June 2010

HealthNet of the Northeast

United Healthcare has acquired the licensed subsidiaries of HealthNet of the Northeast effective May 1, 2010. As a result, it will no longer be able to provide managed care services for its NJ Family Care/Medicaid members. Patients will be able to select a different HMO or will be assigned to AmeriChoice if they do not select another by April 9th. If you see Medicaid patients, please be sure to verify their insurance coverage.

PQRI 2009 PAYMENTS

The incentive payments for 2009 are tentatively scheduled to be dispersed late summer/early fall 2010. The incentive payment, with the remittance advice, will be issued by the Carrier/MAC contractor and identified as a lump-sum PQRI incentive payment. The electronic remittance advice only reflects “LS” (Lump Sum). The paper remittance advice states, “This is a PQRI incentive payment.”

MEDICARE

Lately, with Congress not getting the Medicare Fee Schedule SGR factor issue passed on a timely basis, I have had several inquiries about provider’s options if the 21% cut (or something smaller) is allowed to go into effect.

Providers have 3 options:
1. Remain participating. No change from your current status.
2. Change to Non-participating.
3. Opt out of the Medicare program entirely.

Non-par providers have the option of accepting/not accepting assignment on the claims. Assigned claims process directly to the provider with the allowable at 95% of the current fee schedule. Non-assigned claims process directly to the patient. As a non-par provider, the maximum amount the provider can charge the patient is 115% (known as the “Limiting Charge”) of the Medicare allowable. Medicare believes the pain of getting the monies from the patient is more than the 15% extra that can be collected. As a non-par provider, providers may collect the full Limiting Charge amount at the time of service. And that is the key – it must be collected at the time of service not billed later – as the collection amount is significantly lower.
Note – if you have been par all along, you will have to submit a letter to Medicare during the annual enrollment period which is typically mid-November through December 31 to become non-par. If that has not yet been done, you will have to wait until November to change status.

The third option is to opt out entirely. Major step. The 1997 BBA, allows physicians and other selected providers of Part B services to opt-out of the Medicare Program and establish, in writing, private contracts with Medicare beneficiaries for all covered Part B services, except those services provided for emergency and urgent care. Not all providers may opt out. Private contracting was only authorized for physicians, osteopaths, and selected non-physician providers (clinical psychologists, clinical social workers, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, certified nurse midwives). The Medicare Prescription Drug Improvement, and Modernization Act of 2003 (MMA) extended private contracting to podiatrists, dentists, and optometrists effective December 2003.

Under these private contracts, beneficiaries are liable for payment of the costs of care provided and cannot bill Medicare. Providers sending opt-out affidavits to their Part B claims carriers would be prohibited from billing Medicare for services provided to program beneficiaries or receiving payment linked to Medicare health maintenance organization (HMO) capitation payments for 2 years after the effective date of opt-out on the affidavit. Providers opting-out of Medicare, however, may order services for Medicare patients to be delivered by providers who have not opted-out.

If you want to change your participation status, please call Rich to discuss. There are major opportunities – and pitfalls – depending on a number of factors.

RED FLAG RULE

As you know, the FTC delayed implementation a few months ago until June 1, 2010. The AMA & AOA filed suit against the FTC to exclude physicians from the regulations – but it does not delay it taking effect for physicians. If you have not already implemented a Red Flag Rule policy in your office and need assistance, the AMA offers information and a sample policy which can be used to create one.
http://www.ama-assn.org/ama1/pub/upload/mm/368/red-flags-rule-edu.pdf
http://www.ama-assn.org/ama1/pub/upload/mm/368/red-flags-rule-policy.pdf

Feel free to call Rich if you need any assistance setting up this policy.

Medicare Banking Transition

The Centers for Medicare and Medicaid Services (CMS) recently awarded new banking contracts to U.S. Bank and JP Morgan Chase. Medicare providers do not have to take any action but should be aware that the Medicare payments will be made by a different bank than in the past because of these new banking contractors. Highmark will be transitioned to U.S. Bank on August 2.

May 2010

Medicare Timely Filing CHANGE

On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act (PPACA), which amended the time period for filing Medicare fee-for-service (FFS) claims as one of many provisions aimed at curbing fraud, waste, and abuse in the Medicare program. Under the new law:

· Claims for services furnished on or after January 1, 2010, must be filed within one calendar year after the date of service.

· Claims with dates of service before October 1, 2009, must follow the pre-PPACA timely filing rules.

· Claims with dates of service October 1, 2009, through December 31, 2009, must be submitted by December 31, 2010.

Timely Response to

Medicare Medical Review Documentation Requests

Provider Bulletin from Medicare, April 5, 2010: “Highmark Medicare Services… has determined that providers are not responding to our Additional Documentation Requests (ADRs).

When an ADR is received from either Highmark Medicare Services or the CERT Contractor, please be advised that it is your legal obligation to respond to requests for medical records per the SSA. Once you receive an ADR, all records that support the medical necessity of the service billed need to be copied and sent within the time frame specified in the development request. Title 42 of the United States Code, Section 1320c-5(a)(3) indicates that a physician is obligated to provide evidence that the service given is medically necessary.

If the records are not received or not received timely, we are not able to validate that the service was completed and therefore, the claim will be denied. Consequences resulting from no documentation can include claims subject to prepay review, a referral to the Office of Inspector General, or other legal avenues. Patient authorization is not required to respond to the ADR.”

It is imperative that you respond to these requests timely – otherwise it raises suspicions that fraud is being committed and they see an opportunity to recoup even more money. There are certain basic things that are looked for in the documentation such as legible handwriting and signatures – and “rules” to follow. CPB would be happy to review these requests to help ensure you do not undergo recoupment and/or pre-payment reviews which will seriously slow down your cash flow.

Medicaid Drugs

Medicaid has stated they are finding errors in the NDC codes being used to bill injectable medications which has lead to overpayments. Codes used to bill medications are J0120 – J9999, and some “Q” codes. CPB has always required the client to either give us the code or a copy of the product to ensure we are billing the correct code for you – if you change your manufacturer please notify CPB so we can update the NDC code being used.

Medicaid is also going to begin on-site audits to verify the drug name, amount given, etc. – PLUS the drug acquisition records. So be sure that your medical records are accurate and complete and that you save all drug purchase invoices. Failure to do so will result in recoupment of any money paid.

Medicare ADVANTAGE (PART C) PLAN AUDITS & REQUIREMENTS

Medicare Advantage (MA) plans ask for access to patient records for a number of reasons. Almost all of those reasons boil down to discovering one of two things: were the diagnosis codes submitted:

· Accurate (i.e., properly documented in the medical record), and

· Complete (i.e., all diagnoses documented were submitted).

The circumstances they ask for these records vary. It may be a CMS audit (called a Risk Adjustment Data Validation, or RADV), with potential for huge over-payments levied against the plan based on physician documentation; it can be a plan RADV, so that they can retract these undocumented diagnoses before CMS conducts a RADV, or it can be to ensure that all the documented diagnoses were submitted to the health plan (and CMS) in the first place.

Given that physician documentation does not support the selected diagnosis code more often than not, it's just as likely that chart review will result in loss of revenue to the plan as it is in an increase. When you submit a diagnosis code, you're in effect attesting that this is what is clinically wrong with your patient. The health plan, however, is on the hook to CMS for what you've claimed.

Physicians have a much better understanding of documentation for CPT than they do for ICD-9. So, many health plans conduct RADVs to ensure that what they've received from physicians is accurate. It also allows Health Plans to provide feedback and education to physicians about appropriate documentation.

MA Plans are only required to provide, at a minimum, the same level of services as traditional fee-for-service (FFS) Medicare. For contracted providers, they are not required to follow any of Medicare's fee schedules and often reimburse at a much lower rate than traditional Medicare (even including the patient's co-payment).

These plans often provide more services (e.g., foot orthotics, hearing aids, dental, etc.) than traditional Medicare covers, and may include drug benefits. Traditional Medicare carriers receive a fixed contractual payment to run the Medicare program for a specific area from CMS. Type C carriers are paid by CMS based on a much more complex formula. This often is based on the number of diseases and complexities which are documented in the physician's chart. The amount of scrutiny on this issue by CMS is immense.

April 2010

AETNA

On March 16th Aetna announced via email (forwarded to all clients that have provided us with email addresses) that beginning June 14, 2010 they will no longer send paper EOB’s. CPB is already set up for most clients and will work with whomever necessary to ensure a smooth transition.

However, please note that if you still wish to have paper EOB’s that you can complete an “Exclusion form”. Of course, we’ll be glad to do that for you – just let me know.

INSURANCE AUTHORIZATIONS

CPB really needs a copy of all authorizations when you receive them (if not already sent with the charges) so we can update info in the notes. We get quite a few Horizon denials for no auth (usually, but not always, after the first auth is no longer valid). In all cases, we need the initial auth and all subsequent auths to be sent to CPB with charges or when received. That will provide us with the information needed to get claims paid without needing to contact your office for the information. Better cash flow, no interruption for either office, and more efficient for everyone.

Of course, if the charge requires an authorization and you do not have one yet, please hold it until the authorization is received. Insurers won’t pay without the auth # anyway.

THERAPY CAPS

On March 23, 2010, President Obama signed legislation that extended the Therapy Cap Exceptions Process until December 31, 2010.

CHALLENGING ECONOMIC TIMES - Maximizing REVENUE

The best way to improve your patient collections is to be proactive. Here are a few common ways to do that:
· Collecting deductibles and co-insurances from patients without secondary insurance on the day of service.
· Collect copayments upon arrival of the patient – before they see the provider. If you do not already have a sign in your waiting room that states "Payment is expected when services are rendered unless other arrangements are made in advance", you may want to consider adding one. If a patient arrives without cash, a check, or credit card, consider rescheduling their appointment (unless an emergency, of course) so they can bring their copayment, coinsurance, or any outstanding deductible. We have had clients who told us that when faced with having to reschedule, patients have gone to their car and miraculously found cash and credit cards!

This “trains” the patient that this really is a firm policy and ensures timely payment. If questioned by patients, explain that it keeps the cost of running the practice down since mailing patient statements does cost money. Some discretion may be appropriate if this only happens rarely.
· Get a copy of all insurance cards and verify addresses and phone numbers each visit. Accurate information is required by insurers – if what is received by them doesn’t match their records, it will delay payment while they verify identity.
· Include all required authorizations with the charges – no benefit to send the charges before we get the auth. Insurers won’t pay without it anyway.
· If an insurer is not paying, get the patient involved early. If the care is elective, delay further services until insurance issues are worked out and payments are made.
· Don’t accept promises! Unless your creditors accept them. In which case, let all of us know! Of course, you can promise to treat the patient further when their insurance company pays.

SOFTWARE UPDATES

One of the concerns we are hearing recently is patients who forget their appointments. Our software vendor has just released an “Auto-Dialer” product that can be used with our appointment system to automatically call pts a day or 2 prior to their appt as a reminder. Expected to be ready to demo in early April.

They also released another new product called a “Digital Pen” which also is used with our appointment system. If you choose to use this product, CPB will cover the cost. Also expected to be ready to demo in early April.

Both of these products would improve the efficiency of your office and cash flow (patients who show up create revenue!). Please give Rich a call if you are interested.