Top

(Information provided by the American Medical Association)

The AMA has received the following message from the Centers for Medicare and Medicaid Services (CMS) regarding the details of Medicare claims processing under the new law.

"On June 25, 2010, President Obama signed into law the ‘Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010.’ This law establishes a 2.2 percent update to the Medicare Physician Fee Schedule (MPFS) payment rates retroactive from June 1 through Nov. 30, 2010. The Centers for Medicare and Medicaid Services (CMS) has directed Medicare claims administration contractors to discontinue processing claims at the negative update rates and to temporarily hold all claims for services rendered June 1, 2010, and later, until the new 2.2 percent update rates are tested and loaded into the Medicare contractors’ claims processing systems. Effective testing of the new 2.2 percent update will ensure that claims are correctly paid at the new rates. We expect to begin processing claims at the new rates no later than July 1, 2010. Claims for services rendered prior to June 1, 2010, will continue to be processed and paid as usual.

"Claims containing June 2010 dates of service which have been paid at the negative update rates will be reprocessed as soon as possible. Under current law, Medicare payments to physicians and other providers paid under the MPFS are based upon the lesser of the submitted charge on the claim or the MPFS amount. Claims containing June dates of service that were submitted with charges greater than or equal to the new 2.2 percent update rates will be automatically reprocessed. Affected physicians/providers who submitted claims containing June dates of service with charges less than the 2.2 percent update amount will need to contact their local Medicare contractor to request an adjustment. Submitted charges on claims cannot be altered without a request from the physician/provider. Physicians/providers should not resubmit claims already submitted to their Medicare contractor."

Top

There has been much conflicting information regarding physician and other provider enrollment in the Medicare PECOS system.   Due to the confusion, we are including the following information which was supplied by CMS.

The Centers for Medicare & Medicaid Services (CMS) is working with providers to address concerns about enrollment in the Provider Enrollment Chain and Ownership System (PECOS) to ensure that Medicare beneficiaries continue to receive the health care services and items they need.  PECOS is the electronic system used to enroll physicians and eligible professionals into the Medicare program.

As part of those efforts, CMS will, for the time being, not implement changes that would automatically reject claims based on orders, certifications, and referrals made by providers that have not yet had their applications approved by July 6, 2010.   While more than 800,000 physicians and other health professionals have enrolled and have approved applications in the PECOS system, some providers have encountered problems.  CMS is continuing to update and streamline the process, and more providers have been enrolled in the past few days.

CMS issued an interim final regulation on May 5, 2010 implementing provisions of the Affordable Care Act that permit only a Medicare enrolled physician or eligible professional to certify or order  home health services, durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) , and certain items and services under Medicare Part B.  The new law applies to orders, referrals and certifications made on or after July 1.  The comment period for the regulation closes on July 6, after which the comments will be reviewed and considered before a final regulation is issued. 

The Affordable Care Act provisions and the regulation were designed as steps to prevent fraud in Medicare by ensuring that only eligible and identifiable providers and suppliers can order and refer covered items and services to Medicare beneficiaries.

Many physicians and other providers and suppliers have continued to make good faith efforts to comply with the requirements of the law and regulation.  These efforts will be a significant factor in determining the procedures and processes that will be incorporated in the final rule.

While the regulation became effective July 6, 2010, CMS will not implement automatic rejections of claims submitted by providers that have attempted to enroll in PECOS.  However, until the automatic rejections are operational, providers should not see any change in the processing of submitted claims, they will continue to be reviewed and paid as they have historically been reviewed and paid.

Additionally, though CMS is taking a more deliberative approach to using the PECOS enrollment system, the agency will employ a contingency plan to meet the ACA requirement that written orders and certifications are only issued by eligible professionals effective July 1.

CMS will continue to send informational notices to providers reminding them of the need to submit or update their enrollment and will work with the provider community to provide guidance on enrollment and will process all applications expeditiously.  
 

Top

The Internet-based Provider Enrollment, Chain and Ownership System (Internet-based PECOS) can be used in lieu of the Medicare enrollment application (i.e., paper CMS-855) to:

• Submit an initial Medicare enrollment application
• View or change enrollment information
• Track the enrollment application through the web submission process
• Add or change a reassignment of benefits
• Submit changes to existing Medicare enrollment information
• Reactivate an existing enrollment record
• Withdraw from the Medicare Program

Note: Internet-based PECOS will be made available for suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) later this year.

Advantages of Internet-based PECOS

• Faster than paper-based enrollment (45 day processing time in most cases, vs. 60 days for paper)
• Tailored application process means you only supply information relevant to YOUR application
• Gives more control over your enrollment information, including reassignments
• Easy to check and update information for accuracy
• Less staff time and administrative costs to complete and submit enrollment to Medicare

Using Internet-based PECOS Is Easy!

Learn how to use the system by visiting the Getting Started Guide for Provider and Supplier Organizations on the CMS website.  Remember, creating a record in Internet-based PECOS can take several weeks for an organization provider.  It is recommended that you begin this process (if necessary) well in advance of any upcoming enrollment actions.  For more information on this setup process, visit the CMS website (www.cms.hhs.gov) and select Provider and Supplier Organization Overview. 
 

Top

Palmetto GBA is sponsoring 2 Medicare Part B Update Workshops in West Virginia. The workshops are specifically designed for providers with fewer than 10 full time employees. The session will include Medicare updates and reimbursement changes and be followed by a question and answer session. All small provider specialty offices are welcome to attend.

The first workshop will be held in Wheeling, West Virginia on Wednesday, August 11, 2010 from 1 p.m. to 4 p.m.   For additional information and to register, please visit:
http://www.palmettogba.com/palmetto/providers.nsf/vMasterDID/877KLR7850?opendocument

 The next day, Thursday, August 12, 2010, the same workshop will be presented in Beckley, West Virginia, from 1 p.m. to 4 p.m.  To register, please visit:
http://www.palmettogba.com/palmetto/providers.nsf/vMasterDID/877KLS3814?opendocument

Top

The Centers for Medicare & Medicare Services (CMS) has launched the official website for the Medicare & Medicaid EHR Incentive Programs. This website provides the most up-to-date, detailed information about the EHR incentive programs.

The Medicare and Medicaid EHR Incentive Programs will provide incentive payments to eligible professionals and hospitals as they adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology.

Bookmark this site and visit http://www.cms.gov/EHRIncentivePrograms/ often to learn about who is eligible for the programs, how to register, meaningful use, upcoming EHR training and events, and much more!

Top

Mountain State has finalized the review of the changes made by CMS to its 2010 RBRVS schedule. As the result of this review, Mountain State has concluded that adopting the changes would have a negative financial impact to the provider network. Consequently, Mountain State will not adopt the 2010 CMS RVUs for July 1, 2010 and the current Mountain State fee schedule (using CMS 2009 RBRVS) will continue in effect.

Mountain State will continue to use the 2009 CMS RBRVS values to include the West Virginia Geographic Practice Cost Index (GPCI) for all professional network providers in West Virginia and bordering counties.

Mountain State would like to provide an example regarding the RBRVS calculation for commercial business using the CMS WV GPCI related to the RVU work, practice expense and malpractice components. The laboratory fee schedule which uses Ingenix RVUs is not subject to the application of the WV GPCIs.

The GPCI values for West Virginia are:
Work = 1.0
Practice Expense = 0.827
Malpractice = 1.353

The formula for 2009 physician fee schedule payment amount is as follows:
2009 Non-Facility Pricing Amount =
[(Work RVU * Work GPCI) + (Transitioned Non-Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)]
* Mountain State Market Factor
2009 Facility Pricing Amount = [(Work RVU * Work GPCI) + (Transitioned Facility PE RVU * PE GPCI)
+ (MP RVU * MP GPCI)] * Mountain State Market Factor

For more questions regarding this notice please contact your External Provider Relations Representative or visit the Mountain State Blue Cross Blue Shield website at www.msbcbs.com

Top

Mountain State Blue Cross Blue Shield has announced the dates for their 2010 Provider Workshops.   For those unable to attend the workshops, the company plans to offer webinars.  These workshops are an excellent means of obtaining the latest news about the plan.

Here are the locations for the fall conferences.  More information about the workshops and the webinars will be coming soon.

Wednesday, September 15—Wheeling, WV—Oglebay Park
Wednesday, September 22---Beckley, WV------Tamarack
Wednesday, September 29---Parkersburg------Mountain State Corporate Office
Wednesday, October 13-------Morgantown-------Lakeview Resort
Wednesday, October 19-------Charleston---------Holiday Inn Charleston House

Top

Top

This information supplied by Molina (Unisys).

Molina (Unisys) reminds providers that if he/she is contracted with WV Medicaid, he/she must bill WV Medicaid for services provided to Medicaid members.  Participating WV Medicaid Providers cannot bill or collect fees from any Medicaid member unless the service is not covered by Medicaid. 

In order to bill the member for any non-covered service, a physician must have the member (patient) sign a document stating the member is aware that WV Medicaid does not cover the service and that the member will be held responsible for payment.  The member must sign this document prior to services being rendered.  Once services are rendered, participating WV Medicaid providers cannot bill members if the service turns out to be a non-covered service. 

If the physician does not accept WV Medicaid, he/she may request that the member sign an Advanced Beneficiary Notice (ABN) letting the member know that the practice does not accept WV Medicaid.   If this is done, the physician can bill the member.  If a physician sees and/or treats the member without an ABN, the member is NOT liable for payment.

BMS encourages non-participating providers to visibly post a sign in their office saying that he/she does not accept WV Medicaid members.  

For additional information, physicians may contact Molina Provider Relations at 1-888-483-3380. 

Top

More than $350 million is available in the UnitedHealth Group settlement fund to compensate physicians and their patients for 15 years of artificially low payments for out-of-network services. This settlement is the result of diligent work by the American Medical Association (AMA), the Medical Society of the State of New York and the Missouri State Medical Association. This settlement is the latest legal action in which the courts and regulators expose and prohibit a price-fixing scheme used by UnitedHealth Group and other health insurers to underpay physicians and patients for out-of-network care.
 
The AMA recommends that you file by October 5. 2010.  As a part of the UCR Settlement, UnitedHealth Group has agreed to make a settlement payment of $350 million, which will be distributed to physicians and patients whose payments for out-of-network services were based on skewed data from the insurer’s UCR database.

The AMA has created resources to aid physicians in filing a claim. Please visit www.ama-assn.org/go/ucrsettlement to access an educational webinar, a comprehensive FAQ list and a step-by-step guide to help maximize recovery of the settlement. Claim forms need to be completed and submitted by October 5, 2010. Don’t miss this opportunity to collect your share of the $350 million.

As a reminder, Dr. Edward Koza of United Health Group will be meeting informally with several staff members at the WVSMA office on Friday, July 16, at 9:00 AM.   If you would like to attend this meeting, please contact Karie Sharp (karie@wvsma.com) or Barbara Good (Barbara@wvsma.com). 

Top

The WVSMA, in partnership with Practice Management Institute, offered a second one day Chart Auditing for Physician Services class on Saturday, July 10, 2010.  Office administrators, nurses, coding/billing professionals and compliance officers attended the class which was held at St. Francis Hospital in Charleston.  

Participants received intense instruction in the following areas:

Adapting a systematic approach to cross-checking records
Improving communication with physicians and staff about chart documentation
Ensuring that appropriate levels of service are billed
Verifying appropriate levels of history, exam, and medical decision-making
Properly evaluating the nature of the presenting problem
Billing consultations versus other E/M services
Learning a step-by-step process to implement an internal audit program

The WVSMA will continue to offer classes and continuing education seminars for physician practices so be sure to watch for future announcements of upcoming events.
 

Top

The Medical Group Managers Association (MGMA) will hold their fall conference at Stonewall Jackson Resort in Roanoke, WV, on Wednesday, October 6 and Thursday, October 7, 2010.   More details, including reservation information, will be coming soon from the MGMA.

The Office Managers Association (OMA) will hold their fall conference at Pullman Plaza in Huntington, WV, on Thursday, October 14 and Friday, October 15, 2010.   Reservation information will be available soon. 

Both of these conferences feature outstanding speakers and workshops.   Physician practices can benefit greatly if their office administrator/manager attends.  For additional information, please contact Barbara Good (Barbara@wvsma.com).  

Top

• • Medicare Fee Schedule Update
• • CMS Begins Processing Claims With a 2.2% Increase
• • CMS to Review PECOS Enrollment Process
• • CMS Allows Using PECOS Instead of the Medicare Enrollment Application
• • Palmetto GBA Sponsors Forums
• • The Electronic Health Record (EHR) Incentive Program Website Now Available on CMS.gov
• • Mountain State Blue Cross Blue Shield Contracting and Reimbursement 2010 Update
• • Mountain State Blue Cross Blue Shield Provider Workshops
• • Molina Update
• • Billing WV Medicaid for Medicaid Members
• • United Healthcare Settlement Information
• • Chart Auditing Class a Great Success!
• • Save the Date for These Fall Conferences!

Like most professionals practicing medicine, are you tired of not having a life of your own?  Has your career completely taken over?  Wexford Health Sources, Inc. is currently seeking Medical Directors for openings at the Lakin Correctional Center located in West Columbia, WV, Mt.Olive Correctional Center in Mt. Olive, WV and St. Mary’s Correctional Center in St. Mary’s, WV.