July 2010

Electronic Medical Records (EMR’s)

Lots of discussion is occurring about EMR’s. One of the key considerations is, aside from working well for you, is that it must meet “meaningful use” criteria. If it does not meet it before or after you buy it – it will result in no Medicare bonus payment to you! One of those criteria is certification which many EMR programs do not have and are being sold based upon a promise that it will be. Be VERY careful buying such a program – if they do not obtain the certification – no bonus money!

Mark R. Anderson, FHIMSS, CPHIMS, CEO and Healthcare IT Futurist, AC Group, Inc. (http://www.acgroup.org) is an EMR expert who has provided the following statistics:

• 42% of Physicians have purchased EHR
• Only 7% are using EHR in full production
• 72% of EHR installs are not fully operational after a year or de-installed
• 19% stopped using within 1 year

Further, another EMR expert estimates there are about 400 different companies selling EMR’s with less than 10% of surviving the eventual market shakeout. Looked at another way – providers have a 90% chance of selecting a vendor that will go out of business! Clearly you need to carefully select which package you purchase and will want to ensure you have flexibility. One of the questions to ask is will the EMR provide an “HL7” file that can be imported into our software for billing? If so, then your billing data will continue to be safe if the EMR product develops any issues - like going out of business.

AUDITS / MEDICAL RECORD REQUESTS

We are beginning to see medical record requests for a variety of audits – mostly all Medicare. And we are hearing this is occurring nationally. We strongly suggest that you carefully review the requests before responding and be sure that:

• All the requested documentation is returned, and that it is legible.
• All signatures meet Medicare signature requirements.
• Send it timely – generally the sooner, the better.
• Documentation is not altered once it has been sent.

If they receive no response, all charges are denied. If already paid, they will move to recoup the payments. It also raises other concerns which could lead to further action.
CMB is experienced with these issues and will be glad to assist you.

PAYMENTS FOR DRUGS

If we are billing any drugs for you to NJ Medicaid, we must use the National Drug Codes (NDC’s) numbers in order to get you paid. These #’s are based on the manufacturer, dosage, etc. If you change any of that – buy from a different manufacturer, change the dosage, route of administration, etc., we will need to know the NDC # from the packaging prior to billing.

RED FLAG RULE

Late in May, after the June 1 Client Bulletin was printed, the FTC delayed implementation until December 31, 2010.

ICD-10 Conversion

It has the potential to completely disrupt the payment system – for MANY reasons. This is not an exaggeration. While Medicare (along with TriCare, Medicare Advantage, and Railroad MC) says it will go to ICD-10 on 10/1/13, no other payors are required to!

For example, let’s say the patient has Medicare 1’ and Blue Shield 2’. We bill Medicare with 1 of the 68,000 ICD-10 codes, but when it auto crosses over to the 2’, Blue Shield does not accept ICD-10 – only ICD-9 (about 13,000 codes) – so refuses payment. So then we have to decide which ICD-9 code matches to each ICD-10 code. In a best case scenario, we successfully accomplish that and the provider gets paid.

But provider training in documenting what is required to be specific enough to code the additional 55,000 ICD-10 codes alone will be a significant task.

Medicare INPATIENT CONSULTS

Occasionally there are patients whose initial inpatient E/M service is less than CPT 99221 (a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity). National Government Services (NGS) Medicare has stated: "There may be instances where subsequent hospital care codes best fit the description of the service rendered. NGS recommends the use of subsequent care codes 99231 or 99232 for those encounters that would have previously been coded using consultation codes 99251 or 99252, since these would match the complexity of the visit codes (problem focused history and physical/straightforward medical decision making; expanded problem focused history and physical and straightforward medical decision making) for the 99251 and 99252, even if this is a provider’s first visit with the patient during the hospitalization. National Government Services advises not to code the 99499 in these instances."

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.