in Michigan that aims to large physician groups in Virginia.reduce costs and improve outcomes in oncology
treatment.Other payers also are aligning themselves with local providers in ACO arrangements. The program will be available to in-network
oncologists who are part of Physician Resource Management, a doctor-owned consulting group for oncology practices.
Partners HealthCare marks $42 million for Aetna and Cardinal Health earlier this year
introduced a pathways program in Florida. They Massachusetts taxalso introduced similar initiatives last year in One prominent Boston health system plans to Washington, D.C., Maryland and Northern pay $42 million under a tax in Massachusetts' Virginia. healthcare cost-containment law.
The money from Partners HealthCare, which Source: Cigna
totals less than one-half of 1% of the system's 2012 expenses, will help finance a state trust fund for investment in healthcare reform initiatives by distressed Massachusetts Florida Blue, healthcare hospitals.
system team for The Massachusetts law, an ambitious and widely accountable care watched attempt to contain rising healthcare
costs, includes provisions to promote health organizationinformation technology, accountable care and NCH Healthcare System, Naples, Florida, will new payment models. participate in an accountable care program with The tax could raise $135 million from Partners, Florida Blue, the state's Blue Cross and Blue other large hospital operators and insurers. The Shield company.tax is limited to hospital operators with at least $1 billion in assets and less than half their In its first year, the accountable care revenue from public payers. organization will use a "value-based payment
structure" and will include only Florida Blue members in the Naples market, but it is expected to expand in the future.
STATES UPDATES
Source: modernhealth
WCH Times | 29
Question:t
Question:t
other words, when the global diagnostic service code is billed, for example, chest x-ray as described by HCPCS code 71010 (no modifiers), the locality is determined by the ZIP code applicable to the testing facility, i.e. where the TC of the chest x-ray was furnished. The testing facility (or its billing agent) enters the address and ZIP code of the setting/location where the test took place. This practice location is entered in Item 32 on the claim. As explained above, in Hi,order to bill for a global diagnostic service I am a Pediatrician and I am planning to open code, the same physician or supplier entity PC in Bronx. Currently I am working on must furnish both the TC and the PC of the submitting documents. I would really appreciate diagnostic service and the TC and PC must be if you can advice me what exact documents I furnished within the same MPFS payment need to include to get a permission. locality. A listing of the current PFS locality structure,
You must submit a Certificate of including state, locality area (and when
Incorporation with a $90.00 filing fee. We also applicable, counties assigned to each locality
will need a copy of your Board Certification in area) may be accessed from
Pediatrics from the American Medical Board of that specialty. Also provide your NYS Medical License number. Send that to NYS Education
on the Department.
CMS website.(Select “Medicare PFS Locality Configuration” from the menu on left.)
Separate Billing of Professional Interpretation If the same physician or other supplier entity does not furnish both the TC and PC of the diagnostic service, or if the same physician or other supplier entity furnishes both the TC and PC but the professional interpretation was furnished in a different payment locality from
If the global diagnostic service code is where the TC was furnished, the professional billed, the biller (either the entity that took the interpretation of a diagnostic test test, physician who interpreted the test, or must be separately billed with separate billing agent) must report the address modifier -26 by the interpreting and ZIP code of where the test was furnished on physician.the bill for the global diagnostic service code. In
Answer:t
Answer:t
Should PC be billed in the same location where the TC was performed as government identified due to the geographic locations?
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html
QUESTIONS AND ANSWERS
Dora Mirkhasilova,Credentialing Specialist
Victoria Uzakova,Supervisor
WCH Times | 30
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