Beginning July 1, 2007, medical practices will be eligible for a 1.5% bonus under the Tax Relief and Health Care Act of 2006.This is the act that authorized the creation of the Physician Quality Reporting Initiative (PQRI), an initiative that will pay physician practices a capped bonus for reporting validated quality measures during the second half of 2007.The PQRI establishes a financial incentive for eligible professionals to participate in a voluntary quality program.
All Medicare enrolled healthcare professionals are eligible to participate in the program, regardless of whether they have signed a Medicare participation agreement to accept assignment. No registration is required to participate in the bonus program.It is also important to note that the bonus will be paid on the total Medicare allowed charges for covered Medicare Physician Fee Schedule services during the 6 month period and not just for the quality measures reported.In other words, physicians may earn 1.5% of their total Medicare allowable for claims submitted from July 1, 2007 through December 31, 2007.The initiative applies only to traditional Medicare and is not applicable to Medicare Advantage plans and private fee-for-service plans.The bonus payments will be made in a lump sum payment in mid-2008 and the bonus will be paid to the holder of record of the Taxpayer Identification Number (TIN).
Sixty-six (66) quality measures were posted on December 5, 2006, and eight (8) more were added, as allowed by the statute.The final list of 74 PQRI quality measures is posted on the CMS website, www.cms.hhs.gov/PQRI, as are the detailed measure specifications.
The reporting period is July 1- December 31, 2007 and the reporting is claims based.CPT Category II codes (or temporary G-codes where CPT Category II codes are not yet available) will be used for reporting quality data.Codes may be reported on paper-based CMS 1500 claims or electronic 837-P claims.These quality codes are to be reported with a $0.00 charge.
Additional information about Category II codes may be found in Appendix H of the CPT 2007 Professional Edition.
The PQRI measures apply to services that eligible professionals provide to Medicare beneficiaries in their offices and other settings. CMS is implementing an extensive outreach and education plan to assist physicians in implementing process to capture the quality data that is to be reported under the PQRI program.
As more information becomes available regarding the PQRI program, we will include it in the WESGRAM Online.
Are you ready for PQRI? The WVSMA wants to ensure that all physician practices are educated and knowledgeable about the PQRI (Physician Quality Reporting Initiative) so that you may collect the full reimbursement bonus.
In order to assist our physician practices as they prepare for PQRI, the WVMSA is hosting a teleconference event on Tuesday, June 5, 2007 from Noon-1:30 PM. Dr. Barbara Connors, Chief Medical Officer for CMS Region III, will be the presenter for the teleconference. She will discuss the reporting initiative and answer questions about participation in the PQRI. Those of you who attended the 2007 Mid-Winter Conference heard Dr. Connors speak and know what an excellent speaker she is.
There is no charge for the teleconference and physicians and staff may attend the call as long as only one phone line is used. Because of the importance of the subject, we anticipate a high volume of callers, so pre-registration is necessary. It is important to note that if you are planning to sit in with a group, only one person needs to register to receive the call-in data. Registration will close at 12:00 PM EST on June 4, 2007, or when available space has been filled.
To register for the call, go to http://www2.eventsvc.com/palmettogba/series/ and click Region 3: What You Need to Know About PQRI. After you fill in the requested information, click "Register". You will be sent a "Thank you for registering" page and will receive a confirmation email shortly afterward. You may print and save the page in case your server blocks the confirmation emails.
For those who are unable to attend, a replay option will be available shortly after the end of the call. This replay will be accessible from 3:30 PM EST June 5, 2007, until 11:59 PM on June 8, 2007. The call in information for the replay is (800) 642-1687 and the pass code is 9063728.
This program has been arranged for you by Barbara Good, WVSMA Physician Practice Advocate.
Although CMS has implemented a contingency plan for the use of the NPI, physicians must still obtain NPI numbers by May 23, 2007. The NPI contingency plan permits Medicare and commercial insurers to continue accepting legacy provider identification numbers until May 23, 2008.You may visit the CMS website, http://www.cms.hhs.gov to read the full contingency plan announcement or the NPI overview.
CMS made the decision to announce guidance on its enforcement approach after it became obvious that many covered entities would not be able to fully comply with the NPI standard by May 23, 2007.The contingency plan clarifies that covered entities who can prove that they have been making a good faith effort to comply with the deadlinemay implement contingency plans for paying claims until May 23, 2008.
Because the NPI is mandated by HIPAA law, the date of implementation can not be changed.The only course of action is to relax the enforcement of the implementation date. Under section 1176(b) of the HIPAA legislation, HHS may not impose a civil money penalty where the failure to comply is based on reasonable cause and is not due to willful neglect, and the failure to comply is cured within a 30 day period.HHS has the authority under the statute to extend the period within which a covered entity may cure the noncompliance.CMS has announced that as long as covered entities, including health plans and physicians, continue to act in good faith to come into compliance.This means that the entity must be working towards being able to accept and send NPIs.If this is the case, then they may establish contingency plans to facilitate the compliance of their trading partners.
It is important to note that after May 23, 2008, legacy numbers will not be permitted on any inbound or outbound transactions.
CMS will determine on a case by case basis whether reasonable cause for noncompliance exists, and if so, the extent to which the time for fixing the noncompliance should exist.
Remember that applying for an NPI is fast, easy and free.If you have not obtained your NPI, you may do so at the National Plan/Provider Enumeration System (NPPES) website, http://nppes.cms.hhs.gov/.
The Competitive Acquisition Program (CAP) was implemented as a requirement of section 303 (d) of the Medicare Modernization Act.This program, for traditional Medicare Part B subscribers only, is for Part B drugs and biologicals not paid on a cost or prospective payment system.Beginning January 1, 2006, physicians were given a choice of buying and billing these drugs under the average sales price (ASP), or obtaining the drugs from a vendor selected in a competitive bidding process.
Participation in the CAP is voluntary, but once a physician has elected to participate in CAP, he/she must obtain all drugs on the CAP drug list from Bioscrip, the approved CAP vendor for 2007.Bioscrip will be responsible for submitting a claim for the drug to the designated carrier and for collecting the deductible/co-insurance from the beneficiary. Physicians may still continue to purchase and bill Medicare under the Average Sale Price (ASP) system for those drugs that are not provided by BioScrip, Inc.
The regular 2007 CAP physician election period concluded on December 1, 2006. Physicians who are new to Medicare may still elect to participate in the CAP during their first 90 days of Medicare participation by submitting a Physician Election Agreement form.When members of a group practice bill Medicare using the group's Physician Identification Number (PIN) or (NPI), they commit as a group practice to participate in the CAP.
Open enrollment for the CAP program is going on now, from May 1, 2007 through June 15, 2007.The Physician Election Agreement form is available on the CMS website.Completed and signed election forms must then be returned by mail to Palmetto GBA.Participation will then begin on August 1, 2007.
**The Beckley workshop will be shared with participants of the Beckley Chapter of the Office Managers Association's seminar.To register for this seminar, please contact Pat Almond (304) 256-0770 or via email pat_almond@beckleysurgical.com.
The Mountain State Blue Cross Blue Shield Physicians Advisory Committee (PAC) held its inaugural meeting recently. Meeting attendees, both physician members and other attendees, felt the committee accomplished a significant amount during the time they were together. The PAC is composed of physicians from various geographic areas of the state.Also included on the PAC are provider representatives who deal with billing, coding and administration issues.Evan Jenkins and Barbara Good serve as the WVSMA representatives on the PAC.
The purpose of the PAC is to give physicians a mechanism to offer advice, recommendations and comments to MSBCBS regarding provider billing, coding and administrative issues.These issues may include improvement of health care delivery, clinical quality, cost-effectiveness of services, communication and cooperation.
The PAC does not have jurisdiction to consider any of the following issues:
MSBCBS clinical polices concerning medical necessity, investigational or experimental service determinations, or criteria for coverage,
Scope of coverage,
Eligibility,
Level of fees or plan reimbursement,
Individual provider billing, payment or coverage disputes or appeals,
Legal interpretation of MSBCBS's contracts, policies or manuals.
The PAC roster will soon be published on the MSBCBS website (www.msbcbs.com).Physicians who have issues that they wish to be addressed by the PAC may send an email to PAC@MSBCBS.com or contact Barbara Good, WVSMA Physician Practice Advocate, at Barbara@wvsma.com.
MountainState Blue Cross Blue Shield recently announced an increase in the conversion factors, effective July 1, 2007, for services provided on or after this date.MSBCBS is also adopting the CMS Transitional RVU values and the Budget Neutral Work Factor as of July 1, 2007.
A summary of the new reimbursement methods and fees may be found on the MSBCBS website www.msbcbs.com
On May 2, 2007, the Wall Street Journal published the results of AthenaHealthcare's second annual payor rankings.AthenaHealthcare, which is a provider of payment software and services for physicians, ranked more than 130 national and regional health insurers based on how accurately and timely they reimburse physicians.The rankings are done by tracking claim payment times, denial rates and adherence to Medicare's payment rules for its physician clients.Data from 8500 practices was used for the rankings.
CIGNA, who ranked 5th last year, is ranked #1 this year.The plan attributes the rise in rank to investments in claims-paying technology.Aetna, ranked #2 in overall performance, actually having the lowest days in Accounts Receivable of any payor.United Health Group, Inc. ranked last with an average claims payment time of 38.3 days.
You may view the complete 2007 Health Insurance rankings at www.athenaPayerView.com.
Physicians who are prescribing controlled substances for patients and are concerned about prescription drug diversion now have a means to check and see that the drugs are being used appropriately.
The WV Board of Pharmacy now has a program, the Controlled Substances Monitoring Program, where physicians may go online and check to see if patients are obtaining additional controlled substances from other physicians.
To enroll in the Controlled Substances Monitoring Program, physicians may contact Michele Hanchosky, an analyst at the WV Board of Pharmacy, (304) 558-0558 to obtain an application.Once registered, you will be able to go online to check to see the quantity of controlled substances a patient is obtaining.Physicians who are presently using this system have found it to be very beneficial.
AccessWV is a health plan created by West Virginia statute to provide health insurance to West Virginians who have been unable to find health insurance or who have been denied health insurance in the private market because of a medical condition. It also provides coverage to people who are eligible under the Federal Portability Act or under the IRS Health Coverage Tax Credit Program
The AccessWV plan does not require West Virginia physicians to accept their members; however, since this plan provides competitive benefits and a reasonable payment rate, physicians are encouraged to accept those individuals covered by AccessWV.
AccessWV is administered by PEIA using their subcontractors, Wells Fargo and ExpressScripts. Claims should be sent to the same Post Office Box as PEIA and CHIP claims. Bills are processed using the same procedures as currently used for PEIA and CHIP. Payments are made weekly. Providers will receive a check or electronic funds transfer from the State Treasurer's office and a separate remittance advice from Acordia National (Wells Fargo). AccessWV utilizes the same precertification and prior authorization policies and procedures that are applicable for those persons covered by PEIA. Acordia National's dedicated line for AccessWV is 1-866-864-6142.
AccessWV pays at the PEIA fee schedule for services provided by West Virginia providers and suppliers, Participating out-of-state providers are paid based on Acordia contracts. To encourage members to receive services in West Virginia, claims from out-of-state providers are subject to higher cost-sharing. The legislation prohibits "balance billing" of AccessWV members. The AccessWV co-pays are the same as the PEIA PPB Plan A copays.
AccessWV encourages physicians to refer their patients who are unable to find health insurance in the regular market due to health conditions. The toll-free number for AccessWV is 1-866-445-8491.
The American Medical Association Private Sector Advocacy Unit has asked that state associations alert physicians to a solicitation tactic being used by Three Rivers Provider Network.The solicitation document being distributed to physicians appears to be a routine request for a W-9 form in order to reimburse for services rendered to a Three Rivers member or payor. Physicians are asked to sign and fax a reimbursement form to Three Rivers.
In actuality, the form is an agreement, and if the physician signs, he/she is agreeing to be "in network" with Three Rivers Provider Network.In addition, a physician who signs the agreement agrees to accept 25% off their fees. The Three Rivers agreement states that there is no fee schedule and that members shall be billed in accordance with regular billing practices.It also states that the facsimile signature of the physician legally binds the party (ies) to the two year agreement.
The AMA has sent a letter to Todd Breeden, Three Rivers CEO, requesting that Three Rivers describing concerns about this solicitation.At this time, there has been no reply received from Three Rivers.
Physicians can still restrict access to their prescribing data despite a recent court ruling in New Hampshire. A federal judge recently struck down a New Hampshire law that banned the purchase and resale of physician data for use by drug companies, concluding that the law violated the First Amendment because it improperly restricts commercial speech.
The American Medical Association reminds all physicians that they may still elect to prevent pharmaceutical sales representatives from accessing their data through the AMA Physician Data Restriction Program (PDRP). The PDRP empowers physicians to opt out of sharing prescribing data with pharmaceutical sales representatives. The PDRP keeps the data available for researchers to advance important public health benefits, such as timely and appropriate communication about drug recalls and evidence-based medical research. The AMA does not collect, sell or have access to prescribing data.Instead, it provides a way for doctors to determine how their data will be used. All physicians are eligible for the PDRP.
Physicians are reminded that beginning July 1, 2007 any billing for drugs must include the appropriate NDC number.The NDC number being submitted must be the actual NDC number on the package or container from which the medicine was administered.You are also required to include the Unit of Measurement when billing the NDC number.
Unisys has scheduled June Provider Workshops throughout the state.Three sessions will be held at each location listed below.One workshop will be presented by Unisys, one by PEIA and one by Coventry concerning the new PEIA Retiree plan.
The workshop dates and locations are listed below:
Monday, June 4, Martinsburg-Holiday Inn, 301 Foxcroft Avenue
Tuesday, June 5, Flatwoods-Days Inn, 200 Sutton Inn
Wednesday, June 6, Huntington-Big Sandy Superstore Arena, 8th Street and 3rdAvenue
Thursday, June 7, Charleston-200 Civic Center Drive
Monday, June 11, Wheeling-McClure House, 1200 Market Street
Tuesday, June 12, Morgantown- Ramada Inn, I-79 and Exit 148& Exit 1, US 119N
Wednesday, June 13, Parkersburg-Holiday Inn, US Rt. 50 and I-77
Thursday, June 14,Beckley-Country Inns and Suites, 2120 Harper Road
Brickstreet encourages physicians to enroll in their PPO, StreetSelect.Although a claimant may seek initial care by a provider not enrolled in StreetSelect, an attempt will be made to direct any follow up care to a StreetSelect provider.To enroll in StreetSelect, you may contact BrickStreet at (304) 926-3479, ext. 5227.
StreetSelect network physicians are paid a PPO Administrative Medical Case Management Fee (AES01) of $55.00 once a month for a period of 6 months.
Additional information regarding Brickstreet may be obtained at the website www.brickstreet.com.
Do you have an I-9 form on file for each of your employees?If not, you should obtain one for each of your employees, unless he or she was hired before November 7, 1986 and has been continuously employed in your practice.The I-9 form verifies employment eligibility by requesting information and documentation from new employees.
The Immigration Reform and Control Act made all U.S. employers responsible to verify the employment eligibility and identity of all employees who were hired to work in the United States after November 6, 1986.In order to comply with the law, employers are required to complete the Employment Eligibility Verification forms (Form I-9) for all employees, including United States citizens.
Employers are required to maintain I-9 records in their own files for 3 years after the date of hire or 1 year after the date employment is terminated, whichever is later.This means that you should have an I-9 file for current employees, as well as terminated employees whose records remain within the retention period. These documents are not sent to the government; rather, they are kept in your office (or offsite) but you must be able to produce them within 3 days of an official governmental request for the documents.Although it is not a government requirement to have a separate file for these documents apart from the personnel files, it is often recommended that this be done in order to more easily locate the I-9 forms should you be visited by an inspector.
The Office of Management and Budget (OMB) control number on the current I-9 form expired on March 31, 2007 and a new form will be issued soon.You are still required to comply with the employment eligibility verification and may use the forms currently on the website.
The WV Office Managers Association (OMA) is recruiting new members for their organization.The state organization is comprised of 11 chapters conveniently located throughout the state.These chapters have meetings monthly and bi-monthly and are a valuable resource for office managers and the physician practices they manage.
The mission of the OMA is to promote the improvement of professional knowledge of persons in supervisory positions for physicians.This group provides both educational opportunities for office managers and opportunities for networking with other office managers and supervisors.The OMA also monitors the development and promotes awareness of proposed legislation which may impact the health care profession.
Please encourage your office manager to become affiliated with a chapter of the Office Managers Association.If he/she is not a member, the OMA will be glad to send an application and invitation to meetings.For more information, including chapter addresses, please feel free to contact Barbara Good (extension 11 or Barbara@wvsma.com).
Physicians can earn up to 13.5 hours of CME at the "Improving Patient Care with Health Information Technology" conference set for June 15-16 at the Waterfront Place Hotel in Morgantown.
This conference will provide practical information for physicians, nurse practitioners, nurse managers, office group managers and medical group managers to encourage the adoption and implementation of health information technology.
The conference is co-hosted by the West Virginia Medical Foundation's Center for Electronic Health Best Practices and West Virginia University School of Medicine's Office of Continuing Education.
The WVU Office of CME designates this educational activity for a maximum of 13.5 AMA PRA category 1 Credits. Physicians should only claim credit commensurate with the extent of their participation in the activity. This continuing education activity has been provided by the West Virginia University School of Nursing for 16.2 contact hours. The West Virginia University School of Nursing is an approved provider of continuing education by the State of West Virginia Board of Examiners for Registered Professional Nurses, Legislative Rule
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