January 2012

OFFICE CLIENTS

Just a reminder to our office clients that it is important to send a list of patients seen each day so we can verify all patient charges have been received. Ideally it would be the first page after the Batch Cover Sheet.

ATLANTICARE INSURANCE CHANGES

AtlantiCare notified all employees and area providers on December 13th that their insurance will be changing effective January 1, 2012 to 1 of 2 unique Horizon plans – Engaged and PPO. They are also “transitioning to an Accountable Care type model” differentiating providers who are in and out of network. AtlantiCare Tier Network physicians (medical & specialists) have a $10 copay except for preventive care, which is $0 (zero). Non-network physicians have a $35 copay.

PATIENT STATEMENTS

Due to phenomenal growth, CMB has now reached the point that we began to send patient statements twice a month in order to spread patient calls out and further improve your cash flow.

PRIMARY CARE PROVIDERS

January & February are usually the time of year when patients are meeting their annual deductibles. These have increased significantly in the past few years as more policies are being purchased with $1,500 - $5,000 deductibles. As you know, we strongly recommend collecting these balances on the date of service if the patient has no other coverage.
One way to avoid this loss of cash flow early in the year is to include a Well Visit for Medicare patients (and HMO/PPO patients, if they have such coverage). The services are separate and distinct from a non-well visit and can be provided on the same day. The medical record needs to clearly reflect the 2 types of visits and the appropriate co-pay collected.

ELECTRONIC CLAIMS AND PAYMENTS – 5010 FORMAT

On January 1, 2012 the medical billing industry must begin submitting claims and applying payments using the 5010 version. CPB has been submitting all electronic claims in the 5010 format since mid-December and have not seen any significant problems.
Providers should be aware by now from CPB Monthly Client Bulletins that on January 1, 2012 new data requirements go into effect for the submission of electronic claims. The primary affect on providers is that certain additional data is now required in order to be paid. Some of this we have already taken care of on your behalf, such as adding the “Pay To” field which allows payments to be sent to PO Boxes instead of street addresses, and 9 digit zip codes for the location of services.

OFFICE-BASED PROVIDERS (PHYSICIAN AND NON-PHYSICIAN)

For those who see Workers Comp cases, 5010 now requires the name and address of the employer. Failure to provide it will mean the claim will be rejected.
If your office uses the New Patient Form or the Established Patient Form which CPB created, they may need to be updated to capture this information. Please notify me if you need that done.

For those offices which use your own form, you will need to either switch to ours or make provision to capture this information from patients while they are in the office. Let me know ASAP if you need us to prepare one for you.

AMBULANCE

For our ambulance clients, the same requirement pertains. If you are able to capture this information, along with the other information you are already capturing, it will facilitate payment. Failure to obtain it will mean a delay in being able to submit the claim until the patient provides it.

As mentioned above, don’t shoot the messenger. We aren’t excited about it either since it creates additional data entry for us and 1 more reason for W/C carriers to deny claims – resulting in follow-up work. Please call Rich with any questions.

MAKING COPIES OF MEDICAL RECORDS

HIPAA did away with "minimum" charges for copying medical records - or any other method of charging that exceeds the ACTUAL costs of making the copies. HIPAA provides that, in states where the patient may be charged for copies of the chart, the charge may not exceed the actual cost, including labor and postage, of making and sending out the copies.

Note also that if you keep your records in electronic form, the patient can request that that the records be provided in electronic form. In that case the charge would be the cost of labor to make the e-copy, along with the cost of the CD-ROM or other medium used. Remember, if you produce these records in electronic format you should at a minimum password protect them and ideally encrypt them. Only give the password to the patient or legal representative.

December 2011

Medicare Provider Revalidation

“All providers and suppliers who enrolled in the Medicare program prior to Friday, March 25, 2011, will be required to submit their enrollment information so they can be revalidated under new risk screening criteria required by the Affordable Care Act (section 6401a). Providers/suppliers who enrolled on or after Friday, March 25, 2011 have already been subject to this screening, and need not revalidate at this time.Do NOT submit your revalidation until you are notified to do so by your MAC. You will receive a notice to revalidate between now and March 2015.” CMS extended the time frame early in November from 2013 to March 2015 and physicians will be among the last required to revalidate.Be advised that you/we only have 60 days from the date of the letter to submit the revalidation application – and non-physicians will be charged $505. Failure to submit within 60 days results in stopping your Medicare payments. Payment can be made online and is required before the application can be done on PECOS.

PATIENT STATEMENTS

Due to phenomenal growth, CMB has now reached the point that we began to send patient statements twice a month in order to spread patient calls out and further improve cash flow.

2012 Medicare FEE SCHEDULE

SGR Update: Congress has made no progress on legislation to avoid the SGR related 27.4% reduction in the Conversion Factor for Medicare physician fee schedule payments that is slated to take effect on January 1, 2012. You should be prepared for the possibility that Congress will fail to enact even a temporary SGR fix and a significant cut in physician fee schedule payments could occur on January 1.

CMS announced on November 2nd:
“In addition to the SGR related fee schedule adjustment, CMS is also announcing other changes for 2012 as well. Some of the other major changes being adopted in the final rule include:

* CMS is expanding its multiple procedure payment reduction policy to the professional interpretation of advance imaging services to recognize the overlapping activities that go into valuing these services. This policy better recognizes efficiencies that are expected when multiple imaging services are furnished to the same patient, by the same physician or group practice, in the same session on the same day.
* CMS is adopting criteria for a health risk assessment (HRA) to be used in conjunction with Annual Wellness Visits (AWVs), for which coverage began Jan. 1, 2011 under the Affordable Care Act. The HRA is intended to support a systematic approach to patient wellness and to provide the basis for a personalized prevention plan. CMS is increasing AWV payment modestly to reflect the additional office staff time required to administer an HRA to the Medicare population.
* CMS is expanding the list of services that can be furnished through telehealth to include smoking cessation services. CMS is also changing the criteria for adding services to the telehealth list to focus on the clinical benefit of making the service available through telehealth. This change will affect services proposed for the telehealth list beginning in CY 2013.
* CMS is updating or modifying aspects of a number of physician incentive programs including the Physician Quality Reporting System, the ePrescribing Incentive Program and the Electronic Health Records Incentive Program.
The announcement finalizes quality and cost measures that will be used in establishing a new value-based modifier that would adjust physician payments based on whether they are providing higher quality and more efficient care as required by the Patient Protection and Affordable Care Act. The PPACA requires CMS to begin making payment adjustments to certain physicians and physician groups on Jan. 1, 2015, and to apply the modifier to all physicians by Jan. 1, 2017.
* CMS announces that they will implement the third year of a 4-year transition to new practice expense relative value units, based on data from the Physician Practice Information Survey that was adopted in the MPFS CY 2010 final rule.”

ELECTRONIC CLAIMS AND PAYMENTS – 5010 FORMAT

On January 1, 2012 the medical billing industry must begin submitting claims and applying payments using the 5010 version. CPB and our vendor are testing and do not anticipate any problem meeting this deadline.

November 2011

Medicare Provider Revalidation

“All providers and suppliers who enrolled in the Medicare program prior to Friday, March 25, 2011, will be required to submit their enrollment information so they can be revalidated under new risk screening criteria required by the Affordable Care Act (section 6401a). Providers/suppliers who enrolled on or after Friday, March 25, 2011 have already been subject to this screening, and need not revalidate at this time.Do NOT submit your revalidation until you are notified to do so by your MAC. You will receive a notice to revalidate between now and March 2013.”Be advised that you/we only have 60 days from the date of the letter to submit the revalidation application – and non-physicians will be charged $505. Failure to submit within 60 days results in stopping your Medicare payments. Payment can be made online and is required before the application can be done on PECOS.

PROLIA

If you plan to bill Prolia, please let Rich know in advance so we can set up certain bill fields to contain the required data for payment. We will also update your charge form. Until January 1st when a new Prolia specific code will be available, you will bill the unclassified code (we will provide that info to you) plus the regular injection code (not a vaccine code). Since this is specifically used to treat osteoporosis, be sure to “checkmark” one of those diagnosis codes (e.g., 733.0X).

MEDICARE FLU SHOT FEES

Medicare released the Flu vaccine fees for Sept. 1, 2011 – August 31, 2012 on October 5th (great timing!):
Q2035 (Afluria): $11.543
Q2036 (Flulaval): $8.784
Q2037 (Fluvirin): $13.652
Q2038 (Fluzone): $13.306

ABN’s – THEY ARE CHANGING, AGAIN!

A new Medicare Advanced Beneficiary Notice (ABN) format has been released by CMS with an effective date 1/1/12 (just changed to 1/1/12 by CMS on 10/20). If you use an ABN, let Rich know ASAP and we will create an updated version. The 2008 version is not effective after 12/31/11.

BILLING INJECTION CODES 90471 & 90472

If you give 2 or more vaccine injections, you need to use both 90471 & 90472 (1 unit each). If you give 3 vaccine injections, then you would check both 90471 & 90472 and indicate 2 units on the charge form for 90472.

If the injection is for Tetanus for a Medicare patient, Medicare will pay as long as it is not a routine immunization - but we need to know if it is not a routine vaccination so we can bill correctly. We suggest that you indicate “injury” (or whatever is appropriate) on the charge form. We will do the rest. If it is routine and for a Medicare patient, in order to get paid (since it is not covered the patient is responsible) you will need the patient to sign a properly completed ABN.

If you are injecting allergens, use 95115 for 1, or 95117 for 2 or more. In this case, you do not use both codes.

ELECTRONIC CLAIMS AND PAYMENTS – 5010 FORMAT

On January 1, 2012 the medical billing industry must begin submitting claims and applying payments using the 5010 version. CPB and our vendor are testing and do not anticipate any problem meeting this deadline.