The WVSMA’s inaugural Certified Medical Office Manager (CMOM) course being held in April has generated much interest throughout the state. The WVSMA, in partnership with the Practice Management Institute, will offer the four-day Certified Medical Office Manager (CMOM) class, which will teach experienced staff proven strategies to lead the medical practice to increased productivity and efficiency. The class currently has a full enrollment and a waiting list.  Due to the high demand for the course, we anticipate offering another class later in the year.
  
The course will take place in Charleston for two days during two different weeks in order to minimize office downtime.  Participants will be able to “try out” their newly learned skills during the week in between classes.  The course is scheduled for Friday, April 16 and Saturday, April 17, and then again on Friday, April 23 and Saturday, April 24.  The certification exam will be given on April 24.   In order to receive credit for the class, participants must attend all four sessions.  

The WVSMA is proud to be the exclusive West Virginia partner for the CMOM certification.   We anticipate offering additional classes, as well as other certifications, in the not so distant future.
 

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On March 26, 2010, an announcement was made by CMS that they have instructed their contractors to hold claims for services paid under the Medicare Physician Fee Schedule for the first 10 business days of April, 2010. 

The Centers for Medicare & Medicaid Services (CMS) is working with Congress, health care providers, and the beneficiary community to avoid disruption in the delivery of health care services and payment of claims for physicians, non-physician practitioners, and other providers of services paid under the Medicare Physician Fee Schedule (MPFS).  As you are aware, the Temporary Extension Act of 2010, enacted on March 2, 2010, extended the zero percent (0%) update to the 2010 MPFS through March 31, 2010.   

CMS believes Congress is working to avert the negative update that will take effect April 1, 2010.  Consequently, CMS has instructed its contractors to hold claims containing services paid under the MPFS (including anesthesia services) for the first 10 business days of April.  This hold will only affect claims with dates of service April 1, 2010, and forward.  In addition, the hold should have minimum impact on provider cash flow because, under the current law, clean electronic claims are not paid any sooner than 14 calendar days (29 for paper claims) after the date of receipt. 

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The West Virginia Public Employees Insurance Agency recently began an audit to determine the eligibility of their insurees.   PEIA has approximately 90,000 policy holders who claim a total of about 112,000 dependents.   It has been estimated that approximately 6% of the dependents who were covered under PEIA are not actually eligible for coverage.

PEIA has contracted with Healthcare Data Management Inc. (HDM) to identify and remove ineligible dependents from PEIA coverage (health and dependent life insurance coverage). All PEIA policyholders with dependents are being asked to provide dependent eligibility documentation. Policyholders must submit both the grace-period affidavit and the proof-of-eligibility documents by the date in the letter received from HDM. 

Subscribers must provide acceptable documentation to verify the eligibility of each dependent that is enrolled in the PEIA program. The list of proof-of-eligibility documents required are included in the mailing that was sent by HDM.   Examples of documentation include a 2008 Federal Income Tax Return (Page 1 only) and a marriage certificate for a spouse, or a birth certificate for a dependent child.   HDM is requesting only copies of the documentation and not the original forms. 

Interestingly, a similar audting process in Ohio was recently completed.  Ohio’s first review of dependent eligibility found nearly 6,000 dependents of state workers were ineligible for coverage.   Coverage for the ineligible dependents has now been dropped and the action is expected to save the Ohio about $10 million annually.

If patients or physicians have questions regarding the WV PEIA audit, they may contact HDM Customer Service at 1-800-936-0393.

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Physicians who have not updated their enrollment information since the Medicare Provider Enrollment, Chain and Ownership System (PECOS) database was created in 2003 should be on the lookout for a letter from their Medicare contractor requiring them to "revalidate" their information. Physicians are required to respond within 60 days to revalidation requests, or they risk having their billing privileges revoked for up to a year.

The American Medical Association was able to again delay an onerous referring / ordering physician enrollment policy until January 3, 2011. Medicare requires that all submitted claims contain the name and NPI of the referring / ordering physician. Under the new policy, if a physician who is not enrolled in PECOS orders services or refers patients to another physician who bills Medicare, then the claims submitted by the billing physician will not be paid. In other words, if Doctor A refers a patient to Doctor B, and Doctor A is not enrolled in the PECOS system, then Doctor B's claims to Medicare will be rejected starting January 3, 2011. The CMS enrollment program contains a significant number of problematic policies and the AMA will continue to advocate on behalf of physicians so they can spend more time with their patients and less time on their paperwork.

Due to scheduled maintenance, Internet-based Provider Enrollment, Chain and Ownership System (PECOS) will be unavailable from Monday, March 29, 2010 through Monday, April 5, 2010.  Internet-based PECOS allows physicians, non-physician practitioners, providers, and other suppliers (except suppliers of durable medical equipment, prosthetics, orthotics, and supplies [DMEPOS]) to enroll or make a change to their existing Medicare enrollment information over the Internet.

If you would like to enroll or make a change to your existing Medicare enrollment record, you should use Internet-based PECOS prior to March 29, 2010 or after April 5, 2010.
 

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Physicians are reminded that all physicians and non-physician practitioners must comply with Medicare reporting responsibilities and report relevant address and other enrollment changes in a timely manner. For example, failure to report an address change timely may affect your billing privileges and payment of claims.  It is not sufficient to send a letter stating a change in your practice information. You must complete the appropriate Medicare form. 

For more information, see the Palmetto GBA website:

http://www.palmettogba.com/palmetto/providers.nsf/vMasterDID/7WLM358734?opendocument
 

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Although there have been some specifics given, there are still many questions as to the stimulus monies available for electronic health records.

As you may be aware, there are 2 kinds of stimulus monies available---Medicare and Medicaid.   For the Medicare stimulus dollars, physicians must be a licensed non-hospital based eligible professional (MD, DO, Dentist, DPM, OD or Chiropractor).  They also must meet all the criteria for meaningful use (which is changing constantly).  If these qualifications are met, they are eligible for the $44K in 2011/2012, then $39K in 2013, and $24K in 2014.

For Medicaid dollars, eligible professionals include doctors, dentists, NPs, CNWs, and Physician Assistants in a FQHC or RHC.  Providers must also have a minimum Medicaid patient threshold of 30% or more.  A pediatrician must have 20% or more and an RQHC or RHC---30% or more “needy” patients.   These incentive dollars (up to $63, 750) are to be based on maximum allowable cost up to 6 years. 

Both stimulus packages are based on the physicians’ use of a CCHT certified EHR system.  

It is important to remember that the stimulus dollars are based on usage of the EHR system, and are not given in order to purchase a system.

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In order to more efficiently register newborns in the UniCare system and avoid denial of nursery payments, effective June 1, 2010, hospitals serving UniCare’s members enrolled in West Virginia’s Medicaid Managed Care program are required to obtain an authorization when a newborn is admitted to the hospital nursery. This process coincides with UniCare’s contractual obligation to notify the Bureau for Medical Services of all deliveries by UniCare-covered mothers within 30 days of the date of birth.

Important Details Regarding Policy Change

Providers serving Medicaid Managed Care members are required to obtain an authorization for nursery admission, regardless of length of stay or reasons for admission. This may be done by completing the Newborn Enrollment Notification Report form and sending it to UniCare within three business days of delivery. Failure to obtain an authorization will result in denial of a hospital’s claim for nursery charges. Providers may appeal these denials by following the appeal procedures described in the UniCare provider manual.

For denials issued within 90 days after the effective date of June 1, 2010, UniCare may overturn the denied nursery claim when the following is done:

1. File a claims appeal following time limits from date of denial as outlined in UniCare’s Provider Operations Manual (available on the provider website); and
2. Include a completed Newborn Enrollment Notification Report form.

Once the 90-day grace period has passed, UniCare will uphold the denial on appeal and they will not pay the claim.

The Newborn Enrollment Notification Report form has two new fields that must be completed – the ICD-9 and Diagnosis Description, both of which are required for authorization of nursery services.  The updated form may be found online by following these steps:

1. Visit www.unicare.com and click on the Providers tab to the left, and then under Learn More, click on State Sponsored Plans.
2. Click West Virginia – Medicaid Managed Care to access the Provider Resources page.
3. Under Forms and Tools, click Forms and Tools Library.
4. In the Forms and Tools Library, click on– Newborn Enrollment Notification Report under the General Forms header.

You will find a copy of the updated Newborn Enrollment Notification Report form for your use as the second page of this document.
If physicians need to admit a baby for health reasons beyond a normal nursery admission, please complete the Newborn Enrollment Notification Report and the Request for Preservice Review. The latter form is located in the Prior Authorization Toolkit on our provider website.

To submit the authorization, please use:
Utilization Management Fax: ……… 1-888-209-7838
Utilization Management Phone: …… 1-866-655-7423

If you have any questions, please contact UniCare’s Customer Care Center at 1-800-782-0095.

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It was recently learned that UnitedHealthcare was denying certain claims of physicians who only provide part of a patient's antepartum care as a result of spontaneous abortion, change of insurance or transfer to another practice. The circumstance was primarily affecting antepartum services using E&M codes and reported with modifier 25 on the same day as the ultrasound in which physicians would itemize the antepartum services by reporting E&M codes.

When the matter was brought to the attention of UnitedHealthcare, it was found that the denials were caused by a systems error that has since been corrected. According to UnitedHealthcare, physicians who received these claim denials for services rendered on or after Aug. 17, 2009 do not need to appeal or refile their claims. Instead, UnitedHealthcare will reprocess these claims. Physicians should receive corrected payments by the end of May.

Claims submitted to UnitedHealthcare on or after Mar. 15, 2010 will be processed according to the posted reimbursement policy available at www.UnitedHealthcareOnline.com.  UnitedHealthcare should be commended for its quick response in addressing this issue.   
 

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• • WVSMA CMOM Class Update
• • Medicare and Tricare Claims to Be Held
• • PEIA Audit
• • Medicare PECOS System Updates
• • Medicare Reporting Responsibilites
• • EHR Stimulus Update
• • BrickStreet Update
• • UniCare Update Regarding Newborn Registration Policy Change
• • United Health Care Update
• • West Virginia Office Managers Association "Save the Date"