January 2010

PROVIDER MEDICAL RECORD SIGNATURES

CMS and other insurers are VERY active with pro-payment and post-payment audits (CERT & RAC) and are carefully reviewing medical record documentation. One of the critical requirements that is checked on EVERY medical record is the presence of an acceptable provider signature. This type of denial is easy to avoid. In the December Highmark Medicare Report, page 3 (top) it states:

“Also, note that in keeping with standard auditing principles, items such as signatures, attestations, and other addendums which are added to the medical record after the date of the Additional Documentation Request (ADR) letter will generally not be considered as acceptable documentation. Furthermore, providers who exhibit a pattern of adding documentation after ADR requests could be subject to corrective action.

If you receive a request for medical records from the CERT contractor or Highmark Medicare Services, it is critical that the signed physician order for all diagnostic tests be included. Without the order, the services could be determined to be medically unnecessary and the claim will be denied.”

We have also been told by Highmark Medicare that “Electronically Signed” signatures are not acceptable – each document/note/order must have a handwritten signature.

Thus, before sending any documentation to Medicare or any other insurer, it is critical that all providers, physician and non-physician, are sure their signature is on EVERY document/note/order and that it be recognizable as their signature. CPB will be glad to review all documents for completeness prior to sending them to an insurer. See the separate article from the Highmark Medicare Medical Director in your MCO packet.

DEFINITION OF “NEW PATIENT”

We occasionally are asked what constitutes a new patient. The definition of a new patient is found on the first page of the narrative instructions at the beginning of the E/M section of your CPT manual where it states: "...A new patient is one who has not received any professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past 3 years."

As you can see, the billing tax ID, change in office location, joining another practice, whether you need to set up a chart or not (maybe the first with the patient was in the hospital setting).....none of those things make any difference for determining new vs established. The only criterion is whether you've seen the patient in the past 3 years (36 months) or whether anyone else of your specialty in the same practice you're with at the time of the appointment has seen the patient within the past 3 years.

Though it isn’t necessarily a "federal guideline," the Medicare program does follow it. And, since it's part of the CPT definition of the service, it's applicable to all payers (including self pay) unless the payer tells you in writing they have an alternate definition for "new patient."

2010 PART B DEDUCTIBLE

The Centers for Medicare & Medicaid Services (CMS) announced the Part B annual deductible for 2010 is $155.00 (it was $135 in 2008 & 2009). With the poor economy, it is more important than ever to make every effort to collect all co-pays, deductibles (if known), and co-insurances on the date of service. The key is getting the payment before they receive your services, or at worst, before they leave your office.

2010 MEDICARE PHYSICAL, OCCUPATIONAL & SPEECH THERAPY CAP

The Therapy Cap for 2009 is $1,860 through December 31, 2010. However, as of December 28th, the Medicare Cap Exceptions process for independently practicing physical, speech and occupational therapists has not been extended by Congress beyond December 31, 2009. Patients who near the Cap have the option of transferring their care to an outpatient hospital setting or signing an Advanced Beneficiary Notice.

Medicare PROVIDER Participation Status – DATE CHANGE

As you are probably aware the current Medicare Fee Schedule is set to decrease by 21% unless Congress acts to change it. One option that providers have is to change from participating to non-participating status. If you wish to consider becoming non-par due to the potential fee decrease and, for physician, the elimination of consults, it can be done until 3/17/10. Call me if you want to discuss financial ramifications. Non-par status offers about a 9-10% increase in what patients can be charged compared to the par fee schedule. There are some significant caveats to consider, including the need for patients to pay on the date of service (please call Rich to discuss), and patients will need to be notified ASAP.

December 2009

HOLIDAY SCHEDULE

CPB will be closed at 1:00 on Christmas Eve, Christmas Day and New Years Day. We hope you enjoy the holidays! We will also close at noon on Wednesday, December 2nd for our Annual Employee Appreciation Day.

AUDITS – PRE-PAYMENT, CERT OR RAC

If you receive an audit request, whether prepayment, CERT, or RAC, we suggest that you notify CPB immediately before responding and let us look at the documentation to ensure it is complete. It is far better to make sure it is right the first time than to have the money taken back (or not paid) then file an appeal. Plus, a timely response is required or the claim is also denied for lack of documentation.

2010 PART B DEDUCTIBLE

The Centers for Medicare & Medicaid Services (CMS) announced the Part B annual deductible for 2010 is $155.00 (it was $135 in 2008 & 2009). With the poor economy, it is more important than ever to make every effort to collect all co-pays, deductibles (if known), and co-insurances on the date of service. The key is getting the payment before they receive your services, or at worst, before they leave your office.

Also, just a reminder that cash flow will be slow for the first 2-3 months of the year due to the current economy and patients showing greater reluctance to visit their physicians.

2010 MEDICARE PHYSICAL, OCCUPATIONAL & SPEECH THERAPY CAP

The Therapy Cap for 2009 is $1,860 through December 31, 2010. However, the Medicare Cap Exceptions process for independently practicing physical, speech and occupational therapists does not appear to have been extended beyond December 31, 2009. A copy of the CMS article has been included for our PT/OT clients.

Medicare PROVIDER Participation Status

As you are probably aware the current Medicare Fee Schedule is set to decrease by 21% unless Congress acts to change it. One option that providers have is to change from participating to non-participating status. If you wish to consider becoming non-par due to the potential fee decrease and, for physician, the elimination of consults, it can be done until 1/31/10. Call me if you want to discuss financial ramifications. Non-par status offers about a 9-10% increase in what patients can be charged compared to the par fee schedule. There are some caveats to consider and patients will need to be notified ASAP.

NEW PROVIDER ENROLLMENT REQUIREMENTS FROM CMS – DATE CHANGE

Effective October 1, 2009 CMS is expanding the claim editing requirements in claims for ordering/ referring physicians for DMEPOS products and services. The claim editing is being added to verify that the ordering/referring provider on a claim is eligible to order/refer and is enrolled in Medicare by comparing enrollment in Medicare's PECOS software. This affects both physician and nonphysician practitioners. Until April 5, 2010 this will only be a warning but after that date if the ordering/referring provider is not on the national PECOS file, claims will not be paid.

A partial list of providers who can order/refer are:
Doctor of Medicine or Osteopathy;
Podiatric Medicine;
Chiropractic Medicine;
Physician Assistant;
Certified Clinical Nurse Specialist;
Nurse Practitioner;
Clinical Psychologist; and
Clinical Social Worker.

We strongly advise that you verify you are current on the PECOS database as soon as possible since we fully expect long delays getting approved after January 1. To verify with PECOS that you are setup, you can call 866-484-8049. If you filed a new enrollment application and were approved within the last two years or so, you should be fine. If not, and you are the ordering or referring physician for any DMEPOS provider (including your own claims), after January 4 that provider will not be paid.

To login to PECOS, use your NPI user name and password. Go to:
https://pecos.cms.hhs.gov/pecos/login.do on the CMS website.

Providers can read the educational material about Internet-based PECOS that is available at
http://www.cms.hhs.gov/MedicareProviderSupEnroll/04_InternetbasedPECOS.asp#TopOfPage
Once at that site, scroll to the “Downloads” section of that page and click on the materials that apply to you and your practice.

RED FLAG RULES DELAYEd AGAIN!

As announced by the FTC on November 2, 2009:

“At the request of Members of Congress, the Federal Trade Commission is delaying enforcement of the “Red Flags” Rule until June 1, 2010, for financial institutions and creditors subject to enforcement by the FTC.”

Also in the same announcement:“On October 30, 2009, the U.S. District Court for the District of Columbia ruled that the FTC may not apply the Red Flags Rule to attorneys.”

November 2009

THANKSGIVING HOLIDAY + ANNUAL CPB EMPLOYEE APPRECIATION DAY

CPB will be closed Thanksgiving Day and the Friday after Thanksgiving to provide our staff a long weekend. We hope you enjoy the holiday also!

We will also close at noon on Wednesday, December 2nd for our annual Employee Appreciation Day.

Medicare AUDITS

CPB has seen the first of pre-payment audits that are being conducted by Highmark Medicare. The provider billed a 99254 - but when the Consult report was reviewed Highmark downcoded it to 99253. Upcoding of E&M codes is a major focus of all CERT & RAC audits so it is important to be accurate. As of October 29th, we have also now seen several post-payment audit requests.

PIP DaILY MAXIMUM INCREASED
The new daily max for PIP claims was increased from $90 to $99 effective for treatment on or after 8/10/09.

NEW PROVIDER ENROLLMENT REQUIREMENTS FROM CMS

Effective October 1, 2009 CMS is expanding the claim editing requirements in claims for ordering/ referring physicians for DMEPOS products and services. The claim editing is being added to verify that the ordering/referring provider on a claim is eligible to order/refer and is enrolled in Medicare by comparing enrollment in Medicare's PECOS software. This affects both physician and nonphysician practitioners. Until December 31 this will only be a warning but effective January 4, 2010 if the ordering/referring provider is not on the national PECOS file, claims will not be paid.

A partial list of providers who can order/refer are:
Doctor of Medicine or Osteopathy;
Podiatric Medicine;
Chiropractic Medicine;
Physician Assistant;
Certified Clinical Nurse Specialist;
Nurse Practitioner;
Clinical Psychologist; and
Clinical Social Worker.

We strongly advise that you verify you are current on the PECOS database as soon as possible since we fully expect long delays getting approved after January 1. To verify with PECOS that you are setup, you can call 866-484-8049. If you filed a new enrollment application and were approved within the last two years or so, you should be fine. If not, and you are the ordering or referring physician for any DMEPOS provider (including your own claims), after January 4 that provider will not be paid.

To login to PECOS, use your NPI user name and password. Go to:
https://pecos.cms.hhs.gov/pecos/login.do on the CMS website.

Providers can read the educational material about Internet-based PECOS that is available at
http://www.cms.hhs.gov/MedicareProviderSupEnroll/04_InternetbasedPECOS.asp#TopOfPage
Once at that site, scroll to the “Downloads” section of that page and click on the materials that apply to you and your practice.

SAY “GOODBYE” to CONSULT CODES
Starting January 1, 2010 Medicare is considering no longer recognizing CPT consulting codes. If that occurs, you will need to bill the appropriate E/M service code, either outpatient or inpatient, new or established. We will let you know if/when that is confirmed.

EMR – “MEANINGFUL USE”

The Health Information Technology Committee has made its initial recommendations to define “meaningful use.” If you would like to view their matrix, let Rich know – the URL is VERY long and it will be easier for you if it is emailed. Then you can click the link rather than manually enter it or follow a rather convoluted trail to get there.

RED FLAG RULES

The FTC announced on July 29th that the Red Flag Rules will be delayed again with a new date of November 1, 2009. CPB expects this to be the final delay, or not! Once the FTC releases their guidance, CPB will create a sample policy & procedure available to all clients which can be modified to suit each provider.

HITECH also requires changes to HIPAA Privacy & Security. We expect to create a sample policy & procedure which will be made available for clients. If you are interested in either or both, please give Rich a call.

October 2009

Patient’S WITH INJURIES

Please be pro-active - we are starting to see more delayed claims due to diagnoses that indicate the patient was injured. Diagnoses such as laceration, fracture, etc. often cause insurers to delay payment until the patient is sent a Coordination of Benefits (COB) letter and returns it – which often is not done very timely. To avoid this, please ask patients to tell you where & how the injury occurred, and the date. Then we need to know if it was MVA, Workman’s Comp or other so we can indicate that on the claim also to minimize payment delay. The “regular” insurers do not owe payment as primary for WC and only rarely for MVA, so will always “pend” those claims until the patient responds directly to them.

Medicare’S RECOVERY AUDIT CONTRACTORS (RAC’s)

CPB will begin to include information about the Recovery Audit Contractors (RACs) in the monthly bulletins as relevant information is found. RACs were created by Congress to audit all Medicare payments retroactively and to recover what has been deemed to have been paid incorrectly. In the initial RAC test program, billions of dollars were recovered so this program MUST be taken seriously.

However, the RAC auditors (there are 4 of them for the USA) are required to propose what issues each will audit and receive approval from CMS in advance. The Region A RAC has received approval for 3 DME audits so the process has begun. We expect to see other issues approved within the next few months that will target other providers.

One of the more common reasons that money is refunded is for failure of the provider to respond to the RAC’s request for documentation! In those cases, the auditor has the authority to take back all money paid for the services it requested documentation for. And, you can expect that will draw more attention to that provider’s practice to audit other services.

As always, payment is based on the written documentation in the patient’s medical record so that document is key. Before replying to a records request,
· Review what is being requested
· Review the chart documentation to be sure it addresses ALL of the request. If documentation from other visits, reports, etc. is needed to completely show why a service was provided, be sure to include it when responding. If necessary, include a cover letter explaining why each service was performed.

Be sure to respond before the deadline. The sooner the better.

RED FLAG RULES & HITECH

The FTC announced on July 29th that the Red Flag Rules will be delayed again with a new date of November 1, 2009. CPB expects this to be the final delay, or not! Once the FTC releases their guidance, CPB will create a sample policy & procedure available to all clients which can be modified to suit each provider.

HITECH also requires changes to HIPAA Privacy & Security. We expect to create a sample policy & procedure by mid-November for that also which will be available for clients.

If you are interested in either or both, please give Rich a call.

NEW clients

CPB is always looking for new clients and appreciates referrals from our existing clients.

If you know a colleague who is experiencing slow cash flow, poor insurance collections, or any of the many non-payment issues – please refer them to CPB. In today’s economy, providers cannot afford to “leave money on the floor” or only collect the easy money.

Insurers pay lots of people to find reasons not to pay providers. With our cutting edge, comprehensive, strategic financial systems to collect not just the easy money but also the difficult reimbursement that takes human effort. CPB results are tough to beat!

MORE EHR

Several physician clients have expressed an interest in starting to look at EHR programs. We now have the names of 5 promising programs. If you are interested in becoming part of the demos, let me know.

September 2009

Labor Day Holiday

CPB will be closed on Monday, September 7th to celebrate the holiday. We hope you and your staff enjoy it as well.

NEW clients

CPB is always looking for new clients and appreciates referrals from our existing clients.

If you know a colleague who is experiencing slow cash flow, poor insurance collections, or any of the many non-payment issues – please refer them to CPB. In today’s economy, providers cannot afford to “leave money on the floor” or collecting only the easy money.

Insurers pay lots of people to find reasons not to pay providers. With our cutting edge, comprehensive, strategic financial systems to collect both the easy and hard reimbursement, CPB results are tough to beat!

RED FLAG RULES & HITECH

The FTC announced on July 29th that the Red Flag Rules will be delayed again with a new date of November 1, 2009. CPB expects this to be the final delay, or not! Once the FTC releases their guidance, CPB will create a sample policy & procedure available to all clients which can be modified to suit each provider.

HITECH also requires changes to HIPAA Privacy & Security. We expect to create a sample policy & procedure by mid-September for that also which will be available for clients.

If you are interested in either or both, please give Rich a call.

MORE EHR

Several physician clients have expressed an interest in starting to look at EHR programs. We now have the names of 5 promising programs. If you are interested in becoming part of the demos, let me know.

August 2009

Labor Day Holiday

CPB will be closed on Monday, September 7th to celebrate the holiday.


RED FLAG RULES DELAYED AGAIN

The FTC announced on July 29th that the Red Flag Rules will be delayed again with a new date of November 1, 2009. Per the FTC announcement, their staff will “redouble its efforts to educate them (small businesses) about compliance with the "Red Flags" Rule and ease compliance by providing additional resources and guidance to clarify whether businesses are covered by the Rule and what they must do to comply."


COLLECTING DEDUCTIBLES, COPAYS & COINSURANCES

A report that was released on June 23 by the Dept. of Health and Human Services found the annual cost of co-pays and deductibles for those with employer health care plans increased 21% from $1,260 in 2001 to $1,522 in 2006. Management consulting firm McKinsey & Co. in 2007 issued a report that said doctors collect only about half of the balance due from patients which translates to $14 billion to $30 billion in bad debt annually.

Providers traditionally receive most of their income from insurers, but in the past few years there has a real shift for patients to higher deductibles and copays. This makes collecting patient balances at the time of care more important as even insured patients are increasingly on the hook for an ever-larger share of costs. Clearly, successful practices need to find ways to collect more at the time of service.

Not collecting on the days of service is not good because the odds of providers getting full payment go down the moment the patient leaves the office. For big ticket items – either high cost services or high frequency services – collections issues can be avoided by verification of benefits prior to the visit and requiring payment before services are provided.

The key is to train patients to pay this money and staff to ask for it prior to seeing the patient. Some practices even remind patients of the amount of payment owed during the appointment reminder phone call. A good strategy is to educate patients that these are legitimate charges which are not only not covered by their insurance, but health plans and state and federal insurance laws require that copays, deductible, and co-insurance be collected as a disincentive to over-utilizing healthcare services.

HITECH & Electronic Health Records (EHR) Payments

Medicare will pay up to $44,000 per physician for the “meaningful use” of Electronic Health Records. Medicaid will pay up to $65,000 per eligible provider. The ARRA references the Medicare definition of physician found in Section 1861(r) of the Social Security Act. This includes MD, DO, Dentist, podiatrist, optometry and chiropractor.

NPs & CNMs are eligible for Medicaid incentives but not Medicare incentives. PAs are only eligible to the extent they work in Rural Health Clinics “led” by the PA. In order to receive the Medicaid incentive payment, the 30% of patient visits must be with Medicaid patients. Thus, even though the Medicaid incentives are higher, most physicians will not be able to meet the 30% threshold. Pediatricians can receive a lower Medicaid incentive payment by achieving a 20% Medicaid Threshold.

The incentive program specifically excludes “hospital based” physicians such as emergency medicine, pathology and anesthesiology. The secretary is authorized to define other physician specialists as hospital-based. The rationale behind this exclusion is that these physicians will use a system bought by the hospital and not incur any direct or indirect costs associated with the purchase or use of the EHR.

These incentives are available for each "provider" in a group practice. For example two physicians and three PAs, would be eligible for up to $65k EACH under the Medicaid plan. As written, the incentive payment is available for each “eligible professional”. Therefore the amount of the incentive is calculated on a per provider basis rather than per organization.

One final note, providers who qualify for both can collect from either Medicare or Medicaid, but not both.

MORE EHR

Several physician clients have expressed an interest in starting to look at EHR programs. We have the names of 4 promising programs, one of which has some interesting features. If you are interested in becoming part of the demos, let me know.

Observation Codes

Recently hospitals have begun to push the use of admitting patients to Observation Status, particularly for Medicare patients. This has resulted in confusion with how the billing is to be done in accordance with CMS policy. According to Highmark “

“When a physician decides to place a patient in “hospital observation” status, that patient has not formally been admitted to the hospital. The physician who placed the patient in "hospital observation," is the only one who may care for the patient during his/her stay in observation, and the only one that may bill hospital observation codes.

In order to bill the initial observation care codes, 99218-99220, the following must be created and maintained:
· A medical observation record for the patient which contains dated and timed physician’s admitting orders regarding the care the patient is to receive while in observation;
· Nursing notes; and
· Progress notes prepared by the physician while the patient was in observation status.

If applicable, this record is in addition to any record prepared as a result of an emergency department or outpatient clinic encounter.

When payment is made for an initial observation care code, it is for all the care rendered by the physician on the date patient was placed in observation. All other physicians who see the patient in observation must bill the outpatient/office visit codes (99201-99205, 99211-99215), or outpatient consultation codes (99241-99245), for the services they provide to that patient.

For example, if an internist admits a patient to observation and asks an allergist for a consultation on patient's condition, only the internist may bill the initial observation care code. The allergist must bill using the outpatient consultation code that best represents the services provided. The allergist cannot bill inpatient consultation because the patient was not admitted as a hospital patient.”

For additional information, see the CMS Intranet Only Manual PUB 100-4, Chapter 12, Section 30.6.8 - Payment for Hospital Observation Codes (Codes 99217-9220).

Use of 99211 when doing INR’s

Highmark Medicare Services Position on the Necessity of E/M Services Submitted as a Component Service of Anti-Coagulation Management.

July 27, 2009

Highmark Medicare Services continues to experience both questions and confusion regarding the billing of 99211, (office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician), in addition to the laboratory blood draws for warfarin management.

An evaluation and management (E/M) service (99211) would be allowable if it is determined that the patient's medication needs adjustment, the INR is not therapeutic, or if the patient has symptoms that need to be addressed.

The billing of an E/M service in addition to obtaining the clinical specimen (phlebotomy or fingerstick) is not medically reasonable and necessary if the following conditions are met:

If the INR is within the therapeutic range, and

1. the documentation does not support a need for adjustment of warfarin dosage, or
2. the documentation does not support that the patient is symptomatic, or
3. the documentation does not support the presence of a new medical co-morbidity or dietary change.
Rather, information may be relayed to the beneficiary telephonically, and there is no need for a face-to-face E/M service.

In this clinical setting, the medical necessity of a unique clinical service may be predicated upon the clinical circumstances of a previous visit, i.e., a significantly sub or supra-therapeutic INR necessitates quick follow-up. Use of a flow sheet and established protocol helps to provide both good patient care and documentation of medical necessity in these cases. Documentation of the services provided by the physician or nurse, discussion of symptoms, side effects, patient observations, etc. are considered supportive of the 99211 service.

The American Heart Association/American College of Cardiology Foundation Guide to Warfarin Therapy suggests that the INR be checked daily until the therapeutic range has been reached and sustained for two consecutive days, then 2 or 3 times weekly for 1 to 2 weeks, and then less often based on stability of results. Once the INR becomes stable, the frequency of testing can be reduced to intervals as long as 4 weeks. Highmark Medicare Services expects to see the educational component of anticoagulation management reflected in the use of 99211 in the early post-initiation visits, and less frequently as the stable target of anti-coagulation is reached. Two cited European studies make a strong case for Patient Self-Testing and Management, in which case, the patient education would be documented within the appropriate level of an established E/M service, where time/counseling service guidelines would apply.

Physician Signature Requirements for Diagnostic Testing

July 31, 2009

Medicare has identified a recent increase in the number of CERT errors attributed to the lack of physician orders for diagnostic tests. A diagnostic test includes all diagnostic x-ray tests, all diagnostic laboratory tests, and other diagnostic tests furnished to a beneficiary.

An “order” is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physician/practitioner (e.g., if test X is negative, then perform test Y). An order may be delivered via the following forms of communication:

· A written document signed by the treating physician/practitioner, which is hand-delivered, mailed, or faxed to the testing facility;
· A telephone call by the treating physician/practitioner or his/her office to the testing facility; and
· An electronic mail by the treating physician/practitioner or his/her office to the testing facility.

If the order is communicated via telephone, both the treating physician/practitioner or his/her office, and the testing facility must document the telephone call in their respective copies of the beneficiary’s medical records.

NOTE: While a physician order is not required to be signed on orders for clinical diagnostic tests paid on the basis of the clinical laboratory fee schedule, the physician fee schedule, or for physician pathology services; the physician must clearly document, in the medical record, his or her intent that the test be performed. Failure to do so may result in denial of the service which may subsequently lead to the patient being responsible for payment. Furthermore, the absence of a signature on an order may lead to a medical record audit of the ordering physician to verify that the physician's intent is indeed documented as directed in the regulation. Therefore, HMS recommends that physicians provide their signature on all orders for diagnostic and laboratory services.

Make sure that your office, billing, and/or laboratory staffs are aware of this updated guidance regarding the signature requirement for diagnostic tests and are complying with this regulation. Also, note that in keeping with standard auditing principles, items such as signatures, attestations, and other addendums which are added to the medical record after the date of the Additional Documentation Request (ADR) letter will generally not be considered as acceptable documentation. Furthermore, providers who exhibit a pattern of adding documentation after ADR requests could be subject to corrective action.

If you receive a request for medical records from the CERT contractor or Highmark Medicare Services, it is critical that the signed physician order for all diagnostic tests be included. Without the order, the services could be determined to be medically unnecessary and the claim will be denied.

You can find additional information on the CMS Internet Only Manual: PUB 100-2, Chapter 15, Section 80.6.1.

Physician Signature Requirements for Diagnostic Testing

July 31, 2009

Medicare has identified a recent increase in the number of CERT errors attributed to the lack of physician orders for diagnostic tests. A diagnostic test includes all diagnostic x-ray tests, all diagnostic laboratory tests, and other diagnostic tests furnished to a beneficiary.

An “order” is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physician/practitioner (e.g., if test X is negative, then perform test Y). An order may be delivered via the following forms of communication:

· A written document signed by the treating physician/practitioner, which is hand-delivered, mailed, or faxed to the testing facility;
· A telephone call by the treating physician/practitioner or his/her office to the testing facility; and
· An electronic mail by the treating physician/practitioner or his/her office to the testing facility.

If the order is communicated via telephone, both the treating physician/practitioner or his/her office, and the testing facility must document the telephone call in their respective copies of the beneficiary’s medical records.

NOTE: While a physician order is not required to be signed on orders for clinical diagnostic tests paid on the basis of the clinical laboratory fee schedule, the physician fee schedule, or for physician pathology services; the physician must clearly document, in the medical record, his or her intent that the test be performed. Failure to do so may result in denial of the service which may subsequently lead to the patient being responsible for payment. Furthermore, the absence of a signature on an order may lead to a medical record audit of the ordering physician to verify that the physician's intent is indeed documented as directed in the regulation. Therefore, HMS recommends that physicians provide their signature on all orders for diagnostic and laboratory services.

Make sure that your office, billing, and/or laboratory staffs are aware of this updated guidance regarding the signature requirement for diagnostic tests and are complying with this regulation. Also, note that in keeping with standard auditing principles, items such as signatures, attestations, and other addendums which are added to the medical record after the date of the Additional Documentation Request (ADR) letter will generally not be considered as acceptable documentation. Furthermore, providers who exhibit a pattern of adding documentation after ADR requests could be subject to corrective action.

If you receive a request for medical records from the CERT contractor or Highmark Medicare Services, it is critical that the signed physician order for all diagnostic tests be included. Without the order, the services could be determined to be medically unnecessary and the claim will be denied. You can find additional information on the CMS Internet Only Manual: PUB 100-2, Chapter 15, Section 80.6.1.

July 2009

July 4th Holiday

Since July 4th falls on a Saturday, CPB will be closed on Friday, July 3rd to celebrate the holiday.


CIGNA

After hours care. CIGNA will allow separate reimbursement for after-hours CPT codes 99050 and 99058. CPT descriptions:
· 99050 is "services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (e.g., holidays, Saturday or Sunday), in addition to the basic service.”
· 99058 “services provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to the basic service.”

Effective April 20, 2009, CIGNA will begin requiring documentation for certain CPT code combinations when modifier 25 is used and on April 27th the same will begin for modifier 59.


Cost of Injections and Other Supplies

Before deciding to purchase and administer various medications and supplies, it is critical that you verify what Medicare & other insurers will pay for the products you wish to use, then negotiate with the suppliers what you are willing to pay. CPB can assist with insurance allowances. Be sure to factor in the cost of your usual bad debt percent (most of our clients are around 1% or less). This way you will know if it is financially worthwhile and can weight other factors.

The typical concern we hear is that the cost product exceeds the payment - which is usually learned after the product was already purchased. Knowing the reimbursement in advance allows you to negotiate from a position of strength with the sales person.


HITECH & Electronic Health Records (EHR) Payments

Medicare will pay up to $44,000 per physician for the “meaningful use” of Electronic Health Records. Medicaid will pay up to $65,000 per eligible provider. The ARRA references the Medicare definition of physician found in Section 1861(r) of the Social Security Act. This includes MD, DO, Dentist, podiatrist, optometry and chiropractor.

NPs & CNMs are eligible for Medicaid incentives but not Medicare incentives. PAs are only eligible to the extent they work in Rural Health Clinics “led” by the PA. In order to receive the Medicaid incentive payment, the 30% of patient visits must be with Medicaid patients. Thus, even though the Medicaid incentives are higher, most physicians will not be able to meet the 30% threshold. Pediatricians can receive a lower Medicaid incentive payment by achieving a 20% Medicaid Threshold.

The incentive program specifically excludes “hospital based” physicians such as emergency medicine, pathology and anesthesiology. The secretary is authorized to define other physician specialists as hospital-based. The rationale behind this exclusion is that these physicians will use a system bought by the hospital and not incur any direct or indirect costs associated with the purchase or use of the EHR.

These incentives are available for each "provider" in a group practice. For example two physicians and three PAs, would be eligible for up to $65k EACH under the Medicaid plan. As written, the incentive payment is available for each “eligible professional”. Therefore the amount of the incentive is calculated on a per provider basis rather than per organization.

One final note, providers who qualify for both can collect from either Medicare or Medicaid, but not both.

MORE EHR

Several physician clients have expressed an interest in starting to look at EHR programs. We have the names of 2 promising programs, one of which has some interesting features. If you are interested in becoming part of the demos, let me know.

June 2009

July 4th Holiday

Since July 4th falls on a Saturday, CPB will be closed on Friday, July 3rd to celebrate the holiday.


Days IN ACCOUNTS RECEIVABLE (DAR)

Days in Accounts Receivable (DAR) is a standard measure of how fast money that is owed to you is collected. It is usually calculated over the previous 3 months by dividing your actual accounts receivable (AR) (minus bad debt and other long term receivables, such as litigation) by the average daily charges. The lower the number the better – the lower the # means it took less days to collect your money.

Recently our professional association, Healthcare Billing and Management Association (HBMA), performed its first annual DAR survey and we participated. I am extremely pleased to report that in our specialties CPB was as much as 50% lower than both the national average and median DAR! To help you compare your numbers, on the back of your Monthly Letter under the DAR Graph, we have included the statistics for your specialty so you can compare to the graph.

This is objective confirmation of the high quality work that CPB performs for you!


Red Flag Rules Delayed Again

On April 30th the FTC again delayed the implementation of the Red Flag Rules from May 1 to August 1, 2009. The FTC indicated that it is allowing this extra time for Congress to act to either exclude medical practices or not. My guess is that politically they will not do so due to pressure from identity theft groups who would say it increases consumer risk.


ABN’s

Whenever you have a patient sign an ABN, we strongly recommend that you collect your fee that day. If the patient balks at paying that day, our experience is that they will not pay later either. You are using the ABN because you are fairly certain that Medicare (or other payors) will not be paying. Let the patient know you will submit the charges to their insurance and refund the payment if insurance pays.


HITECH & Electronic Health Records (EHR) Payments

Medicare will pay up to $44,000 per physician for the “meaningful use” of Electronic Health Records. Medicaid will pay up to $65,000 per eligible provider. The ARRA references the Medicare definition of physician found in Section 1861(r) of the Social Security Act. This includes MD, DO, Dentist, podiatrist, optometry and chiropractor.

NPs & CNMs are eligible for Medicaid incentives but not Medicare incentives. PAs are only eligible to the extent they work in Rural Health Clinics “led” by the PA. In order to receive the Medicaid incentive payment, the 30% of patient visits must be with Medicaid patients. Thus, even though the Medicaid incentives are higher, most physicians will not be able to meet the 30% threshold. Pediatricians can receive a lower Medicaid incentive payment by achieving a 20% Medicaid Threshold.

The incentive program specifically excludes “hospital based” physicians such as emergency medicine, pathology and anesthesiology. The secretary is authorized to define other physician specialists as hospital-based. The rationale behind this exclusion is that these physicians will use a system bought by the hospital and not incur any direct or indirect costs associated with the purchase or use of the EHR.

These incentives are available for each "provider" in a group practice. For example two physicians and three PAs, would be eligible for up to $65k EACH under the Medicaid plan. As written, the incentive payment is available for each “eligible professional”. Therefore the amount of the incentive is calculated on a per provider basis rather than per organization.

One final note, providers who qualify for both can collect from either Medicare or Medicaid, but not both.

PQRI

Clients doing the PQRI program, be SURE to follow the guides and use the correct codes and modifiers. The PQRI codes are required for patients whether Medicare is primary, secondary, or tertiary. Failure to do so will result in not being counted toward the required 80% of claims which could result in zero payment.

For those who have not started, a new reporting period begins July 1 – December 31, 2009 for Measures Groups (30 consecutive patients). Medicare will pay 2% for all charges for all patients for claims with those dates of service.

If you are interested, contact Rich before June 10th so there is time to modify your charge forms.

May 2009

Medicare Deductibles

Amazingly this year, we are STILL seeing patients meeting their Medicare deductibles as recent as today, May 1, 2009. This is by far the latest in the calendar year we have seen in our 19 years of business.


HOSPITAL OBSERVATION STATUS

Recently some physician clients have been experiencing occasional issues with differentiating hospital observation vs. inpatient status. Because the patient can be on a floor in what appears to be an inpatient bed, it can be confusing. In speaking with the VP of Medical Affairs of one hospital, he said it solely depends on the admission orders – they will either say “admit to hospital” or “admit to observation.” The CPT codes are different for each. If in doubt, and to avoid a delay in your payments, we suggest verifying the status before sending us your billing information.

If you need any assistance, please feel free to call.


Common Myth

Every once in a while a patient will write a check for part of their balance and write “Paid in Full” on it. This has no force or effect legally – imagine if you wrote it on your next mortgage check! If it was true, we would have all done it. In those cases, you can safely cash the check and the patient can be billed for any remaining balance.

Not A Myth

When calling a patient about medical issues, it is a violation of HIPAA Privacy to discuss issues with a spouse or parent of a child who has reached majority age (18) without written permission to do so. That does not prevent you from reminding patients about appointments by calling and/or leaving a message, unless the patient has specifically asked you not to.


HITECH ACT

The new federal HITECH Act provides financial incentives to physicians, hospitals and certain other providers through either the Medicare or Medicaid programs for the "meaningful use" of Electronic Health Records.

A word of caution, the financial incentives can be offset thru seeing less patients if the system is not efficient. If you decide to test an EHR system, be sure you have a no risk, trial period during which you can return it for no further obligation if you do not like it. If you find a system you like, CPB will arrange to have it interfaced with our system.

A quick look at the Medicare physician financial incentives to use EHR:

Now if they could just make it quick and easy to use!

April 2009

Medicare Deductibles

Amazingly this year, we are STILL seeing patients meeting their Medicare deductibles as recent as today, April 1, 2009 (not an April Fool’s joke!). This is by far the latest in the calendar year we have seen in our 19 years of business.


OIG WOrk Plan 2009

Each year the OIG publishes its Work Plan for the coming year & CPB reproduces the relevant targets for our clients. The mission of the Office of Inspector General (OIG) is to protect the program integrity of the Department of Health and Human Services (HHS). In fulfilling that mission, the OIG must:
· Conduct and supervise audits and investigations;
· Prevent and detect fraud and abuse;
· Promote economy, efficiency and effectiveness; and
· Inform HHS and Congress about deficiencies and problems.

That mission leads the OIG to conduct a comprehensive review each year to identify potential problem areas and vulnerabilities in the HHS programs. Those areas deemed most worthy of follow up are then included in their annual Work Plan and used to focus OIG activities. You may find the full report at:
www.oig.hhs.gov/publications/docs/workplan/2009/WorkPlanFY2009.pdf

Relevant 2009 OIG Items:
Evaluation and management services during global periods: The OIG will review the number of E&M services provided since global periods were established in 1992 to insure that E&M services were not billed separately.

Outpatient physical therapy services provided by independent therapists: Focusing on services provided by independent therapists with high utilization (including improper use of Therapy Caps), the OIG will ensure that federal guidelines are followed.

Patterns related to high utilization of ultrasound services: In high areas of ultrasound utilization, the OIG will investigate medical necessity.

March 2009

OFFICE FINANCIAL POLICIES

As everyone knows, there are two parts to getting ahead with money – making it and saving it! This article will discuss some ways to consider how to watch the money you do collect.
· For office payments – patient co-pays, deductibles, and coinsurance – require that 2 people be involved in reconciling at the end of the day. The collector (front desk usually) of the $ should NEVER be the depositor. There should be a form that the front desk completes each day showing who paid, how much was paid, and in what form (cash, check, credit card, 2 chickens, etc.). These total office payments should match the amount reported on each Charge form and be attached to the daily charges when sent to CPB. The bank deposit ticket should match that form, minus any deductions, which the provider approves. CPB is part of an independent check and balance on your behalf in this case – total office payments should match your deposit form which matches what CPB enters and reconciles.
· When insurance & patient statement payments arrive, who opens and deposits them? If it isn’t you, it should be opened by 1 person and deposited by another. Standard accounting practice.
· Be sure to reconcile the total payments you receive (and record!) in the office each month with the “38” payment codes reported back to you in CPB’s Month-end Reports. They should match!
· Your money handling procedure should be a written document that you require everyone to follow EXACTLY as it is written. Be sure to ask when things do not seem right – trust your “gut!”
· Watch for embezzlement:
- Do any employees appear to be living beyond their means? Could be an indicator of something suspicious, or not.
- Does a key money handler not take vacation time claiming that s/he is too important to be gone? Could be s/he is worried about getting caught, or not.
- Are any employees being contacted by bill collectors? Desperate people will take drastic measures.
- When hiring new staff, consider doing credit checks in addition to reference checks. Statistically, a lower credit rating could be an indication of added risk for the provider.
- Physician offices are great places to find drugs for addicts. Does an employee always arrive early or late (alone time in the office), or is chronically tardy or absent without explanation? Addicts will take desperate chances to satisfy their cravings.


Referrals, Authorizations, and “Billable Lists”

Not having valid referral or authorization, or performing services not on a provider’s “Billable List” leads to denied payment with no other recourse. These items are part of the requirements that providers contractually agree to in their Participation Agreements. There is no appeal for treating a patient for services not on a Billable List, or without referrals or authorizations. When in doubt, send them elsewhere or realize that you are likely providing a free service. CPB makes the following recommendations:

Referrals & Authorizations
Our strong suggestion is that if a pt presents without a required referral or authorization that they be given 2 options (absent a medical contraindication otherwise):
1. Go get the referral and/or authorization and return with it before being seen. If necessary, offer to schedule a new appt. Seeing them and hoping they will return with the referral has a high failure rate.
2. Pay cash/credit card for the service before being seen & only after signing a document indicating they understand their options and are electing to pay cash for the service. This gives them an incentive to get the referral to get repaid for their payment. And if they do not, you have payment for your services.

Billable List

Patients who need a service not on a provider’s Billable List should be given the follow options:
1. Be referred to another provider,
2. Sign a document indicating their understanding that they are paying cash, in advance, for the service they are requesting.

Another important point – just because the insurer gives a Precert/Authorization # does not mean they will pay the claim. Should it mean they will? Absolutely! But they often look for other reasons not to pay – not on the Billable List, patient’s coverage expired, etc

Usually HMOs place responsibility on the provider for seeing the pt without required approvals (a Billable List is an approval – approval to provide that service and get paid for it) and without a signed document showing the patient chose to be seen/treated without the required referral. If the insurer denies payment - the EOB shows no pt responsibility and if you have no signed “ABN” type document - you may need to return any copay collected. The document needs to be very similar to an ABN & indicate:

1. Description of the service requested
2. Why the provider expects a denial (no referral or authorization, not on Billable List, too frequent, etc. )
3. The cost of being seen without the referral. Better to estimate high than low & collect the money before treating!

Then if the patient disputes anything, we are in a STRONG position to argue that the patient knew in advance the consequences of not having a valid referral by showing a copying of the signed agreement. HMO’s, PPO’s, etc. cannot deny a patient’s right to see a provider, or for you to get paid, as long as the patient has been properly informed.

Yes, we recommend collecting the payment before providing the service. If the patient won’t pay on the day of service, we can pretty much guarantee they will not pay later. But at least you will not have wasted time treating that patient and can see another patient who is covered.




LATE BREAKING NEWS
Economic Stimulus Bill – Electronic Health Records (EHR’s)

The Economic Stimulus Bill is providing incentives for providers (only physicians) to begin using “certified” Electronic Health Records. These incentive payments are available for 5 years with $18,000 available for the first year with decreasing amounts each subsequent year. In total, if a physician qualifies for the maximum each year, the total value of the incentive payments will be $44,000. About 70% of the money is front-loaded into the first 2 years.

This is PER PHYSICIAN. So in a two physician practice, the amount available could be over $88,000. In a large multi-specialty group practice, the amounts would be even higher. The statutory language says the provider is eligible for an "amount equal to 75 percent of the Secretary's estimate of the allowed charges." Neither the legislative text nor the conference report accompanying the legislation clarifies what this means. Consequently, we expect that the regulations and guidance that will naturally flow from this legislation will clarify what this means.

There will be no incentive payments for physicians who begin using a certified EHR after 2014. Furthermore, physicians who fail to adopt and use EHR by 2015 will see their Medicare payments reduced.

For physicians who have high Medicaid patient volumes (i.e. 30% or higher for most specialties), the Medicaid incentives are $64,000 over 5 years. Physicians won't be able to double dip but must decide to either get the Medicare incentives OR the Medicaid incentives.

The incentives are NOT available to "provider-based" physicians - initially defined as ER, Pathology, and Anesthesiology. However, the Secretary of HHS has the discretion to add other so-called "provider-based" physicians.

The bonus is for "meaningful use" which is defined in the legislation as:

-Using certified EHR technology that includes electronic prescribing; and
-Using EHR technology that allows electronic exchange of health information.
-Eligible professionals must submit information for the period on the clinical quality measures (PQRI) and other measures selected by the Secretary of the Department of Health and Human Services (HHS).

When the provider actually purchased the EHR is not relevant to the receipt of the bonus payment. Providers already using one are ahead of the curve. HOWEVER, the system the physician uses must be CERTIFIED, which is not yet defined.

Although certification standards for EHR are in existence, new standards will be published and in place prior to the commencement of the bonus payments. While many of the current standards will likely remain in place, the new standards will address interoperability of the EHR system. YOU MUST ensure that whatever system you use, the system meets the certification requirements that are in place in 2011, not the standards in place now. I hope this was helpful!

February 2009

ePRESCRIBING (eRx)

Just a reminder that providers that can qualify for the 2% Medicare bonus must send 1 of 3 special codes to Medicare when billing each office visit or consult code. They cannot be sent at a later time. There are other requirements that make it important for you to begin sending these codes ASAP. We can add these codes to your Charge form – just let us know - and we will automatically handle the rest for you when we enter the patient charges. If you want to know what your bonus might be based on 2008 Medicare payments/Allowed Amounts, contact Rich. If you know your total Medicare payments, divide by .80 and you will be fairly close to the full Allowed Amount.

PQRI is also still an option for another 2% bonus but will need to start quickly in order to meet the 80% threshold of annual claims. Charge form changes are necessary and the program is a bit more complicated than eRx – contact Rich if interested.


HIGHMARK Medicare Audits – COMPLIANCE ISSUES
Attached with this month’s Client Bulletin are 3 audit reports from Highmark which were announced January 28, 2009 that were performed on Washington, D.C. providers. For the codes reviewed, they found the following codes billed incorrectly X% of the time:
· 99244 66% Office Consult
· 99245 89% Office Consult
· 99254 82% Hospital Consult
· 99255 89% Hospital Consult
· 99233 79% Hospital Subsequent Visit

As a result, it is VERY likely that Highmark will be doing the same audits on providers in NJ and the other states they handle. A few suggestions if you receive a request for medical records:
1. Be sure to respond timely. No response means Medicare’s full payment will be recouped for that service.
2. Be sure each document requested is sent, including visit notes, reports, etc.
3. Be sure all documentation is complete, legible (a big issue for handwritten notes) and supports the level of service billed. If it cannot be read, it is considered to not have been done.
4. If necessary, include a Cover letter with each record explaining anything that will help the reviewer understand the service billed. Make it easy for them.

Repeated patterns of incorrect billing fall into the “fraud” category and can lead a provider to be placed on 100% prepayment review – meaning all charges must be sent on paper claims with the supporting documentation attached. Payment delays can be 45 -60 days vs. 14 you have now when we send electronically.
ECONOMY – Collection of CO-PAYS, DEDUCTIBLES & CO-INSURANCES

Every day the newspaper & TV are telling lots of stories of layoffs, decreases in hours, pay-cuts, bankruptcies, etc. as I am sure you have also heard. CPB is expecting to see slower payments by insurers, increased denials (to delay payment) with subsequent appeals, etc. A few ideas to deal with impacts on your practice:
· Implement a patient recall program to remind patients when a service is due. Book the next appointment when talking with the patient.
· Set limits on “virtual” appointments – treating patients over the phone. Recently diagnosed problems may be OK, but for new problems it may be better to see the patient.
· Postpone raises – far better than a layoff.
· Re-evaluate staffing hours and employee benefits
· Hire part-time staff if possible, without benefits
· Delay equipment purchases that cannot be cost or function justified.

With the poor economy, it is more important than ever that you make every effort to collect all co-pays, deductibles (if known), and co-insurances on the date of service. We are beginning to see significant numbers of patients who say they have no job and will not be able to pay their bill. In some cases this may be true, but most are on unemployment and probably would pay if asked before seeing the provider. The key is getting the payment before they receive your services, or at worst, before they leave your office. Our highest collection rate clients have this policy already in place and are very successful in collecting co-pay, deductibles, etc. on the day of services.

Offices that have problems with patients not being prepared to pay their co-pay (especially offices that take credit card payments!) are due to the front desk “training” the patient that this is acceptable behavior. Of course, providers need to support their Front Desk staff when a patient tries to avoid payment. If you want to take care of the chronic "I forgot my payment" syndrome, you need to make it more advantageous for the patient to REMEMBER their payment instead!

When patients are given the option to reschedule their appointment, you'll be surprised at the number of people who "suddenly" remember that emergency $20 bill stuck in a pocket in their wallets, purse, or in their car, remember their credit card number, or will call their spouse to get it!

Payers require you in your contract to collect co-pays as a disincentive to over-utilize services. Patients need to know in advance (a month or 2 is plenty) and be sure it applies to patients from all payers who require co-pays and co-insurances (patients without secondary insurances). This policy should become a permanent part of your practice's financial policy statement. It also helps to have a professionally designed sign on the wall next to the check in desk announcing the policy. Patients also should be reminded when their appointment is made to please bring their co-pay. New and established patients should be provided with a copy of the new financial policy to sign at their first appointment after the policy statement has been revised. CPB has sample Financial Policies upon request.

FTC “Red Flag” Rules Delayed UNTIL May 1, 2009

See the separate information enclosed in your monthly packet.

January 2009

2008 RECAP

The year 2008 was a very good year for CPB clients with collection rates among the highest in the industry (high is good!) and Days in Accounts Receivable among the lowest (low is good – measures the number of days, on average, it takes to collect your reimbursement). However, with the tough economy, 2009 is likely to be a challenging year due to layoffs, bankruptcies, business closings, etc. More on that below.

ANNUAL CHARGE FORM CHANGES

The Charge form is a key part of any insurance audit so ensuring it is current is important. CPB has completed our review of all Charge form (Superbill) codes for office-based clients:
· Deleted, revised and new CPT, ICD-9 and HCPCS codes. Forms were updated accordingly if CPB maintains them or the client was notified with necessary changes for those who maintain their own forms.
· The Medicare Allowed Amounts form was sent to each client.
· Charge vs. insurance maximum allowed. Clients were notified as indicated.
· Highmark Medicare’s new LCD’s were updated on both the Charge form and in CPB’s billing software.

This is a very time-consuming but critical service which we provide to minimize insurers excuses to delay or deny payment and thus maximize client cash flow.


ECONOMY – Collection of CO-PAYS, DEDUCTIBLES & CO-INSURANCES

With the poor economy, it is more important than ever that you make every effort to collect all co-pays, deductibles (if known), and co-insurances on the date of service. We are beginning to see significant numbers of patients who say they have no job and will not be able to pay their bill. In many cases this is likely to be true, but most are on unemployment and probably would pay if asked before seeing the provider. The key is getting the payment before they receive your services, or at worst, before they leave your office. Our highest collection rate clients have this policy already in place

2009 PART B DEDUCTIBLE

The Centers for Medicare & Medicaid Services (CMS) announced the Part B annual deductible for 2009 is $135.00 (the same as it was in 2008).


2009 MEDICARE PHYSICAL, OCCUPATIONAL & SPEECH THERAPY CAP

The Therapy Cap for 2009 is $1,840 through December 31, 2009. The Medicare Cap Exceptions process for independently practicing physical, speech and occupational therapists has also been extended to December 31, 2009.


FTC “Red Flag” Rules Delayed UNTIL May 1, 2009

On October 22, 2008 the Federal Trade Commission (“FTC”) announced that it will “suspend enforcement” of the “Red Flag” rules until May 1, 2009. The “Red Flag” rules require “financial institutions” and “creditors” with “covered accounts” to develop and implement a written program to detect and deal with identity theft. Medical providers who do not collect in full on the day of service are considered “creditors.

CPB will be fully compliant before the deadline and will likely offer an educational program sometime in April for your employees to assist with your compliance.

December 2008

CPB HOLIDAY CLOSURE DATES

Just a reminder that CPB will be closed on Thursday, December 25th, Friday December 26th, & January 1st for the Christmas & New Years holidays. Wednesday, December 24th we will be open from 9:00 AM – 5:00 PM. We hope each of you enjoy your own special holidays.


Medicare CARRIER TRANSITION ON NOVEMBER 14

This seems to have occurred without any significant issues.


ECONOMY – Collection of CO-PAYS, DEDUCTIBLES & CO-INSURANCES

With the poor economy, it is more important than ever that you make every effort to collect all co-pays, deductibles (if known), and co-insurances on the date of service. We are beginning to see significant numbers of patients say they have no job and will not be paying their bill. In many cases this is likely to be true, but many are on unemployment and probably would pay if asked before seeing the provider. The key is getting the payment before they receive your services.

More in the future about “Regulation Z” which adds restrictions when billing a patient more than 4 times in a payment plan.


Medicare Vaccine Fees 2008-2009

Hot off the press from Medicare.
90655 $16.88 Flu vaccine, Ages 6-35 months, IM
90656 $18.20 Flu vaccine, age 3 years and up, IM preservative free
90658 $13.22 Flu vaccine, split virus, IM
90660 $22.32 Flu vaccine, intranasal
90732 $32.70 Pneumonia vaccine, IM
90740 $119.42 Hepatitis B vaccine, dialysis or immunosuppressed dose, IM
90746 $59.71 Hepatitis B vaccine, adult dose, IM

Clients – let us know if you are using anything other than 90658 for the Flu Vaccine? We can update Charge forms quickly.


2009 PART B DEDUCTIBLE

The Centers for Medicare & Medicaid Services (CMS) announced the Part B annual deductible for 2009 is $135.00 (the same as it was in 2008).


2009 MEDICARE PHYSICAL, OCCUPATIONAL & SPEECH THERAPY CAP

The Therapy Cap for 2009 is $1,840 through December 31, 2009. The Medicare Cap Exceptions process for independently practicing physical, speech and occupational therapists has also been extended to December 31, 2009.


ANNUAL CHARGE FORM CHANGES

CPB is in the process of reviewing all client Charge forms for new CPT, ICD-9 and HCPCS codes. Many of you have already been notified of required changes and the rest will be shortly. The Charge form is a key part of any insurance audit so ensuring it is current is important.

If there are any changes you would like to see, please let Rich know by Friday, December 5th.


FTC “Red Flag” Rules Delayed UNTIL May 1, 2009

On October 22, 2008 the Federal Trade Commission (“FTC”) announced that it will “suspend enforcement” of the “Red Flag” rules until May 1, 2009. The “Red Flag” rules require “financial institutions” and “creditors” with “covered accounts” to develop and implement a written program to detect and deal with identity theft.

CPB will continue to follow this and make the necessary operational and software adjustments. I am sure that your professional associations will be notifying you of this also if they haven’t already. If you have any questions, feel free to call me.


Compliance - Americans with Disability Act

According to the law firm Kern Augustine Conroy & Shoppmann, P.C.: “A Hudson County jury returned a verdict of $400,000 against a physician for refusing to provide an English-to-sign language interpreter for his deft patient because it was too costly. Although the interpreter would have cost the physician more than the office visit reimbursement, the fact that the doctor had $425,000 in annual income for the jury to decide that the expense was not an undue hardship. Under the Americans with Disabilities Act, places of "public accommodation" (including physician offices) must provide ancillary aids and services, including interpreters, unless it presents an undue hardship or would fundamentally alter the nature of the service."

November 2008

Medicare CARRIER TRANSITION ON NOVEMBER 14

Most clients have now sent CPB a copy of the Medicare letter indicating their new EFT has been processed. That letter is the only way you know that your EFT has been properly set up so that your Medicare payments will continue after the transition to the new Medicare carrier on November 14. If you have not already done so, please be certain to send us a copy of that letter while it is still something you can find. In the event of any problems, CPB will then be able to advocate for you.

Highmark has announced “three (3) system dark days” for November 15-17 during which time providers will not be able to verify beneficiary eligibility, claim status, etc. Electronic claims will be submitted Monday morning as we usually do but will not be moved by Highmark into their processing system until Monday night, November 17th. It is possible there will be a 1 day payment delay.

FTC “Red Flag” Rules Delayed UNTIL May 1, 2009

On October 22, 2008 the Federal Trade Commission (“FTC”) announced that it will “suspend enforcement” of the “Red Flag” rules until May 1, 2009. The “Red Flag” rules require “financial institutions” and “creditors” with “covered accounts” to develop and implement a written program to detect and deal with identity theft.

The FTC’s decision to delay enforcement appears to have been the result of pressure from, among others, the American Medical Association and a consortium of other healthcare organizations. These organizations complained, quite reasonably, that they and their members had no prior reason to familiarize themselves with FTC rules to which they have historically not been subjected to. The FTC is not presently changing its position on the broad reach of the rule. “Creditors” are defined to include any service provider (such as physicians and other healthcare providers) that does not get paid at the time of service. This makes collection of copayments on the day a patient is seen even more important. A “covered account” includes any relationship which involves information, such as social security numbers, that is vulnerable to identity theft.

The Red Flag rules are important to healthcare providers & billing services because billing companies will also likely be considered to be “service providers” to their clients. Of course, third party billing companies may be directly covered by the Red Flag rules, given the breadth of the key definitions.

“Service providers” are entities who provide services to a creditor in connection with one or more covered accounts. As part of a Red Flag program, the Rule requires creditors to exercise “appropriate and effective oversight” of service provider relationships. This will almost certainly follow the general HIPAA “business associate” paradigm that third party billing companies are already familiar with, and will likely require some new internal processes for healthcare providers and third party billing companies.

Technically, this suspension of enforcement is not the same as a delay in implementation. However, the suspension was provided, according to the FTC announcement, specifically to give financial institutions and creditors “additional time in which to develop and implement written identity theft programs.” On its face, it appears that the suspension of enforcement will have, as a practical matter, the same effect as a formal delay in implementation.

You may review the FTC press release here: http://www.ftc.gov/opa/2008/10/redflags.shtm.

CPB will continue to follow this and make the necessary operational and software adjustments. I am sure that your professional associations will be notifying you of this also if they haven’t already. If you have any questions, feel free to call me.


Financial Hardship
CPB regularly receives questions about why providers should not write off co-pays, deductibles and co-insurance balances. We are often further challenged to show why this is restricted. In 1998 the federal Office of the Inspector General published Compliance guidelines for Individual and Small Group Physician Practices which addressed this issue. Writing off co-pays, deductibles and co-insurance balances is considered an “inducement” for patients to over-utilize healthcare services. Referrals include not just physician-to-physician, but also patient self-referral.

Federal Register / Vol. 65, No. 194 / Thursday, October 5, 2000 / Notices
Subject: OIG Compliance Program for Individual and Small Group Physician Practices

"In particular, arrangements with hospitals, hospices, nursing facilities, home health agencies, durable medical equipment suppliers, pharmaceutical manufacturers and vendors are areas of potential concern. In general, the anti-kickback statute prohibits knowingly and willfully giving or receiving anything of value to induce referrals of Federal health care program business.

In addition to developing standards and procedures to address arrangements with other health care providers and suppliers, physician practices should also consider implementing measures to avoid offering inappropriate inducements to patients. Examples of such inducements include … waiving coinsurance or deductible amounts without a good faith determination that the patient is in financial need or failing to make reasonable efforts to collect the cost- sharing amount.”

CPB routinely works with patients to obtain the necessary documentation to protect our clients. Patients with financial need are cooperative. Those who are not, leave the provider with risk if patient balances are written-off inappropriately.

More next month about “Regulation Z” which adds restrictions when billing a patient more than 4 times in a payment plan.

October 2008

Medicare CARRIER TRANSITION ON NOVEMBER 14

Most clients have now sent CPB a copy of the Medicare letter indicating their new EFT has been processed. That letter is the only way you know that your EFT has been properly set up so that your Medicare payments will continue after the transition to the new Medicare carrier on November 14. If you have not already done so, please be certain to send us a copy of that letter while it is still something you can find. In the event of any problems, CPB will then be able to advocate for you.

We have been watching Medicare carrier transitions across the nation the past few months. Some have been smooth, others have not. In at least one case, charges that were paid without any problem were denied due to new Carrier Determinations – resulting in delayed and/or denied claims. For New Jersey, NGS will transition to Highmark. While CPB has done everything asked to ensure the transition is smooth, the possibility exists that payment delays will occur. We recommend that clients plan accordingly.


CMS Announces Medicare Premiums, Deductibles for 2009

The standard Medicare Part B monthly premium will be $96.40 in 2009, the same as the Part B premium for 2008. This is the first year since 2000 that there was no increase in the standard premium over the prior year. This monthly premium paid by beneficiaries enrolled in Medicare Part B covers a portion of the cost of physicians’ services, outpatient hospital services, certain home health services, durable medical equipment, and other items.

By law, the standard premium is set to cover approximately one-fourth of the average cost of Part B services incurred by beneficiaries aged 65 and over. The remaining Part B costs are financed by Federal general revenues.


FTC “Red Flag” Rules

The HBMA Government Relations Committee has become aware of the Federal Trade Commission’s so-called “Red Flag” rules for “financial institutions” and “creditors” which become mandatory, on November 1, 2008. There remains some debate among healthcare attorneys, trade associations and others about the applicability of the “Red Flag” rules on hospitals and physicians. However, the potential impact of these requirements on health care providers and their close implementation date led the Committee to ask HBMA’s counsel to review the regulations and prepare the following:

In brief, the Red Flag rules require financial institutions and creditors to implement identity theft prevention programs to detect, prevent and mitigate identity theft in connection with an existing or new account. These programs must be in writing, tailored to the particular financial institution or creditor and designed to detect relevant warning signs (the “Red Flags”) that indicate identity theft and respond appropriately.

The regulations do not mention health care providers. However, the definition of creditor is extremely broad. Anyone who regularly extends credit in connection with a covered account is within the scope of the Red Flag rules. Credit includes the right to purchase services and defer payment. A covered account includes any account for which there is a reasonably foreseeable risk to the customer or the creditor from identity theft. A creditor must be under the jurisdiction of the Federal Trade Commission for the Red Flag rules to apply. While the jurisdictional rules are convoluted, they are based on the Federal Trade Commission’s enforcement authority under the Fair Credit Reporting Act, which is interpreted very broadly.

Several creditable national health care organizations have concluded that when a health care provider issues an invoice, instead of being paid at the time of service, the health care provider may be a creditor under the Red Flag rules. Given the breadth of the definition of a covered account and the Federal Trade Commission’s broad jurisdictional ambit, it thus appears possible that physicians and other providers may be required to comply with the Red Flag rules. There are indications that clarification of this may be sought by one or more of these organizations from the Federal Trade Commission.

The HBMA Government Relations Committee will continue to analyze the Red Flag rules and their application to third party billing companies, including reaching out to the national health care organizations that are already involved in this issue and to provide further information and analysis as it becomes available. As things develop, CPB will keep you informed.

September 2008

MEDICARE FEE SCHEDULE

On July 15th, 2008 Congress passed the Medicare Improvements for Patients and Providers Act of 2008. This legislation cancelled the scheduled 10.6% fee reduction mandated by the SGR and replaced the reduction with a .5% increase which is the same amount paid by Medicare from January 1st, 2008 through June 30th, 2008.

CPB had a strategy to delay sending claims until after the increase had passed and sufficient time was allowed so that full payment would be received. I am glad to say that strategy worked and all clients did receive their full payment.


Medicare EFT

Just a reminder, if you did not return the EFT (Electronic Funds Transfer) form as required by the new Medicare Carrier, you will not be paid until you do once the transition occurs in November. There is usually a HUGE processing backup as the transition nears – avoid the delay in payment by getting these forms filed today. Call us if you need help.


EVALUATION AND MANAGEMENT CODING

The July 2008 version of the Evaluation & Management Services Guide, which provides evaluation and management services information about medical record documentation, International Classification of Diseases and Current Procedural Terminology codes, and key elements of service, is now available on the Centers for Medicare & Medicaid Services Medicare Learning Network at http://www.cms.hhs.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf .

August 2008

MEDICARE FEE SCHEDULE & THERAPY CAP STATUS

On July 15th, 2008 Congress passed the Medicare Improvements for Patients and Providers Act of 2008. This legislation cancelled the scheduled 10.6% fee reduction mandated by the SGR and replaced the reduction with a .5% increase which is the same amount paid by Medicare from January 1st, 2008 through June 30th, 2008. Medicare expected to begin making the adjusted .5% payment no sooner than July 22nd and no later than July 29th. Claims submitted with a service date of July 1st or after were being paid at the 10.6% reduced fee schedule. As soon as possible, the carriers will begin reprocessing these claims automatically and will remit the additional payments to the provider in the same fashion the reduced payment claims were paid. Please note that payments will likely come in “lump sum payments” of one or several checks. Payment details will accompany these lump sum payments.

To avoid the 10.6% reduction, and since CMS already directed the carriers to delay payment for 10 business days (which ended July 15th), CPB withheld submitting Medicare charges until July 17th. We hope this allowed Medicare to process these claims and pay the full amount to you – without the 10/6% reduction – and thus avoid the reprocessing delay. We will know July 31st or August 1st if that strategy worked.

It appears that CMS has established a process that will allow the carriers to adjudicate the supplemental payments efficiently. Should this not be the case CPB will handle, of course.


Medicare Improvements for Patients and Providers Act of 2008

In addition to the fee schedule, this bill also:

· Reduced Medicare beneficiaries’ coinsurance for mental health services to the same level applied to other outpatient medical care. Transitions from current 50-50 (Medicare-patient split) to 80-20 (Medicare patient split) over a six year period. Transition begins in 2009.
· Extends the exceptions process for therapy (PT, OT, SLP) limits through December 31, 2009.
· Imposed an 18-month delay of Phase 1 of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Acquisition Program (CAP), with a corresponding 18-24 month delay of Phase 2 and subsequent applications of the program. Furthermore, the new law modifies the CAP to ensure a fair bidding process and to protect beneficiaries. In lieu of the competitive bidding, payment rates for items included in the CAP will be reduced.
· Provided incentives for practitioners who use a qualified e-prescribing system in 2009 through 2013. The new law requires practitioners to use a qualified e-prescribing system beginning in 2011. Once the mandate is in effect, providers who fail to use an e-prescribing system will have payments reduced by up to 2%. The new law prohibits application of financial incentives and penalties to those who write prescriptions infrequently, and the new law permits the Secretary of HHS to establish a hardship exception to providers who are unable to use a qualified e-prescribing system.
· Excluded Podiatrists from DMEPOS accreditation requirements.
· Delayed the Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program. As a result of this delay, the special accreditation deadlines previously established for the second round of the program have been cancelled. Specifically, prior to enactment of this new law, suppliers must have been accredited or have applied for accreditation by July 21, 2008 to be eligible to submit a bid for the second round of competitive bidding and must have obtained accreditation by January 14, 2009 to be eligible for a second round contract. Both of these deadlines have been cancelled and no longer apply.
The deadline of September 30, 2009 that was previously established by which all DMEPOS suppliers must be accredited is still in effect.

Waiving Retroactive Beneficiary Cost Sharing Due to Increases in Payment Under MIPPA

The HHS Office of the Inspector General has issued a policy statement that assures Medicare providers, practitioners, and suppliers affected by retroactive increases in payment rates under the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 that they will not be subject to OIG administrative sanctions if they waive retroactive beneficiary cost-sharing amounts attributable to those increased payment rates, subject to the conditions noted in the policy statement. To view the document, go to http://oig.hhs.gov/fraud/docs/alertsandbulletins/2008/MIPPA_Policy_Statement.PDF on the web.


NEW MEDICARE PART B CARRIER
Highmark Medicare was awarded the Jurisdiction 12 contract & will replace Empire Medicare for New Jersey on November 14, 2008 for PA, MD, NJ, DE & the District of Columbia. They are requiring a new CMS-588 EFT Agreement (Electronic Funds Transfer) from every provider that is currently receiving their Medicare payments electronically. To avoid the rush in November, we would suggest that you do this early. Highmark sent that information to you in July – please forward to CPB and we will complete it for you to sign.


Recovery Audit Contractors (RAC)- Nearly $700 Million in Improper Medicare Payments

“The Centers for Medicare & Medicaid Services (CMS) released a new report on July 16th offering fresh evidence that the recovery audit contractors (RACs) pilot program is successfully identifying improper payments. The findings will also help the agency improve the program as it is expanded nationwide within two years, officials say.
The evaluation report shows that $693.6 million in improper Medicare payments was returned to the Medicare Trust Funds between 2005 and March 2008. The funds returned to the Medicare Trust Funds occurred after taking into account the dollars repaid to health care providers, the money overturned on appeal and the costs of operating the RAC demonstration program. In most cases, it is all about documentation.
Of the overpayments, 85 percent were collected from inpatient hospital providers, and the other principal collections were 6 percent from inpatient rehabilitation facilities, and 4 percent from outpatient hospital providers.

The RACs corrected over $1 billion of Medicare improper payments from 2005 through March 27, 2008. Roughly 96 percent of the improper payments ($992.7 million) were overpayments collected from providers, while the remaining 4 percent ($37.8 million) were underpayments paid to providers.

Of the $1 billion in improper payment determinations by the RACs, providers chose to appeal only 14 percent of the RAC decisions. Of all the RAC overpayment determinations, only 4.6 percent were overturned on appeal. Throughout the demonstration, the RAC program has cost only 20 cents for each dollar collected.

Most of the improper payments that the RACs identified occurred when health care providers submitted claims that did not comply with Medicare’s coverage or coding rules. The types of inadvertent errors leading to improper payments, found by the RACs include billing for a procedure multiple times (for example, when a health care provider charged Medicare for conducting three colonoscopies on the same patient on the same day), incorrectly coded procedures, and submission of duplicate claims resulting in two payments to a provider.

The program, designed to protect the Medicare Trust Funds and beneficiaries from improper payments, began in California, Florida and New York in 2005 and in July 2007 expanded to Arizona, Massachusetts and South Carolina. The law states the national program must be implemented by Jan. 1, 2010 for all states. To view the entire Press Release: http://www.cms.hhs.gov/apps/media/press_releases.asp”

July 2008

NPI # Information From Medicare
Payments are flowing properly!

MORE NPI # INFORMATION - OTHER THAN MEDICARE
As you know, the NPI # became mandatory for all insurers on May 23rd. As of 6/27/08 we have not received any rejected claims and are sending NPI #’s only (as required by law). We will continue to watch and address any issues as needed.

MEDICARE FEE SCHEDULE & THERAPY CAP STATUS
In order to prevent the exceptions process from expiring, Congress & the President must act prior to July 1. If no action, Therapy Caps – modifier will no longer work after $1,810 reached (based on date of service) – patients need to receive treatment at an outpatient hospital department or sign an ABN. If on or after July 1, a beneficiary has already reached the therapy cap amount for calendar year 2008, Medicare will no longer pay for the services unless they are provided in an outpatient hospital setting. Use of the modifier will not be effective on or after July 1, regardless of whether the patient had previously qualified for an exception to the therapy cap.

PATIENT’S EMAIL ADDRESSES
Technology has now reached the point that we can now send patient statements via email. Some in the billing industry have been sending them for the past 2 years. This appears to be working smoothly and saves providers the cost of USPS postage. We will be contacting each client to discuss implementing this over the next few months. If you have any comments or concerns, please give Rich a call.

NEW MEDICARE PART B CARRIER
Highmark Medicare was awarded the Jurisdiction 12 contract & will replace Empire Medicare for New Jersey on November 14, 2008 for PA, MD, NJ, DE & the District of Columbia. They will be requiring a new CMS-588 EFT Agreement (Electronic Funds Transfer) from every provider that is currently receiving their Medicare payments electronically. To avoid the rush in November, we would suggest that you do this early. Highmark will be sending information to you in July.

BILLING
There are companies that have the ability to keep credit card information on file which can then be used to set up payments to pay patient co-pay, deductible, and co-insurance balances. If you are interested in considering such an option, let Rich know. We can show you some pretty interesting options.


CPB Holidays!

CPB will be closed on July 4th for the Independence Day holiday.
We will also be closed half a day on Friday, July 11th for our annual Employee Appreciation Day. We will be open from 9:00 – 12:00 then closed the remainder of the day.

June 2008

NPI # Information From Medicare

This is no longer an issue. Payments are flowing properly!


MORE NPI # - OTHER THAN MEDICARE

The NPI # became mandatory for all insurers on May 23rd. As of 6/2/08 we have not received any rejected claims and are sending NPI #’s only (as required by law). We will continue to watch and address any issues as needed.


CPB’S NEW PHONE #

CPB now has a new main phone #: 609-465-8900 (note it is not “463”). The old # (609-463-8107) will continue to work indefinitely and the toll free # for your patients has not changed.


PATIENT EMAIL ADDRESSES

Technology has now reached the point that we can now send patient statements via email. The billing industry has been sending them for the past 2 years. This appears to be working smoothly and saves providers the cost of USPS postage. We will be contacting each client to discuss implementing this over the next few months. If you have any comments or concerns, please give Rich a call.


BILLING FOR SOMEONE OTHER THAN THE ACTUAL PATIENT

Questions are occasionally asked about billing for a patient who is not insured using a spouse’s insurance card and name. This is more common with the higher insurance deductibles that are now being seen but can occur for other reasons, as well.
This is clearly insurance fraud and not something any provider should be part of. The OIG takes a particularly dim view of this and, if caught, can lead to exclusion from treating patients from Medicare, Medicaid and other federal programs for a period of 5 years, plus state sanctions including fines and imprisonment. We strongly advise that provider’s not allow a patient to put them into such a position to risk losing their medical license. If you wish to treat such a patient it would be better to work out a discounted payment plan with them.

BILLING FOR PATIENT BALANCES – CREDIT CARDS?
There are companies that have the ability to keep credit card information on file which can then be used to set up payments to pay patient co-pay, deductible, and co-insurance balances. If you are interested in considering such an option, let Rich know[RCP1] . We can show you some pretty interesting options.


REVISED CMS “INCIDENT TO” RULES

We just became aware that Medicare will be updating the Benefit Policy Manual (Pub 100-2, Chapter 15, Section 60) with what they are referring to as a "clarification" of the "Incident To" regulations. The effective date is June 2, 2008.

The most significant new requirements in this transmittal appear to be:
· The original plan of care must now explicitly "authorize" the subsequent service by the NPP (which is the billed “Incident To” service).
· Additionally, the physician who is in the office and supervising when the "incident to" service is provided must now also be documented in the medical record (prior to this, it just needed to be billed under the supervising doctor's name. It wasn't necessary for that to be documented in the medical record, too).
· If a follow-up visit wasn’t anticipated, but occurs with a non-physician, it will need to be specifically authorized in writing in the medical record by the physician in the office at that time prior to the patient being seen by the non-physician practitioner (PA, NP, etc.) or other trained employee.
Offices who utilize the "Incident To" provisions may want to read the full document (see link below) carefully so that any operational changes your office needs to make will be able to be in place by the beginning of next month! The “meat” of the article begins on page 9. Feel free to call with any questions. http://www.cms.hhs.gov/transmittals/downloads/R87BP.pdf .