The migration to version 5010 is required before January 1, 2012. All claims submitted in the version 4010A1 will be rejected after December 31, 2011.  With less than 60 days left to prepare, offices need to be ready!  Keep in mind that the last day to submit claims in the “old” format is December 31, 2011, which is a Saturday.

You must achieve an approved 5010 837 test file before you can submit version 5010 production claims. If you experience issues with version 5010 testing, it will delay your ability to submit version 5010 production claims. Not being able to submit version 5010 production claims will impact your timely claims submission and cash flow at the start of January 2012.

Effective January 1, 2012, all production electronic claims for Medicare Part A and Part B must be submitted in version 5010. Version 4010A1 claims will no longer be accepted and will be rejected after December 31, 2011.

With timeframes, heavy schedules and end-of-year claim filing, practices should not wait until late in November or into December to begin version 5010 testing and move to version 5010 production.

System vendors must test the new ANSI-formatted programs.  Submitters who programmed their own system must complete a testing phase.  

Practices should have already been in discussion with their clearinghouses and vendors regarding their readiness for ANSI 5010.   You should make sure that your current agreement includes regulation updates.   You should also find out when they are planning to update their systems and if the upgrade will include access to all acknowledgements and reports.

One of the main changes with the federally mandated HIPAA 5010 upgrade is that a PO Box can no longer be submitted in the “Billing Provider” field.  The “Billing Provider Address” must be a street address.

A PO Box or lock box address should only be entered in the “Pay to Provider” address field.

The change to 5010  is happening as part of the Final Rules that were published by the U.S. Department of Health in January 2009. The rules require upgrades to electronic standard transactions under HIPAA to version 5010. Please work with your electronic claim submission vendor to make sure you’re ready for all 5010 format changes before the January 1, 2012 implementation date.

The WVSMA recommends that you should get a statement of readiness in writing from your vendor and clearinghouse.   Don’t wait until your payments stop before upgrading to 5010! 

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The Centers for Medicare and Medicaid Services (CMS) and its contractors have been attempting to send letters and call physicians who they believe may be subject to the 2012 Medicare e-prescribing penalty to remind them to apply for an exemption by November 1, 2011 to avoid the penalty.  Physicians, however, shouldn't wait for a letter or a call from CMS to apply for an exemption. If you haven’t yet applied for an exemption, you need to do so before November 1, 2011.
 
Beginning January 1, 2012, eligible professionals who have not successfully met the requirements of the electronic prescribing (eRx) incentive program will be subject to the 2012 eRx payment adjustment. The adjustment will reduce Medicare payment rates by 1 percent of the provider’s allowable Medicare Part B charges.

Eligible professionals and group practices should determine if they are subject to the 2012 eRx payment adjustment by reviewing the MLN Special Edition Article #SE1107, '2011 Electronic Prescribing Incentive Program Update – Future Payment Adjustments'.  If you believe that you may be subject to the 2012 eRx payment adjustment, you should determine if you meet any of the hardship exemption categories specified by CMS in the 2011 Medicare eRx Incentive Program Final Rule. 

In addition, a Quick Reference Guide is available to help you understand the changes that the eRx Final Rule made to the 2011 Medicare eRx Incentive Program.  To be considered for an exemption under the significant hardship exemption category eligible professionals must: have registered for either the Medicare or Medicaid EHR Incentive Program.  (For instructions on how to register for one of the EHR Incentive Programs, refer to the Registration and Attestation page of the EHR Incentive Programs section of the CMS Web site.)
 
Eligible professionals must also how that they adopted certified EHR technology no later than October 1, 2011, and provide identifying information about the certified EHR Technology.
 
Please note that in order to qualify for an exemption to the 2012 eRx payment adjustment under this significant hardship exemption category, it is not necessary that an eligible professional receive an incentive payment under the Medicare or Medicaid EHR Incentive Program.

Eligible professionals wishing to register for the Medicaid EHR Incentive Program in states that have not yet launched their respective programs may initiate the registration process at the CMS Registration and Attestation System and obtain a registration number, even though they will not be able to successfully complete registration. If a state has not launched its Medicaid EHR Incentive Program, the state name will not appear in the drop-down menu for eligible professionals to choose from. However, a registration number is assigned even if registration is not successfully completed.

In order to initiate registration for the Medicaid EHR Incentive Program, please visit the CMS Web site and follow the instructions to begin the registration process. Obtaining a CMS EHR Incentive Programs registration number, even if the registration is not successfully completed, suffices for the purposes of applying for a significant hardship exemption for the 2012 Medicare e-Prescribing payment adjustment.

To request an exemption, individual eligible professionals must submit their hardship exemption requests through the Quality Communications Support Page and group practices participating under the group practice reporting option (GPRO) must submit hardship exemption requests via a letter to CMS. Please remember that CMS will review these requests on a case-by-case basis. All decisions on significant hardship exemption requests will be final. For additional information and resources, please visit the CMS Web site, www.cms.gov.  

Also, eligible professionals need to contact CMS if they want to know if the hardship exemption was granted.   When you apply for the exemption, you should have received an email that stated that the hardship exemption had been received and was being processed.   After 30 days, you may contact the QualityNet Help Desk at gnetsupport@sdps.org or 1-866-288-8912 (8:00 AM to 8:00 PM EST) Monday through Friday.  
 

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CMS New Enrollment Forms

The Centers for Medicare & Medicaid Services (CMS) is encouraging providers to use the new Medicare enrollment forms, such as the 855I for individual practitioners and the 855B for group practices. The enrollment forms were updated in July and the new forms must be used beginning November 1, 2011.  The new forms have “07/11” in the bottom left corner and the enrollment changes are detailed by CMS. 


Beneficiary Cost-Sharing for Medicare-Covered Preventive Services Under the Affordable Care Act: Reminder

Effective for Dates of Service (DOS) on or after January 1, 2011, Medicare provides 100 percent payment (in other words, waives any deductible, coinsurance or copayment) for many Medicare-covered preventive services.

Section 4104 of the Affordable Care Act waived deductibles, copayments, or coinsurance effective for DOS on or after January 1, 2011, for the following Medicare-covered preventive services:

The Initial Preventive Physical Examination (IPPE or “Welcome to Medicare Visit”); the Annual Wellness Visit (AWV); and
those preventive services that are identified with a grade of A or B by the United States Preventive Services Task Force (UPSTF) for any indication or population; and are appropriate for the beneficiary.

For more information, please see MLN Matters Number: SE1129.  This article serves as a quick reference for the changes to deductibles, copayments, or coinsurances for preventive services.


Notice of New Interest Rate for Medicare Overpayments and Underpayments: First Notification for FY 2012

The Department of the Treasury has notified the Department of Health and Human Services that the private consumer rate has been changed to 10.875 percent effective October 20, 2011, for Medicare overpayments and underpayments.


2011 Version of Advance Beneficiary Notice of Noncoverage Must Be Used Beginning January 1, 2012

Providers and suppliers are allowed to use either the 2008 or 2011 version of the Advance Beneficiary Notice of Noncoverage (ABN) through the end of this year. Beginning January 1, 2012, they must begin using the 2011 version. ABNs issued after January 1, 2012, that are prepared using the 2008 version of the notice will be considered invalid by Medicare contractors.

The new version of the ABN CMS Form CMS-R-131 was released by CMS in May of 2011.  There have been only minor formatting changes made to the form but the new ABN forms say “rev.2011”.   Until January 1, 2012, you may use the “old” form; however, after January 1, 2012 you must use the new form or the notice will be considered invalid.   

The form may be found on the CMS website, www.cms.gov. 


Prohibition on Balance Billing Qualified Medicare Beneficiaries (QMBs)

Qualified Medicare Beneficiaries (OMB) are persons entitled to Medicare Part A and are eligible for Medicare Part B; have incomes below 100 percent of the Federal Poverty Level; and have been determined to be eligible for QMB status by their State Medicaid Agency.

In this situation, Medicaid pays the Medicare Part A and B premiums, deductibles, co-insurance and co-payments for QMBs.

At the State’s discretion, Medicaid may also pay Part C Medicare Advantage premiums for joining a Medicare Advantage plan that covers Medicare Part A and B benefits and Mandatory Supplemental Benefits.

Regardless of whether the State Medicaid Agency opts to pay the Part C premium, the QMB is not liable for any co-insurance or deductibles for Part C benefits

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Revalidation Initiative

All new and existing providers enrolled with Medicare prior to March 25, 2011, must revalidate their enrollment information in accordance with the Patient Protection and Affordable Care Act, but only after receiving notification from the Medicare Administrative Contractor (MAC). Even if your records were entered into PECOS on March 24, 2011, you are still required to revalidate the information.
Between now and March 23, 2013, Palmetto GBA will send out notices to begin the revalidation process for each provider who must revalidate.  Physicians will have 60 days from the date of the letter to submit complete enrollment forms.   If they do not submit the revalidation forms as requested, their Medicare billing privileges may be deactivated. 

Physicians do not need to take any action until they receive the letter to revalidate.  Palmetto GBA has said that if you currently participate in Part B, you will not have to pay an enrollment fee.

Additional information may be found in MLN Advisory SE1126.


Additional Fields for Additional Documentation Request (ADR) Letters

Palmetto GBA is participating in a pilot to include additional information on ADR letters necessary for Electronic Submission of Medical Documentation (esMD). Medicare systems will be updated to add a documentation ID number and to allow contractors to include information about submitting medical documentation via the esMD mechanism in their Additional Documentation Requests (ADRs).


Online Provider Services (OPS)

Physician practices can save time and money by verifying patients’ Medicare eligibility electronically, before filing claims.  In addition to eligibility, the Online Provider Services (OPS) application provides information access over the Web for claims status, online remittances and financial information (the last three checks paid).   

Register for Palmetto GBA’s free Online Provider Services (OPS) tool for Internet access to eligibility information, claim status, duplicate copies of remittance notices, and some financial information. You can participate in OPS if you have a signed electronic data interchange (EDI) Enrollment Agreement on file with Palmetto GBA.  This form is located on the EDI Enrollment area of the Palmetto GBA website. 

Only one Provider Administrator per EDI Enrollment Agreement/per PTAN can initially register. You will be registered as the Provider Administrator and can add more users through the ADMIN tab. You can assign back-up Administrators. Keep in mind that these administrators will have access to all information functions by default. You can also add Provider Users who have access to individual functions, such as eligibility or claims status.

You must register separately for each PTAN. If you have multiple PTANs associated with an NPI, you must register each PTAN. Each PTAN will have a unique User ID. 


Second Demand Overpayment Letters Discontinued

Effective October 4, 2011, Palmetto GBA discontinued mailing second overpayment demand letters. You will now only receive one overpayment demand letter. If you submit a check, please include a copy of the demand letter to expedite the process.   For Palmetto GBA J11 West Virginia providers, 1uestions regarding financial issues should be sent to:

Palmetto GBA - J11 Part B
Finance & Accounting Mail Code: AG-340
P.O. Box 100128
Columbia, SC 29202-3128

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Be Ready For the New 2012 CPT Codes! 

The new CPT codes must be used as of January 1, 2012.   Make sure you have your 2012 Coding Books so that you may code and bill properly.

There will be 278 new, 139 revised, 98 deleted and 22 re-sequenced codes to CPT in 2012.   The WVSMA is going to help you prepare for the new CPT codes for 2012.   Watch for more information coming soon!!

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The WVSMA has held three CMOM classes---the Inaugural class in Spring 2010, the September 2010 class, and the 2011 class.   If you or your office manager attended the class in 2010, please be aware that you need 12 Continuing Education Units (CEUs) by December 31, 2011, in order to maintain the certification.  If you have not received your CEU paperwork from the Practice Management Institute (PMI), please contact Barbara Good (Barbara@wvsma.com)  for assistance. 

Also, classes are being planned for Spring, 2012.  Requests have been made for classes in the Morgantown and Huntington areas. If you are interested in a possible class in Morgantown or Huntington, please let Barbara Good know.  The CMOM course is a four day class and we need a minimum number to offer the class in your area.   This is a great class and one that is guaranteed to equip you to run your practice more efficiently and successfully.

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Several months ago, the WVSMA reported that 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, Integra stated that any provider who currently accepts MasterCard as payment must now accept the new Integra E-Pay Prepaid MasterCard method of payment. 

Instead of a check for reimbursement, physicians are now receiving  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 are  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’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. 

Physician practices who have contacted Integra, as well as other TPAs who are instituting this process, have been able to successfully “opt out” of the new reimbursement process.  In the meantime, the other TPAs have also allowed physicians to “opt out”.  

Since the WVSMA has heard from physician practices who did not know that they had the option to “opt out”, we decided to again include the information about Integra and contact information for the TPA.  If you wish to contact Integra BMS regarding this issue, you may address your concerns to:

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

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If you missed attending one of the October conferences, you missed a lot!   The West Virginia Medical Group Management Association held their fall conference in early October.  Speakers for the event included Kenneth Keller, Southwind Vice President; Patrick Hamilton, CMS Health Insurance Specialist, Jeremiah Samples, WV Office of the Insurance Commissioner; Jill Newberry, CPA, CPC, Senior Manager of Arnett & Foster, and Phil Weikle, Interim Chief Operations Officer for the West Virginia Health Information Network.  The conference provided good information, in addition to great networking opportunities.

The West Virginia Office Managers Association also held their annual conference in October.   The conference was a special celebration of the group’s 25th Anniversary in existence.   The diverse program for the conference included speakers on Coding (Letha Sparks, CPC, CPC-1), Compliance Issues (Michael Harmon), WV Labor and Employment Laws (Attorney Eric Kinder), and Cutting Overhead in the Medical Practice (Rose Moore, CPCI, CEMC, CCP).    An insurance payor forum featuring representatives from a variety of payors also spoke at the conference.

Both these groups provide great opportunities for networking, as well as sharing resources and information.   If your office manager/administrator is not currently a member of one of these organizations, you should encourage him/her to become involved.  The knowledge gained and relationships developed will greatly assist you in your practice development.

For information about either organization, please contact Barbara Good (Barbara@wvsma.com).
 

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Aetna reminds physicians that all claims must be filed within 120 days of the service rendered.


Appeals and Reconsiderations

Reconsiderations must be received within 180 days of the initial claim decision.  Reconsideration can be requested by calling the Provider Service Center (PSC) at 888-632-3862 or requesting the claim be reconsidered via NaviNet.

Level 1 Appeals must be received within 60 days of the reconsideration decision.  The Appeal should include the member name, member ID, Date of Service, Date of Birth, and claim ID.  The letter should provide detailed documentation. 

Level 2 Appeals must be received within 60 days of the Level 1 decision.  The appeal should include the member name, member ID, Date of Service, Date of Birth, claim ID and Appeal Level 1 ID.  The letter should provide more detailed documentation than the Level 1 Appeal.

Level 3 Appeals must be received within 60 days of the Level 2 Appeal decision.  Level 3 should only be used if further documentation can be provided.  All member information should be supplied as for Level 1 and Level 2 Appeals.  

Appeals of all three levels should be mailed to:

 Aetna Appeal
 PO Box 981106
 El Pason, TX  79998-1106

The Aetna Provider Service Center (888-632-3862) handles the following issues:

 All claims inquires of any kind
 Status of provider
 Request for data changes
 Member Information
 Referral/Precertification Information

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CIGNA Remittance Reports Now Available Online

If you currently receive Electronic Funds Transfer (EFT) payments from CIGNA, you now have immediate online access to your remittance reports [Direct Deposit Activity Reports (DDAR) and checkless Explanations of Payment (EOP)] for CIGNA medical plans.* You can access reports the same day you receive your deposit from CIGNA, using the secure CIGNA for Health Care Professionals website (www.cignaforhcp.com).

If you currently receive paper copies of your remittance reports by mail, you will continue to receive these paper reports until September 1, 2011. Beginning September 2, 2011, your remittance reports will only be available on the CIGNA for Health Care Professionals website.

You also have the opportunity to stop delivery of your paper remittance reports before they are automatically discontinued on September 2, 2011. Simply log in to the CIGNA for Health Care Professionals website (www.cignafohcp.com) > My Practice > Remittance Report Delivery Preferences > Change, and select “Online Delivery Only.”

Physicians who need to submit changes to their demographic information may do so via fax or mail.   West Virginia physicians may submit their info via email to
ProviderData@cigna.com, via fax (1-877-358-4301) or to via US mail:

CIGNA Healthcare
Two College Park Drive
Hooksett, NH, 030106
 

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Highmark Blue Cross Blue Shield of WV’s recently held statewide provider workshop was well attended by providers from all over WV.  The day was full of information and education.   Those who were unable to attend the workshop may access the website for information from the conference.  https://www.highmarkbcbswv.com.    Some of the highlights include:

NIA Radiology Management Program

The NIA Radiology Management Program is a comprehensive program for evaluation imaging providers selected to participate in the Highmark West Virginia Outpatient Imaging Program.   This is being done to ensure that Highmark WV providers meet minimum standards required to adequately perform the technical and professional components outlined in the Highmark Privileging guidelines.   Privileging focuses on the imaging facility.

Effective January 1, 2012, all providers performing any type radiology must be privileged.  The privileging program identifies the scope of service for all imaging.  The privileging application may be found on the NIA website, www.RadMD.com.  Click on Highmark WV Privileging Application under the online tools.     If you have questions about the process, you may contact NIA’s Provider Assessment Department (888) 972-9642 or via email (RADPrivilege@MagellanHealth.com).

Credentialing Update

Highmark and CAQH work together for credentialing.  CAQH is Highmark’s preferred method of credentialing, although it is not mandatory.  Physicians and other providers have benefitted from the streamlined credentialing and recredentialing processes as there is a reduction in processing times, as well as a reduction of misplaced documentation.  

CAQH is a data collection provider where the provider completes a single application.  With CAQH, there is a single application, a central location and provider ownership of data.  It replaces multiple plan-specific paper processes with a single and uniform data collection system.  The system is free for providers and they may complete the application online or via fax. 

Supporting documentations are imaged and attached to the electronic record.  Participating organizations can access the data in electronic format at any time if the provider has authorized access.   The data is refreshed periodically to avoid recredentialing cycle problems and updates can be made at any time.

Many organizations support the use of CAQH, including the American Medical Association (AMA), the American Academy of Family Physicians (AAFP) the American College of Physicians (ACP), Healthcare Financial Management Association (HFMA) and the Medical Group Management Association (MGMA).   CAQH is also accredited by NCQA, URAC and the Joint Commission. 

Provider Representatives

Highmark now has seven provider representatives for West Virginia.  Each representative’s contact information, as well as the territory they service, is listed under the provider tab on the Highmark website. 

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(information supplied by University of Charleston)

The University of Charleston (UC) is proud to announce the opening of a new concentration in Pharmaceutical and Healthcare Management (PHM) within its highly successful Executive Master of Business Administration (EMBA) degree program. The PHM concentration is designed to give pharmacists new skills that will enable them to make greater differences in the health of patients living in West Virginia and Appalachia. We would like to invite you to consider joining UC’s EMBA program and electing the PHM concentration this coming January. This new and affordable program emphasis is designed for health care professionals who are already employed in the workplace and who recognize the value advanced education can provide in terms of job and promotion opportunities.

The EMBA concentration in PHM focuses exclusively on the pharmaceutical and health care industry. In contrast to typical MBA programs that only offer electives on health care topics, our program fully immerses the student in the business of pharmaceutical and health care management. You will receive the same rigorous analytical and financial skills offered in a traditional MBA program, while gaining the knowledge and skills needed to understand the economic, financial, organizational, and political structure that is unique to the pharmaceutical and health care industry.

The course is divided into five 12-week modules. Participants meet every other weekend (Friday 5:30 – 9:00 p.m. and Saturday 8:00 a.m. – 5:00 p.m.) for fourteen months. Classes in the first three modules are held at the School of Business campus in the heart of Charleston’s business district. Classes for students electing the PHM concentration then move to the School of Pharmacy on UC’s main campus for the remaining two modules. During the fourteen-month master’s program, students will be taught by, and have access to, highly qualified UC professors, plus approximately thirty senior-level executives from diverse areas of the health care environment, including the pharmaceutical and health care industry, state and federal government, marketing, and entrepreneurial ventures.

If you're considering pursuing a management or director-level position in your company or institution, the University of Charleston is the place for you. Questions about the program should be directed to me at 304-357-4350 or fadialkhateeb@ucwv.edu .  For more information and access to applications for admission, please visit our web site at http://www.ucwv.edu/business/emba_phm/

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• • Are You Ready for 5010?
• • Time is Running Out to Apply for Medicare eRx Exemption!!!
• • Medicare News
• • Palmetto GBA Updates
• • CPT 2012 News
• • Certified Medical Office Manager (CMOM) News
• • Update on Pre-Paid MasterCards for Physician Reimbursement
• • Conference Highlights
• • Aetna Update
• • CIGNA Update
• • Highmark Blue Cross Blue Shield Update
• • University of Charleston to Offer New Degree Program