August 2010

MEDICARE - PECOS

Medicare is reminding all physicians regarding the PECOS requirements for providers who have not re-enrolled or updated their enrollment within the past 6 years. Providers will need an approved enrollment record in PECOS to continue to order or refer items or services for Medicare beneficiaries and to receive incentive payments made by Medicare and Medicaid. If you, or a colleague, need assistance using the internet-based PECOS, please call us.

EMR’s

The final Meaningful Use (MU) criteria came out on July 13th. CMS has lowered the # of standards that must be met in order to qualify for MU and meet the certification standard so providers can receive the incentive bonuses.

Mark Anderson, CEO of the AC Group, said they have conducted a review of 114 EHR vendors, and, as of July 15, believe that 83 of them can meet Stage 1 MU requirements. Although CCHIT is NOT an approved 2011 MU certification body yet, almost everyone assumes they will become one of the certifying bodies. Right now 28 EHR vendors have already received CCHIT 2011 certification and the CCHIT certification process requires more than just the Stage 1 MU requirements. CCHIT has opened up certification again and 48 additional EHR vendors have said they are in the process of getting CCHIT certified.

Primary Care Bonus Payments

Beginning in 2011 and effective until 2016, all primary care physicians, PA’s, NP’s, and CNS’s will be eligible for a 10% bonus in Medicare payments. To qualify, at least 60% of a physician’s total Medicare charges must be comprised of office, nursing home, and home care visits." We will forward details when they are released by CMS.

AETNA EFT

From Aetna: Electronic Funds Transfer (EFT) is available to all providers treating Aetna members for all benefits plans. If you choose free online electronic delivery of your claims payments via EFT, you:

• Get payments transmitted directly into your bank account(s) up to one week faster than with paper EOBs and checks
• Reduce mail, and eliminate trips to the bank, while providing a convenient audit trail.
  
  If you are interested, we can give you the contact information.
  
  MEDICAL IDENTITY THEFT
  
  Recently I was speaking with the Receptionist for one of our clients and reminding her how important it is to verify insurance each visit, plus copy and verify the photo ID for new patients. Her response was that she sometimes was too busy to do that. That was not a surprise since we had noticed a higher # of denials for wrong insurance at that office, which prompted the visit.
  
  Patients are not the only victims of medical identity theft - physicians and other healthcare providers are also victims. If a physician treats a patient who has provided fraudulent information, one of two bad outcomes are likely:
  · If the insurer has already caught the identity theft, the provider will not be paid for the services rendered.
  · If the provider already got paid by the insurance company, they will be required to return those funds when the identity theft is caught. The laws always exempt fraud when an insurer wants money back, so that does not prevent take-backs.
  
  The above can be prevented by carefully checking the photo ID. CPB’s appointment system allows copies of both driver’s licenses and insurance cards to be kept and viewed.
  
  In case you didn't know…
  IRS-CMS & Delinquent Tax Bills
  
  Legislation recently signed by President Obama that delays Medicare cuts until December 1 also establishes a data match program between the Centers for Medicare and Medicaid Services and the Internal Revenue Service. Under the new law, the IRS has the authority to disclose to CMS any information on delinquent tax debts for a provider who has applied to enroll or re-enroll in Medicare. CMS can use information obtained from the IRS in determining whether to deny a provider application for participation in Medicare or to apply enhanced oversight to the provider. Text of the enrolled version of the bill, H.R. 3962, is available at congress.gov.
  
  Cape Medical Billing
  1-888-633-2457

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.