May 2011

Credit card payments

With more insurance policies than ever having high patient and family deductibles (we have seen them as high as $5,000 per year!), you may want to consider offering credit cards as one of your payment options.

We have researched this and it appears that an average cost per month for 75-80 patients to charge $2,500 (an average of about $32 each) is less than $100. Vendors now give offices more ways to collect payments, which gives patients more flexible payment options, including Front Office Payments (card swipe, internet, or both), automated Payment Plans, and Patient Payment Portal solutions. CMB patient statements have the ability to show whichever credit cards you accept so the patient can pay that way for statements also.

If interested we have 2 companies we have interviewed which you could consider.

Consults

Consults, by definition, require a referring physician which cannot be the provider performing the service. If the charge form is missing the name of a referring physician, CMB will always ask if there is one. If not, the only alternative which is compliant with billing rules is to bill a CPT code other than a consult (office visit, subsequent hospital visit, etc.).

Medicare Attestation Begins on April 18. (From CMS)

“Attestation for the Medicare Electronic Health Record (EHR) Incentive Program began on April 18, 2011. In order to receive your Medicare EHR incentive payment, you must attest through CMS' web-based Medicare and Medicaid EHR Incentive Programs Registration and Attestation System.

CMS will release additional information about the Medicare attestation process soon, including User Guides that provide step-by-step instructions for completing attestation, and educational webinars that describe the attestation process in depth.

Here is more information to help you prepare for Medicare attestation: You need to understand the required meaningful use criteria to successfully attest. Meaningful use requirements for eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) participating in the Medicare EHR Incentive Program are different:
EP Meaningful Use Criteria – Must report on 15 core measures, 5 of 10 menu measures, and 6 clinical quality measures, consisting of 3 required core measures and 3 additional measures.
Go to the Stage 1 EHR Meaningful Use Specification Sheets for EPs for information on core and menu measures for EPs.
Go to the Clinical Quality Measures page for information on the required clinical quality measures for EPs.

You should also make sure that you begin your 90-day reporting period in time to attest and receive a Medicare payment in 2011. The last day to begin your 90-day reporting period for 2011 incentive payments is October 1, 2011, for EPs.”

More ICD-10

While ICD-10 starts on October 1, 2013 (2.5 years away), it is only mandatory for HIPAA covered entities/plans. However, some insurers, specifically Medicaid, may not be able to comply with the deadlines. Workers Compensation, auto, attorneys and other types of non-health insurance indemnity plans are not subject to HIPAA and can continue to use ICD-9 - even though it will no longer be maintained or updated. The most current information we have indicates we will indeed see this, so it is critically important to expect coding and operational issues that will result. CMB will be ready, but there are major systems issues that could cause serious disruptions in payments regardless of what you bill with.

FILLING OUT AN ATTORNEY’S QUESTIONAIRE

Question: If you have a patient who was injured and has filed personal injury suit against a company and his attorney is requesting that you fill out a questionnaire regarding your patient to help with his suit, do you have to comply? Should you request payment for your service? If so, how do I determine a reasonable billing rate for my time and effort?

Answer: You are free to either respond or not respond to the attorney's questionnaire. A questionnaire is not the same as responding to a subpoena. It is reasonable for you to be paid for your time if you choose to respond, but you may want to contact the attorney and ask if he is willing to compensate you and to clarify the amount of your charges. If he/she is not willing to pay, then you can decide how to proceed. I would not just unilaterally fill out the questionnaire and then charge the attorney without having a written understanding first. Recognize also that if you "get involved" by responding to the attorney, you may be nominating yourself to become a witness in the litigation. This does not bother some people; others would dread such a possibility. Bottom line is to make a wise choice based on the possible future consequences.

More eRx – Avoiding the 2012 Payment Adjustment

In November, the Centers for Medicare & Medicaid Services announced that, beginning in calendar year 2012, eligible professionals who are not successful electronic prescribers based on claims submitted between January 1, 2011 – June 30, 2011, may be subject to a payment adjustment on their Medicare Part B Physician Fee Schedule (PFS) covered professional services. Section 132 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) authorizes CMS to apply this payment adjustment whether or not the eligible professional is planning to participate in the eRx Incentive Program.

From 2012 through 2014, the payment adjustment will increase each calendar year. In 2012, the payment adjustment for not being a successful electronic prescriber will result in an eligible professional or group practice receiving 99% of their Medicare Part B PFS amount that would otherwise apply to such services. In 2013, an eligible professional or group practice will receive 98.5% of their Medicare Part B PFS covered professional services for not being a successful electronic prescriber in 2011 or as defined in a future regulation. In 2014, the payment adjustment for not being a successful electronic prescriber is 2%, resulting in an eligible professional or group practice receiving 98% of their Medicare Part B PFS covered professional services.

The payment adjustment does not apply if <10% of an eligible professional’s (or group practice’s) allowed charges for the January 1, 2011 through June 30, 2011 reporting period are comprised of codes in the denominator of the 2011 eRx measure.

Please note that earning an eRx incentive for 2011 will NOT necessarily exempt an eligible professional or group practice from the payment adjustment in 2012.

How to Avoid the 2012 eRx Payment Adjustment
· Eligible professionals – An eligible professional can avoid the 2012 eRx Payment Adjustment if (s)he:
-- Is not a physician (MD, DO, or podiatrist), nurse practitioner, or physician assistant as of Jun 30, 2011 based on primary taxonomy code in NPPES;
-- Does not have prescribing privileges. Note: (S)he must report (G8644) at least one time on an eligible claim prior to June 30, 2011;
-- Does not have at least 100 cases containing an encounter code in the measure denominator;
-- Becomes a successful e-prescriber; and
-- Reports the eRx measure for at least 10 unique eRx events for patients in the denominator of the measure.
· Group Practices - For group practices that are participating in eRx GPRO I or GPRO II during 2011, the group practice MUST become a successful e-prescriber.
-- Depending on the group’s size, the group practice must report the eRx measure for 75-2,500 unique eRx events for patients in the denominator of the measure.

April 2011

Medicare EMR PAYMENTS

Recently we were asked what is required to qualify for the Medicare EMR funds for qualified providers:
Be using one of the 200+ ONC 2011 Certified EHR applications,
Use the product in a “meaningful way” for 90 days starting anytime after 01/01/2011, and
Go on-line to register with CMS.

CMS has asked that we remind eligible professionals that they must register in order to participate in the Medicare and Medicaid EHR incentive programs. At least 90 days of reporting is required to qualify. Registration opened on Jan. 3, 2011, at http://www.cms.gov/EHRIncentivePrograms/20_RegistrationandAttestation.asp.


MEDICARE eRx

In November, the Centers for Medicare and Medicaid Services (CMS) announced that, beginning in calendar year 2012, eligible professionals who are not successful electronic prescribers based on claims submitted between January 1, 2011 - June 30, 2011, may be subject to a payment adjustment on their Medicare Part B Physician Fee Schedule covered professional services. If you are a physician (with Medicare patients) who has not started to use eRx yet & wants to avoid a negative payment adjustment in 2012, you will want to get started ASAP. If you are using an eRx program but have not notified CPB, it is CRITICAL that you do so we can ensure that the correct eRx code is being sent with your charges to Medicare. That is how Medicare finds out you are actually using it on patients. The code must be billed at the time of the E&M visit – office, home, hospital, nursing home, etc..

Several of our clients are already using an electronic prescription program and will be able to benefit from the Medicare payment. Some are using a standalone product and others are looking at EMR programs that include this feature. Be sure it is certified with both CMS and Surescripts. The following website includes all products certified by Surescripts – both standalone & included with an EMR program: http://www.surescripts.com/connect-to-surescripts/prescriber-software/all.aspx?mode=viewAll&fullscreen=true&background=off

For a free product: http://www.nationalerx.com

CREDIT CARDS & eCHECKS FOR PATIENT PAYMENTS

As many of you know, high deductible insurance plans are becoming much more common. We are seeing deductibles as high as $5000 per year which is significantly changing insurance paradigm. Instead of receiving payment from an insurance company, we are seeing an increase in balances being applied to those deductibles and in the number of requests from patients for credit card payments.

In response to several requests by clients to set them up with the ability to accept credit card payments, CPB is investigating this option. The process works as follows:
Each client is set up so that the credit card payment goes directly to their bank account.
Patients send the required credit card information either on their statement or fax to us.
Our staff will enter the information on the secure website provided by the vendor with payment only to your bank account. Our staff will enter the payment information into the patient's account as usual.

If you if you are interested in participating in this, please contact Rich.

PROVIDER RELIANCE ON PRECERTIFICATION

NJAC 11:24A-3.4 2(e) which is applicable to all carriers using utilization management programs: "provides that a carrier shall not deny reimbursement retroactively for a covered service provided to a covered person by a provider who relied upon the written or oral authorization of that carrier (or its agents) prior to providing the service to the covered person, except in cases where there is material misrepresentation or fraud."

The New Jersey Department of Banking and Insurance further states "carriers may not circumvent these provisions through the use of quote disclaimers" purporting to reserve the right to retroactively revise utilization management determination."

This should solve the occasional denial but it is important that the billing diagnoses match whatever was used to obtain the precertification.

Medicare Annual wellness visits (AWV) – railroad medicare

Railroad Medicare is stating that they will not be ready to process either of the AWV codes until April 4, 2011. We will automatically resubmit any denied claims. Believe it or not, the RRMC rep told us that they “just received the memo yesterday” (3/7/11)! Funny how everyone else knew about this last Fall.

Ambulance Mileage

On February 23, 2011 UMWA Health and Retirement Fund announced that effective January 1, 2011 (yep, retroactive!) they will also follow the Medicare policy using Load Miles rounded to the nearest tenth of a mile.

NJ PIP PATIENTS

There are 3 medical specialties which are subject to the daily $99.00 NJ PIP Cap – Chiropractors, Therapists (PT & OT), and Osteopaths (for manipulation codes only). The FAQ’s on the NJ PIP website:

Q. “Is the $99.00 a per-provider cap or does it apply to all treatment on that day?
A. The $99.00 is the limit of the insurer’s liability for the CPT codes listed in the rule per day. Therefore, it applies regardless of the number of providers that the injured person visits.”

The only exception is found in N.J.A.C. 11:3-29.4 (m) Application of Medical Fee Schedules:

“… The daily maximum applies when such services are performed for the same patient on the same date. The daily maximum applies to all providers, including dentists. However, when the provider can demonstrate that the severity or extent of the injury is such that extraordinary time and effort is needed for effective treatment, insurer shall reimburse in excess of the daily maximum. Such injuries could include, but are not limited to, severe brain injury non-soft tissue injuries to more than one part of the body. Such injuries would not include diagnoses for which there are care paths in NJAC 11.3-4. … Unless already provided to the insurer as part of a decision point review or precertification requests, billing shall be accompanied by documentation of why the extraordinary time and effort for treatment was needed."

The above indicates that the documentation can be provided as part of the precertification process or documentation can be sent with initial claim. Please be sure to specify on the charge form if, during the preauthorization process (which is the best time to address this issue with the insurer), you were approved to exceed the daily cap, or attach a cover letter supporting "extraordinary time and effort for treatment was needed" as required above.

We believe that in group practices represented by more than one specialty, e.g., PT & OT, that this issue should be addressed during the preauthorization process and request this in writing. This ensures that you are aware prior to treating the patient, rather than after the claim has been denied, whether the insurer has agreed to waive the cap.

This approach is further supported by NJAC 11:24A-3.4 2(e) which is applicable to all carriers using utilization management programs: "provides that a carrier shall not deny reimbursement retroactively for a covered service provided to a covered person by a provider who relied upon the written or oral authorization of that carrier (or its agents) prior to providing the service to the covered person, except in cases where there is material misrepresentation or fraud."

The New Jersey Department of Banking and Insurance further states "carriers may not circumvent these provisions through the use of quote disclaimers" purporting to reserve the right to retroactively to revise utilization management determination."

If the insurer refuses to allow each provider to be paid for treating the patient on the same date of service, we recommend that patient's only be treated by one provider each day in order to avoid the second provider providing unreimbursed care.

In addition, if you see any patient being treated under NJ PIP, you should ask if the patient has an appointment to see any other providers that day. If so, scan or fax the charges to CPB as fast as possible AND call to notify us so we can bill before the other provider does.

Finally, when scheduling appointments for NJ PIP patients, ask if they already have an appointment scheduled with another provider on whatever day you would see them. If possible, schedule them a different day.

If you have any questions, please contact Rich.