Now is the time to begin examining and reviewing your payor contracts for 2012.   If you are making changes, some plans require you to do so at least ninety days prior to the end of the year.  In addition to ensuring that you are receiving the appropriate reimbursement, you’ll want to make sure that your contract language is well understood. 

The AMA has a National Managed Care Model Contract that is available to assist physicians.   AMA members may use the database to search and compare model contract language, issue briefs on important managed care topics, AMA policy and the full text of all individual managed care state laws

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The WVSMA, through our exclusive partnership with the Practice Management Institute (PMI) is bringing some new educational opportunities to your area!  Classes are now scheduled in Beckley and Bluefield.  As we have done in the past, we are making the class schedule more flexible by splitting the day into two classes in case you are only available for ½ day.

CEU credits are available for Certified Medical Office Managers (CMOMs) or other certified professionals.

On Tuesday, October 11, 2011, we will host two programs in Beckley.   On Thursday, October 13, 2011,  the classes will be repeated in Princeton. 

Information about both classes is listed below.  You may choose to take one or both classes on either day.

ICD-10 Coding Proficiency     9:00 AM -Noon

This class will explain the steps you can take now to improve your understanding of ICD-10.   The new codes will be much more descriptive, requiring a good understanding of both anatomy and medical terminology. Participants will leave this class with valuable tips for a smooth transition to ICD-10.

Collecting in a New Economy   1:00 PM- 4:00 PM     

This is an intermediate-level course appropriate for physicians, practice managers, coders and billing staff. Attendees will explore the stages of the collections process beyond payment at time of service. Participants will learn how to set up a manageable, traceable system that gets results without negatively affecting patient relations. The course also includes tips on dealing with difficult collection situations.

Participants will also learn how to determine the effectiveness of their billing procedures, the steps to take before you start to collect on an account, and how to streamline reimbursement and collection policies.

Registration information will soon be available on the WVSMA’s website, www.wvsma.com.  For additional information, please contact Karie Sharp (304) 925-0342, ext 12 or via email Karie@wvsma.com.   

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In today's economy, every practice needs to receive the maximum reimbursement possible for the services provided.  A Certified Medical Coder (CMC) plays an integral role in the reimbursement process, ensuring that proper documentation guidelines are followed while submitting codes to the highest degree of specificity.

The WVSMA is proud to offer the first Certified Medical Coder (CMC) class in West Virginia!  Through our exclusive partnership with Practice Management Institute (PMI), we are able to bring this exciting course to Physicians and Office Personnel in September, 2011. 

The course is a certification designed for physician-based coding professionals.  Classes will cover Medical Terminology, ICD-9-CM Diagnostic Coding, ICD-10-Coding Conversion, HCPCS/CPT Procedural Coding, Ancillary and Advanced Coding.

The program includes “hands on” classroom instruction, a course manual, homework exercises, an exam preparation handbook and the certification exam.   Individuals who are able to demonstrate by exam a superior level of physician-based coding knowledge will be awarded the Certified Medical Coder (CMC) certification.

The CMC classes will be held from 8:30 AM- 4:30 PM at St. Francis Hospital, Charleston, WV, on the following dates:

     Friday, September 9
     Friday, September 16
     Friday, September 23
     Thursday, September 29
     Friday, September 30

The registration form is available on the WVSMA's website.   If you have additional questions, contact Karie (304-925-0342, ext.12) or via email (karie@wvsma.com). 
 

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The West Virginia Medical Group Managers Association (MGMA) will hold their fall conference at Stonewall Jackson Resort, Roanoke, WV, on Thursday, October 6th and Friday, October 7th.   For additional information, you may contact President John Trout (jtrout@greenbrierphysicians.com). 

The West Virginia Office Managers Association (OMA) will hold their annual conference at Pullman Plaza in Huntington, WV, on Thursday, October 20 and Friday, October 21st.  For additional information, you may contact Pam Shafer (pamela.shafer@camc.org), Toni Charlton (toni1447@comcast.net), Vickie Garan (vicdog2@comcast.net), or Donna Zahn (deez921@hotmail.com). 

Both these groups are excellent resources for your office administrator/manager. 

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CMS Fraud Prevention Initiative
(Information supplied by CMS)

If you help people with Medicare, Medicaid and the Children's Health Insurance Program (CHIP), you should know about an expanded federal government effort to reduce fraud and other improper payments in these health care programs to help ensure their long-term viability. 

Significant progress in the fight against health care fraud has already been made as shown by the federal government’s recovery of a record $4 billion last year from people who attempted to defraud seniors and taxpayers.  The Affordable Care Act provides additional resources and tools to enable the Centers for Medicare & Medicaid Services (CMS) to expand efforts to prevent and fight fraud, waste and abuse. The CMS Fraud Prevention Initiative aims to ensure that correct payments are made to legitimate providers for covered appropriate and reasonable services in all federal health care programs. 

Fraud prevention efforts focus on moving CMS beyond its former “pay and chase” recovery operations to a more proactive “prevention and detection” model that will help prevent fraud and abuse before payment is made.  A good example is the recent CMS announcement that for the first time, through the use of innovative predictive modeling technology similar to that used by credit card companies, the agency will have the ability to use risk scoring techniques to flag high risk claims and providers for additional review and take action to stop payments and remove providers from the program when necessary.  

Yet, as important as these aggressive new initiatives are, the first and best line of defense against fraud remains the health care consumer.  You can help by making sure that Medicare beneficiaries have the information they need to identify and report suspected fraud.  This information is available in the CMS Fraud Prevention Toolkit on the web at https://www.cms.gov/Partnerships/04_FraudPreventionToolkit.asp#TopOfPage

The web site contains materials to help you inform Medicare beneficiaries about how to protect themselves from becoming a victim of fraud and how to report it. 

Affordable Care Act Initiative to Lower Costs, Help Doctors and Hospitals Coordinate Care
(Information supplied by CMS)

The U.S. Department of Health and Human Services (HHS) recently announced a new initiative to help improve care for patients while they are in the hospital and after they are discharged. Doctors, hospitals, and other health care providers can now apply to participate in a new program known as the Bundled Payments for Care Improvement initiative (Bundled Payments initiative). Made possible by the Affordable Care Act, it will align payments for services delivered across an episode of care, such as heart bypass or hip replacement, rather than paying for services separately.  Bundled payments will give doctors and hospitals new incentives to coordinate care, improve the quality of care and save money for Medicare.

In Medicare currently, hospitals, physicians and other clinicians who provide care for Medicare beneficiaries bill and are paid separately for their services.  This Centers for Medicare & Medicaid Services (CMS) initiative will bundle care for a package of services patients receive to treat a specific medical condition during a single hospital stay and/or recovery from that stay – this is known as an episode of care.  By bundling payment across providers for multiple services, providers will have a greater incentive to coordinate and ensure continuity of care across settings, resulting in better care for patients.  Better coordinated care can reduce unnecessary duplication of services, reduce preventable medical errors, help patients heal without harm, and lower costs.

The Bundled Payments initiative is being launched by the new Center for Medicare and Medicaid Innovation (Innovation Center), which was created by the Affordable Care Act to carry out the critical task of finding new and better ways to provide and pay for health care to a growing population of Medicare and Medicaid beneficiaries.

The Bundled Payments initiative is based on research and previous demonstration projects that suggest this approach has tremendous potential. For example, a Medicare heart bypass surgery bundled payment demonstration saved the program $42.3 million, or roughly 10 percent of expected costs, and saved patients $7.9 million in coinsurance while improving care and lowering hospital mortality. 

Organizations interested in applying to the Bundled Payments for Care Improvement initiative must submit a Letter of Intent (LOI) no later than September 22, 2011 for Model 1 and November 4, 2011 for Models 2, 3, and 4. For more information about the various models and the initiative itself, please see the Bundled Payments for Care Improvement initiative web site at:
http://www.innovations.cms.gov/areas-of-focus/patient-care-models/bundled-payments-for-care-improvement.html.

Interested parties may obtain answers to specific questions by e-mailing CMS at: BundledPayments@cms.hhs.gov.

This initiative is part of a broader effort by the Obama Administration to improve health, improve care, and lower costs. A brief summary of other efforts, including those authorized by the Affordable Care Act, can be found at: www.HealthCare.gov/news/factsheets/deliverysystem07272011a.html

For more information about the CMS Innovation Center, please visit: http://www.innovations.cms.gov

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Medicare Made Easy: Basic Billing for Beginners

Register today to attend the 'Medicare Made Easy: Basic Billing for Beginners' educational Webinar event. This Webinar will be held September 8, 2011, at 10:00 A.M., and is designed to provide the basics on: Medicare plans and patient eligibility; overview of provider enrollment and Medicare participation; Medicare claims filing and Palmetto GBA Web site navigation.

http://www.palmettogba.com/palmetto/providers.nsf/ls/Jurisdiction%2011%20Part%20B~8J9LH94824?opendocument&utm_source=J11BL&utm_campaign=J11BLs&utm_medium=email

Medicare: Beyond the Basics

Palmetto GBA will host a “Medicare: Beyond the Basics” Webinar on September 22, 2011, at 10:00 A.M.  The purpose of this training event is to provide Medicare information useful to experienced billing staff. Topics will include: medical necessity, National and Local Coverage Determinations (NCDs/LCDs), Maximum Allowed Units (MAUs), 'Incident To,' reciprocal billing, troubleshooting top claim denials, and Palmetto GBA Web site resources.

http://www.palmettogba.com/palmetto/providers.nsf/ls/Jurisdiction%2011%20Part%20B~8J8SQN6556?opendocument&utm_source=J11BL&utm_campaign=J11BLs&utm_medium=email

Further Details on the Revalidation of Provider Enrollment Information

All providers and suppliers enrolled with Medicare prior to March 25, 2011, must revalidate their enrollment information. Newly enrolled providers who submitted their enrollment applications to CMS on or after March 25, 2011, are not impacted. Palmetto GBA will begin mailing notices about the revalidation process anytime between now and March 23, 2013.

There is no need to contact Palmetto at this time. You will be receiving a revalidation notification from Palmetto GBA. 

http://www.palmettogba.com/palmetto/providers.nsf/ls/Jurisdiction%2011%20Part%20B~8KRGQ56641?opendocument&utm_source=J11BL&utm_campaign=J11BLs&utm_medium=email

Health Care Provider Taxonomy Codes (HPTC) Update: October 1, 2011

The Centers for Medicare & Medicaid Services (CMS) has released the summary of changes reflected in the Health Care Provider Taxonomy Code (HPTC) list.
Medicare contractors will update their HPTC tables with this new version effective on January 1, 2012. You may want to share with appropriate staff.

http://www.palmettogba.com/palmetto/providers.nsf/ls/Jurisdiction%2011%20Part%20B~8EMG993112?opendocument&utm_source=J11BL&utm_campaign=J11BLs&utm_medium=email

AT&T System Access

Providers who experience connectivity issues when using AT&T to access an application or product should contact the CDS Help Desk at (888) 807-8610 for assistance.

http://www.palmettogba.com/palmetto/providers.nsf/ls/Jurisdiction%2011%20Part%20B~8KVRBX2461?opendocument&utm_source=J11BL&utm_campaign=J11BLs&utm_medium=email

Medicare Part B Secondary Payor Deductible Issues Resulting from Change Request 7026

Medicare Part B claims processed after April 1, 2011, for which the beneficiary has a Medicare deductible remaining and Medicare is the secondary payor, are erroneously issuing payment. In addition to these overpayments, physical therapy and occupational therapy claims processed after April 1, 2011, where Medicare is the secondary payer and a deductible is not met are being held up by the system and are not being paid. CMS anticipates both of these issues to be resolved in November 2011.

http://www.palmettogba.com/palmetto/providers.nsf/ls/Jurisdiction%2011%20Part%20B~8KVNM67054?opendocument&utm_source=J11BL&utm_campaign=J11BLs&utm_medium=email

October Update to the Calendar Year (CY) 2011 Medicare Physician Fee Schedule Database (MPFSDB)

An October 2011 update has been released to contractors for the Medicare Physician Fee Schedule Database (MPFSDB). In the October 2011 update, there are no new or deleted Healthcare Common Procedure Coding System (HCPCS) codes. Note that there are a number of HCPCS codes with payment indicator changes. 

http://www.palmettogba.com/palmetto/providers.nsf/ls/Jurisdiction%2011%20Part%20B~8L2MUM5782?opendocument&utm_source=J11BL&utm_campaign=J11BLs&utm_medium=email

Claims Denied Incorrectly for Diagnosis

Palmetto GBA has identified a system problem that resulted in some claims denying incorrectly with the message code CO-11 which states 'The diagnosis is inconsistent with the procedure'. This error impacted claims processed from August 19 – 23, 2011, for all Medicare contractors. The system maintainer is currently working to correct this. Once the system issue has been resolved, Palmetto GBA will reprocess all impacted claims. Providers do not need to take any action.

http://www.palmettogba.com/palmetto/providers.nsf/ls/Jurisdiction%2011%20Part%20B~8L4KV24527?opendocument&utm_source=J11BL&utm_campaign=J11BLs&utm_medium=email

Affordable Care Act Initiative to Lower Costs, Help Doctors and Hospitals Coordinate Care

The Centers for Medicare & Medicaid Services (CMS) Bundled Payments initiative will bundle care for a package of services patients receive to treat a specific medical condition during a single hospital stay and/or recovery from that stay. This is known as an episode of care. By bundling payment across providers for multiple services, providers will have a greater incentive to coordinate and ensure continuity of care across settings, resulting in better care for patients.  Better coordinated care can reduce unnecessary duplication of services, reduce preventable medical errors, help patients heal without harm, and lower costs.

http://www.palmettogba.com/palmetto/providers.nsf/ls/Jurisdiction%2011%20Part%20B~8L2GC37437?opendocument&utm_source=J11BL&utm_campaign=J11BLs&utm_medium=email

Announcing the Release of Revised and New CMS-855 Medicare Provider-Supplier Enrollment Applications

Revised versions of the Medicare Provider-Supplier Enrollment Applications
(CMS-855) and the new CMS-855O application form are now available on the CMS Provider-Supplier Web site. Providers and suppliers enrolling for the sole purpose to order and refer are required to begin using the new CMS-855O form immediately. Providers and suppliers using the other CMS-855 forms to enroll in Medicare are encouraged to begin using the revised forms, though may continue to use the old forms through October 2011.

http://www.palmettogba.com/palmetto/providers.nsf/ls/Jurisdiction%2011%20Part%20B~8L2EMF2814?opendocument&utm_source=J11BL&utm_campaign=J11BLs&utm_medium=email

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Aetna has announced a series of webinars for provider education.  Join Aetna for a free, live, interactive seminar and learn how to more easily manage claims payments.

During this 30-minute session, you’ll learn how to access and use:

1.   Claim status inquiries
2.   Claim status reports
3.   Electronic explanation of benefits (including claim reconsiderations)
4.   Claim history reports
5.   Provider Payment Estimator
6.   ERA/EFT (electronic remittance advice/electronic funds transfer)

You’ll also have time to ask questions about how you can use these easy tools in your office or facility.

Click the link below for the session you want to attend.  If the link doesn’t work, you may need to copy and open in your browser.

Sessions are held on the first Thursday of every month from 12–12:30 p.m. ET. Click on the date to register.

September 1, 2011

October 6, 2011

November 3, 2011 

December 1, 2011  

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(Information supplied by CIGNA)

Starting on September 2, CIGNA will no longer mail paper copies of Direct Deposit Activity Reports or Checkless Explanations of Payment to health care professionals who receive payment via Electronic Funds Transfer.  Health care professionals who are not enrolled in EFT will not be affected and will continue to receive paper EOBs and checks via US Mail.

CIGNA initially communicated the policy change to all EFT recipients on May 23, 2011. Since then, we have continued to communicate via email, inserts in payment envelopes, and the quarterly newsletter.  In addition, those who enrolled in EFT since May 23 were informed of the policy change during enrollment.

EFT recipients will have access to DDARs and Checkless EOPs via the website, CIGNA for Health Care Professionals, on the day of the deposit. 

EFT recipients can elect to turn paper back on for up to 180 days at a time via the CIGNA website (select My Practice > Remittance Report Delivery Preferences > Change).  Remittance reports will be available online regardless of the paper delivery settings.

This new policy is rolling out in all states at the same time.

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Highmark West Virginia is offering one statewide Provider Conference.

Please plan on attending Highmark West Virginia's Annual Provider Conference on Monday, September 19, 2011, at the Days Hotel Conference Center, Flatwoods West Virginia.

By attending this conference, you'll get the latest news about Highmark West Virginia products and initiatives, have a chance to ask questions and network with your peers to share insights and best practices.

You may register online at the Highmark BCBS website.  

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Integra BMS, a Third Party Administrator (TPA) for Coalition America (formerly 4Most) recently announced a new provider payment method for reimbursing physicians.   Under this plan, any provider who currently accepts MasterCard as payment must now accept the new Integra E-Pay Prepaid MasterCard method of payment. 

Physicians will receive a MasterCard that has been pre-approved and funded for the exact amount of the Explanation of Benefits transaction.  The funds are deposited into the physician’s account just as with any other MasterCard transaction.  

What this means for physicians is that you will now be absorbing an additional 1%-3% credit card fee for receiving reimbursement via MasterCard.  Although this may be a convenience for the TPA, it is a penalty for physicians.

While physicians have expressed concerns regarding the length of time that it takes to receive reimbursement from the TPA and would like very much to have an expedited payment (i.e. Electronic Funds Transfer), they are also very concerned that the additional charges for the E-Pay method far outweigh any benefit of a quicker reimbursement. 

Upon learning of the proposed change of reimbursement, the WVSMA contacted Integra and requested that they not institute the E-Pay provider payment method for our physicians.  We requested that until such time that Integra is able to provide an EFT system that physicians be able to continue receiving reimbursement via check or other method that does not require a transaction fee or cost shift to the providers.  We emphasized that we did not support any reimbursement method that added an additional burden to or reduction of the physicians’ reimbursement. 

The WVSMA also contacted Coalition America regarding this issue.  Coalition America was not aware of Integra’s new reimbursement method and was not in favor of this type reimbursement. Coalition America did check into the issue; however, they stated that they have no ability to regulate the TPA.   In other words, as with other networks and “silent PPOs”, Integra (the TPA) has no one regulating their actions.

Unfortunately, because of this lack of regulation, Integra is now able to reimburse physicians by this new pre-paid MasterCard.  The only way to avoid the pre-paid MasterCard is to not accept MasterCard for any other services. 

The WVSMA’s response from Integra BMS stated that if physicians voluntarily accept MasterCard, based upon their merchant agreement with MasterCard, they must accept MasterCard as payment and cannot discriminate based upon who is presenting the card.   They further stated that while physicians may not “opt out” of the Integra E-Pay System, those who contact Integra will be dealt with on an individual basis in a timely manner. 

Many of you expressed your displeasure about this method of reimbursement and your concerns have been relayed to Integra BMS. If you wish to contact Integra BMS directly regarding this issue, you may address your concerns to:

Tina Gabriel, Customer Service Manager, Integra Employer Health
Phone  (704) 321-3165     tgabriel@integrahealth.com

The WVSMA is currently meeting with legislators and hopes to prepare legislation in order to better deal with this major issue of regulating PPOs and TPAs. 

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Meet and Greet with Medical Director

UnitedHealthcare's Medical Director Dr. Ed Kosa will be meeting with the WVSMA on Thursday morning, September 8^th, 2011, at 9:00 AM at the WVSMA office.  He will be discussing the plan’s new programs and other issues of importance to your medical practice.

Physicians and staff are welcome to attend this meeting. If you or your office staff are interested in attending this meeting, please RSVP to Barbara Good (Barbara@wvsma.com) or Karie Sharp (karie@wvsma.com).

The previous meetings with Dr. Kosa and his staff have been very productive. The WVSMA is pleased to be able to provide this opportunity to our physicians.

 
Automated Overpayment Recovery Enhancement Process for UnitedHealthcare Medicare Advantage Plans
(Information supplied by United Healthcare)

UnitedHealthcare wants to make sure that the network understands this new enhancement. This recovery activity is different from other recovery efforts such as payment integrity and chart reviews. This process supports operationally driven overpayment claim transactions identified, such as benefit and claim process quality errors.

UnitedHealthcare is enhancing the overpayment recovery process and Provider Remittance Advice (PRA) for all medical providers that submit claims for UnitedHealthcare Medicare plans.
 
In UnitedHealthcare's continuing commitment to simplify administrative processes and improve provider communications regarding overpayment recoveries, an enhancement is being deployed that will:

1.  Send providers advance notification of overpayment recoveries.
2.  Allow automatic offsets of overpayments against future claim payments where allowable by contract and where the provider does   not prefer direct refunds.
3.  Allow current claims to process against the outstanding overpayment balance.
4.  Enhance the Provider Remittance Advice (PRA).

This change applies to all medical providers (participating and non-participating) that submit claims for UnitedHealthcare Medicare Solution plans SecureHorizons® and/or Evercare®, including Private-Fee-For-Service.

Providers can expect the following changes with this enhancement:

1. Overpayment Notification Letter: Once an overpayment is identified, the provider will receive an Overpayment Notification Letter along with claim details. Providers will have 30 days to respond to the notification letter by either sending in a refund check or written inquiry. Providers who choose not to respond will have overpayment recovery claims offset against future claim payments on or after 45 days.

2. An enhanced Provider Remittance Advice (PRA): including a new "Overpayment Reduction Detail" page that states the amount of the original adjustment(s), all offsets, and the current balance.

Physicians and hospitals enrolled in electronic funds transfer (EFT) payments will receive the HIPAA 835 instead of a hard copy PRA.

Overpayment details are provided in the 835 Provider Level Adjustment segment updates. If a provider would like to see more information, he/she can access the hard copy PRA through UnitedHealthcareOnline.com > Claims & Payments > EPS (log-in required). 

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• • Time for a Contract Review
• • The WVSMA Offers Additional Courses for You!
• • Last Chance to Register for the CMC Course
• • Register Now for the WVMGMA and OMA Conferences
• • CMS News
• • Palmetto GBA News
• • Aetna Update
• • CIGNA Update
• • Highmark West Virginia to Hold Provider Conference
• • Integra BMS Reimbursement Change
• • UnitedHealthcare News