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Medicare Payments Stabilized Through 2011
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On December 15 President Obama signed into law H.R. 4994, the “Medicare and Medicaid Extenders Act of 2010,” which stabilizes Medicare physician payments through the end of 2011. The legislation also includes funds to enable Medicare contractors to reprocess claims for physician services affected by provisions of the Patient Protection and Affordable Care Act with a retroactive effective date of January 1, 2010. AMA President Cecil Wilson, MD, and Board of Trustees Chair Ardis Hoven, MD, attended the ceremony, along with representatives of the AARP and the Military Officers Association of America, Senators John Barrasso, MD (R-WY) and Max Baucus (D-MT), and Representatives Pete Stark (D-CA), and Henry Waxman (D-CA).
In a statement made when this legislation cleared the Senate, President Obama noted: “It’s time for a permanent solution that seniors and their doctors can depend on and I look forward to working with Congress to address this matter once and for all in the coming year.” The WVSMA, along with the AMA, is committed to working to develop a long-term solution to the flawed Medicare physician payment formula that will achieve bipartisan support in Congress and by the Administration.
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Register Now For WVSMA's Mid-Winter Conference!
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The West Virginia State Medical Association’s Mid-Winter Conference and Business Meeting will be held on Friday, January 21, and Saturday, January 22, 2011. A full program is planned for the two day meeting, including a special “White Coat Day” at the Legislature. This always popular event will bring physicians and staffs together with fellow medical professionals in an effort to protect our liability reform and advocate for the practice of medicine with West Virginia lawmakers.
Registration for the conference will begin on Friday morning at the Embassy Suites hotel in downtown Charleston. Following a policy issues briefing, we will then move to the Statehouse for visits with legislators where we will discuss the importance of maintaining our medical liability reform and the 2011 WVSMA legislative policy agenda.
Join us at the Embassy Suites Friday afternoon for the popular West Virginia State Medical Association’s Practice Management Conference, Evening Reception, Risk Management Seminar, and Saturday’s WVSMA Annual Business Meeting.
The Embassy Suites Hotel has reserved a block of suites at the rate of $129.00 single/double(inclusive of internet). To reserve a suite at this rate, please make your reservation by 12/30/10 by calling 1-800-EMBASSY or 304-347-8700 X2035 or 304-720-6440 (Shawn Hawkins – in house group room coordinator) or go online to www.embassysuitescharlestonwv.com. After 12/30/10 date the rooms will no longer be available @ the rate listed above. You must use the SMA 3 letter code name when making reservations in order to receive the discounted rate. Online you will enter this SMA 3 letter code in the group/convention code space.
A preliminary schedule, as well as a registration form, is available at the WVSMA’s website, www.wvsma.com.
Mark your calendar now and plan to attend Mid-Winter Conference!
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Medicare News
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(This information supplied by CMS Regional Office In Philadelphia, PA)
A New Home Health Certification Requirement
A new Medicare home health law goes into effect on January 1st that affirms the role of the physician as the person who orders home health care based on personal examination of the patient. Effective in January, a physician who certifies a patient as eligible for Medicare home health services must see the patient. The law also allows the requirement to be satisfied if a non-physician practitioner (NPP) sees the patient, when the NPP is working for or in collaboration with the physician.
As part of the certification form itself, or as an addendum to it, the physician must document that the physician or NPP saw the patient, and document how the patient’s clinical condition supports a homebound status and need for skilled services. The face-to-face encounter must occur within the 90 days prior to the start of home health care, or within the 30 days after the start of care.
While the long-standing requirement for physicians to order and certify the need for home health remains unchanged, this new requirement assures that the physician’s order is based on current knowledge of the patient’s condition. In situations when a physician orders home health care for the patient based on a new condition that was not evident during a recent visit, the certifying physician or NPP must see the patient within 30 days after admission.
The new requirement includes several features to accommodate physician practice. In addition to allowing NPPs to conduct the face-to-face encounter, Medicare allow a physician who attended to the patient but does not follow patient in the community, such as a hospitalist, to certify the need for home health care based on their face to face contact with the patient in the hospital and establish and sign the plan of care. Medicare will also allow such physicians to certify the need for home health care based on their face to face contact with the patient, initiate the orders for home health services, and “hand off” the patient to his or her community-based physician to review and sign off on the plan of care. Finally, in rural areas, the law allows the face-to-face encounter to occur via telehealth, in an approved originating site.
Medicare home health plays a vital role in allowing patients to receive care at home as an alternative to extended hospital or nursing home care. Additional guidance will be available next week via a Special Edition article on the Medicare Learning Network website at: http://www.cms.gov/MLNGenInfo. Questions and answers regarding this requirement will be available the week of December 13th via Medicare’s home health agency website, http://www.cms.gov/center/hha.asp. Finally, physicians may expect a video training module describing this new requirement to be released within the next few weeks.
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Palmetto GBA News
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Redetermination Requests via Fax
Palmetto GBA will now accept Part B redetermination request via fax at (614) 473-6809. There is a 25 page limit and the request must be submitted within 120 days of the date of the original determination.
The redetermination request must contain the following information to be considered a valid request:
1. Beneficiary name
2. Medicare Health Insurance Claim number (HIC)
3. The specific service (s) and/or item for which the redetermination is being requested
4. The specific date (s) of service
5. The name and signature of the party or representative of the party
Physicians should specify if the request is related to a RAC or CERT overpayment. They should also send a copy of the overpayment demand letter and any spreadsheet sent with the demand letter, if it is related to an overpayment request.
New Policy Regarding Immediate Offsets
As of October 1, 2010, Palmetto GBA will no longer allow providers to request immediate offset as a payment method relating to voluntary/self disclosed Medicare overpayments.
Providers must submit a check made payable to Palmetto GBA or Medicare with the overpayment refund form. If the check payee is addressed differently, the check will be returned to the provider.
Overpayment refund forms received without check payment will be processed under established collection procedures mandated by CMS. Interest may accrue on these accounts.
Providers may request an immediate offset once an overpayment has been established and a demand letter has been received. Palmetto GBA suggests that providers request an immediate offset instead of mailing a check to Palmetto. They will then process immediate offset requests as soon as possible; however, this request does not guarantee that interest will not accrue on the overpayment.
Providers may request to be placed on “permanent immediate offset status” by notifying Palmetto GBA with a signed authorization to recoup all existing and any future overpayments through claim payment offset.
Coding Changes
As you are aware, ICD-9-CM codes are valid from October 1st through September 30th of each year. Claims submitted to Medicare with deleted or incorrect codes will be rejected. Any rejected claims must be fixed and resubmitted as NEW claims.
CPT and HCPCS codes are valid from January 1st through December 31st .
There are over 300 CPT code additions, deletions and changes for 2011.
As a reminder--- The WVSMA has made arrangements with Contexo Media for special pricing on coding books (both general and specific), practice management handbooks, software and data files, Medicare billing, compliance and other books. Contexo has a large selection of coding books and other materials that may be viewed on their website, www.contexomedia.com. To receive the special pricing, contact WVSMA’s contact, Cody Erickson, at (801) 365-2321 (phone). (801) 365-0710 (fax) or via email CErickson@contexomedia.com.
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Humana Changes EFT Policy
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Humana supports provider adoption of the Electronic Remittance Advice (835 ERA transaction). The plan has seen positive provider response in the form of significant adoption at all levels of practice and facility size. Adoption of the related Electronic Funds Transfer (EFT) process for actual payment has more potential to grow.
In order to create easier processes for EFT, Humana has implemented the following changes which have:
Significantly reduced lead time between claim finalization and EFT transmittal. This will result in funds being available to the provider 5-6 days sooner than a mailed paper check.
Synchronized the delivery of the ERA data file with the deposit in the provider's bank account.
Implemented a paper-less, web-based ERA/EFT request process that also supports bank account changes and other routine maintenance.
Adopted the CMS-recommended format for EFT transactions (CCD+) that is almost universally accepted by banking institutions.
Request process for Electronic Remittance Advice (ERA) and Electronic Funds Transfer Humana (EFT)
Humana offers providers a web-based, paperless tool for new ERA and EFT requests. This tool is available on the following web sites:
Humana.com (secure provider portal for registered users)
Humana.com (general access portal; prior payment information required for validation purposes)
Availity.com (secure portal)
The web site offers step-by-step instructions for completing the request as well as an FAQ document. Providers have the option of:requesting ERA only for delivery of the HIPAA 835 file via a clearinghouse, requesting ERA and EFT combined,or requesting EFT only (requires providers to obtain remittance data, either paper or download 835 ERA, from the secure Humana.com or Availity.com portals).
In each instance above, Humana discontinues the printing and mailing of the Remittance Advice / Explanation of Remit. This web tool can also be used to conduct routine maintenance to the provider account such as bank account changes, change to ERA clearinghouse or add/delete processing options.
The individual submitting the update request is provided with automated email notifications for those updates and a status of the request.
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Mountain State Prescription Drug Benefit Management Moving to Highmark, Effective Jan. 1, 2011
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(Information supplied by MSBCBS)
As Mountain State physicians are aware, Medco currently manages the prescription drug benefit, including prior authorization requests for certain prescription medications, for New Blue indemnity, SuperBlue® Plus preferred provider plan, SuperBlue Select point of service plan and Highmark Health Insurance Company (HHIC) FreedomBlueSM PPO Medicare Advantage plan. Effective with dates of service on or after Jan. 1, 2011, Highmark will manage the prescription drug benefit for those products. However, Medco will continue to be the claims processor for prescription drug claims for dates of service on or after Jan. 1, 2011.
The Highmark MRxC Program consists of online edits that encourage the safe and effective use of targeted medications. Many of the criteria are automated in order to reduce the administrative burden on physicians and to reduce member disruption. All MRxC programs include a mechanism by which a patient’s specific pattern of drug use is identified at the point of sale, and if the automated criteria are met, the claim will process automatically with no further authorization required. If the automated criteria are not met, the dispensing pharmacist will be prompted to have providers contact Highmark’s Pharmacy Affairs department for standard prior authorization processing.
The drugs or classes of drugs included in the MRxC Program are the Cox-II inhibitors, gastrointestinal medications, agents used for acute migraine, the oral antifungals, pain medications, leukotriene antagonists, medications used for opioid dependence, Strattera and Lyrica. Drugs in these categories are covered, subject to certain requirements.
Other components of Highmark prescription drug management include a Quantity Level Limit Program and Prior Authorization.
Quantity Level Limits
The Quantity Level Limits Program applies retail and mail-order quantity level limits to more than 50 medications. Quantity level limits are applied for a variety of reasons: (1) to prevent the stockpiling of medication; (2) to promote adherence to an appropriate course of therapy for reasons of efficacy and safety; and (3) to prevent medication misuse or abuse. Please take these limits into consideration when prescribing the medications. For additional information and a complete list of medications to which quantity level limits apply, go to www.msbcbs.com, select the Provider tab, go to News Quiklinks, and choose Prescription Drug Clinical Management Programs Summary.
Prior Authorization
Prior authorization is necessary for coverage for certain medications. In these cases, clinical criteria, based on plan coverage conditions approved by the Pharmacy and Therapeutics Committee, must be met or other information must be provided before coverage is considered. The provider must submit documentation of the rationale for the use of the medication before the member is eligible for coverage.
To request a drug that requires prior authorization, please use the following procedure:
• NaviNet-enabled providers: If you are NaviNet-enabled, you must use the NaviNet Authorization Submission function to request prior authorizations for certain prescription medications. Simply go to Authorization Submission, enter the date of service and patient information then select the Prescription Drug category. This secure tool reduces faxing, decreases costs and improves decision communication time to providers.
• Providers who do not have NaviNet can complete a medication request form and fax to 412-544-7546. To obtain a form, please call 1-800-600-2227 and one will be sent to you.
Approvals are promptly loaded into the system, and the prescription can be filled for the member at the pharmacy. In the case of an authorization denial, the system sends the request to a Highmark Medical Director (physician) for review and final decision. The prescribing physician and member are quickly notified.
For additional information and a complete list of the more than 40 medications* for which prior authorization is required, go to www.msbcbs.com, select the Provider tab, go to News Quiklinks, and choose Prescription Drug Clinical Management Programs Summary.
* Please note, some drugs included under this program may be covered, excluded, or require prior authorization depending on the product and/or group-specific requirements.
The Pharmacy and Therapeutics (P&T) Committee has approved all aspects of the MRxC, Quantity Level Limits and Prior Authorization programs and their policies. This Committee is composed of network physicians and pharmacists, who consider the safety, efficacy, and appropriate use of medications when reviewing these policies. Changes and updates to these criteria are distributed quarterly via a Formulary Update, which are distributed to all network providers.
You can also access complete formulary information at http://mydrug.formularies.com.
If you have specific questions about any of these programs, please contact Provider Service at 1-304-424-7795 or 1-800-798-7768, or you may contact your assigned Provider Relations Representative.
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UnitedHealthcare News
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New coordination of benefits policy
Effective December 1, 2010, UnitedHealthcare has switched to a “pay and pursue” coordination of benefits (COB) model for commercial claims processed with a billed amount of $10,000.00 or less.
What this means is that claims less than $10,000 in billed charges will be processed and released for reimbursement regardless of pending coordination of benefits inquiries. The “pay and pursue” model supports UnitedHealthcare’s efforts to improve the provider service process.
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UnitedHealthcare is committed to improving the provider relationship and welcomes any feedback related to COB issues.
UnitedHealthcare Supply Policy update
Per the Centers for Medicare & Medicaid Services (CMS), Healthcare Common Procedure Coding System (HCPCS) supply codes are not separately reimbursed. The costs of supplies are considered included in the Evaluation and Management (E/M) and/or procedure when performed in a physician's or other health care professional’s office. A current list of the supplies not separately reimbursed can be found in the Supply Policy available at UnitedHealthcareOnline.com > Tools & Resources > Policies & Protocols > Reimbursement Policies.
CMS indicates that medical and surgical procedures should be reported with the Current Procedural Terminology (CPT®)/HCPCS codes that most comprehensively describe the services performed. Since July 1, 2001, HCPCS codes A4570, A4580 and A4590 have not been considered valid for Medicare use. Instead, CMS directed physicians and other health care professionals to report the Q codes for more specific billing of casting and splinting supplies.
Consistent with CMS correct coding guidelines, the UnitedHealthcare Supply policy is being revised to deny HCPCS codes A4570, A4580 and A4590. Providers should report the more descriptive HCPCS codes Q4001-Q4051 to report casting and splinting supplies.
This policy will be updated in the second quarter of 2011.
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December 17, 2010
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