PARAREV Weekly eJournal March 9, 2022

ej o u r n a l march9, 2022

Uncovering Lost Revenue Steps To Taking Control Of Lost Revenue

Mental Health

Imaging Guidance

Financial Health

A Booklet For Senior Care

Coding For 1 Interpretations

Important Considerations

PARA Weekly eJournal: March 9, 2022

IMAGING INTERPRETATION AND TECHNICAL COMPONENTS

Q.

We provide the TC only on all images. Are we required to have the professional

interpretation in the record to bill the TC? Nearly all of our images are ready by our contracted PC RAD group who returns a report to us promptly. But there are occasions when a chiropractor or ortho wants to do their own read. These images then, don't go to our PC group. Are we required to have the interpretation report from these ordering providers to be able to bill out the TC? Regarding CAH billing, we've not identified TC on the UB for our CAH claims. It has never been an issue with the radiology group getting paid for their PC on the claim line. However, should we be placing the TC on them when billing as a CAH?

A

. First, with regard to the TC modifier; when a facility reports an

imaging exam in a facility fee revenue code (i.e. a chest x-ray, CPT® 71046 under revenue code 0320 ? Diagnostic Radiology), the revenue code implicitly reports only the technical component ? no ?TC? modifier should be required. The TC modifier is intended for use on professional fee claims when one practice may perform the technical component, but a provider at a different practice performs the interpretation.

Hospitals cannot report a ?global? CPT® for an imaging exam which includes both the technical component and the professional interpretation. Hospitals must report the technical component under a facility fee revenue code; Method II CAHs may also report the professional interpretation with modifier -26 under a professional fee revenue code (in the 096x, 097x, or 098x revenue code series) on the UB04/837i claim form.

That being said, there are a few peculiar payers, such as California Medicaid (Medi-Cal), which require the TC modifier on imaging exams even when it is reported on a facility fee UB04/837i claim form under a facility fee revenue code.

Turning now to your question about the interpretation -- an interpretation of each imaging exam should be on file in the hospital?s medical records in order to support the medical necessity of the service.

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PARA Weekly eJournal: March 9, 2022

IMAGING INTERPRETATION AND TECHNICAL COMPONENTS

Images must be interpreted by an ordering professional for the diagnosis or treatment of an illness or injury, which is the principal condition of coverage by Medicare and any other payer.

Consequently, the hospital should obtain a copy of the interpretation performed by any physician when it is not automatically recorded through using the contracted radiology practice.

X-rays ordered by a chiropractor are not covered, per the Medicare Benefits Policy Manual, and chiropractors are not authorized to bill Medicare for the interpretation of imaging exams. While Medicare allows a physician other than the one actually treating the beneficiary for the disorder of the spine (such as the radiologist or beneficiary?s primary care physician) to order an X-ray to be used by a chiropractor for patient treatment, the chiropractor cannot bill for the interpretation. We recommend that if another physician orders the x-ray for use by a chiropractor, that the contracted radiology group should still provide an interpretation in order to meet Medicare coverage requirements.

More to the point, here?s an excerpt from the Medicare Benefits Policy Manual regarding the limited services that Medicare will cover when performed by a chiropractor ? and it tells us that the x-rays taken for use by a chiropractor must be interpreted by a physician: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf 240.1.1 - M an u al M an ipu lat ion (Rev. 1, 10-01-03) B3-2251.1 Coverage of chiropractic service is specifically limited to treatment by means of manual manipulation, i.e., by use of the hands. Additionally, manual devices (i.e., those that are hand-held with the thrust of the force of the device being controlled manually) may be used by chiropractors in performing manual manipulation of the spine. However, no additional payment is available for use of the device, nor does Medicare recognize an extra charge for the device itself.

No other diagnostic or therapeutic service furnished by a chiropractor or under the chiropractor ?s order is covered.This means that if a chiropractor orders, takes, or interprets an x-ray, or any other diagnostic test, the x-ray or other diagnostic test, can be used for claims processing purposes, but Medicare coverage and payment are not available for those services. This prohibition does not affect the coverage of x-rays or other diagnostic tests furnished by other practitioners under the program. For example, an x-ray or any diagnostic test taken for the purpose of determining or demonstrating the existence of a subluxation of the spine is a diagnostic x-ray test covered under §1861(s)(3) of the Act if ordered, taken,and interpreted by a physician who is a doctor of medicine or osteopathy.

Attached are a couple of MLN articles that offer general information about Medicare coverage of chiropractor services, although neither specifically answers your question .

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PARA Weekly eJournal: March 9, 2022

CODING QUERIES FOR MEDICAL NECESSITY

Q.

Is it ethical for a coder to query a provider simply to get a diagnosis that meets medical

necessity to ensure payment?I have been cautioned against this practice.

A

. There is nothing wrong with sending a query to a provider to

verify that a medically necessary diagnosis was not inadvertently omitted. Physicians and practitioners make mistakes through inadvertence or even typographical errors. A query is not a demand, it?s a question ? and it is not unethical to ask a question.

Ideally, the hospital would verify that a medically necessary diagnosis accompanied the order before performing a lab test or imaging exam.If no medically necessary diagnosis is offered at the time of order, Medicare instructs providers to give the patient an Advance Beneficiary Notice (ABN), which asks the patient to accept financial liability for a test that is not medically necessary.

However, sometimes the process to obtain an ABN is simply not feasible ? and the ABN process can be frustrating for both patients, ordering providers, and the individual tasked with explaining the ABN to the perplexed elderly patient.

A query to the ordering physician, particularly if it offers education as to the medical necessity standard, will reduce the quantity of medical necessity denials, which serves the interests of both the hospital, the ordering provider, the Medicare program, and the patient.

PARAREV's paper on managing medical necessity denials is available at https://apps.para-hcfs.com/pde/documents/Managing_Medical_Necessity_Denials.pdf; see the last page for a template notice to the ordering provider ? here?s an excerpt: Please be advised that our hospital cannot be paid for the above service because the diagnoses for this service does not support Medicare?s standard for medical necessity.

A copy of Medicare?s Local Coverage Determination policy is attached.We would be happy to provide more information on Medicare?s standards for this service upon request.If you have additional diagnosis information that supports the medical necessity of this test, please provide it in the space below and fax this letter back to the HIM department.

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PARA Weekly eJournal: March 9, 2022

CODING QUERIES FOR MEDICAL NECESSITY

Quest Diagnostics has an effective approach to provider education regarding medical necessity.

Quest offers concise guidance to physicians for the lab tests that are most commonly denied for medical necessity in each state. Their educational summary for each lab test offers a list of the diagnosis codes that meet medical necessity requirements, with the codes that are most frequently reported in bold type.

Here?s a link to their website for New Mexico: https://www.questdiagnostics.com/healthcare-professionals/billing-coding/ medicare-coverage-guides/jh-novitas

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PARA Weekly eJournal: March 9, 2022

CODING QUERIES FOR MEDICAL NECESSITY

Here?s a link for the Quest Diagnostics blood glucose summary? it?s only two pages long, diagnosis codes are on page 2: https://www.questdiagnostics.com/content/dam/corporate/restricted/documents/ mlcp/mlcp/national-guides/national-mlcp-190-20-blood_glucose_testing/ National---MLCP---190-20---Blood-Glucose-Testing.pdf

The bottom line is that it is unethical to insist upon or lead an ordering provider to a medically necessary diagnosis.

That being said, it is both compliant and helpful to all parties (including the Medicare program and Medicare beneficiaries) to offer education as to why the diagnosis they provided does not allow for coverage, and to ask an ordering provider if they have anything more to add that perhaps they failed to provide earlier.

If the provider says nothing to add, then that?s the end of it, there?s nothing to add.If we help ordering providers to understand why they?re being queried, oftentimes they?ll cooperate and/or at least think twice before ordering a test that does not meet medical necessity standards in the future.

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PARA Weekly eJournal: March 9, 2022

STAYING FINANCIALLY HEALTHY

HOSPITALSMUSTPROTECTREVENUECYCLE CAPABILITIESTOLIMITCOVID- 19?SFINANCIAL FALLOUTAs t heCOVID- 19 cr isis deepens, hospit al s nat ionwidear escr ambl ing t o ov er comeunpr ecedent ed cl inical and pat ient car edemands and disr upt ions.

As essential as these efforts are, it is also important that providers take steps to protect their revenue cycle operations and limit the economic fallout the pandemic is likely to produce. These actions can include adjusting financial projections to reflect the fast-changing operational environment and implementing alternative revenue cycle processes to help preserve cash flow.

Hospitals with appropriate safeguards should allow revenue cycle staff to work from home.

They should also consider enlisting trusted third-parties to supplement key elements of the revenue cycle, including accounts receivable management, to avoid cash flow disruptions.

Before reviewing operational concerns and considering assistance, any initial effort to meet the anticipated financial impact of the COVID-19 pandemic must start with revising financial performance targets, cash flow projections, and operational plans to reflect the following: - The extended suspension of higher-margin elective surgeries - The impact of increased supply costs and potential supply chain disruptions - The effect of rising labor costs due to extended operational demands - The balance sheet implications of declining investment income due to equity losses - The possibility of payer disruptions affecting prompt reimbursement

OPERATIONAL CONSIDERATIONS In addition to making necessary adjustments in their financial projections, hospitals should be aware of operational issues related to the COVID-19 outbreak that could negatively impact cash flow and overall performance.

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PARA Weekly eJournal: March 9, 2022

STAYING FINANCIALLY HEALTHY Among them: - Coders should be educated in the use of the new COVID-19-related CPT® and HCPCS codes for both private payer and government claims. And stemming from the National Emergency declaration, Medicare has expanded payments for professional services via telehealth, virtual check-ins, and e-visits. Failure to code COVID-19-related care correctly will likely result in denials and payment delays, which may be more difficult and time-consuming to resolve in the current environment - It is important that hospitals monitor clearinghouse or bank electronic data interchange (EDI) capabilities to ensure 837 and 835 files containing claims and payment information continue to transit between payers and providers. Some hospitals have reported sporadic interruptions in their EDI services. Any substantial downtime that prevents timely claims submission or denial resolution could have a significant impact on collections - Hospital payer mix may shift rapidly as a growing number of individuals suddenly find themselves out of work. Organizations should monitor claims frequently to determine if Medicare and Medicaid volume is increasing and/ or commercial reimbursement is falling.

Significant changes could have a major impact on budget projections - Payer hold times for hospital staff working denials in many instances have increased due to limited staff availability at insurance company call centers. As a result, any automation processes that allow claims to be resolved without direct payer-provider interaction should be brought to bear - If they haven?t done so already, hospitals should work with payers to enable the receipt of 266/267 claim status files from clearinghouses to ensure up-to-date information regarding the status of unpaid claims. Payer portals should also be used to monitor and track unpaid claims

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PARA Weekly eJournal: March 9, 2022

STAYING FINANCIALLY HEALTHY WORKING REM OTELY As hospitals reduce non-critical, on-site staff, ensuring that revenue cycle employees can continue coding, filing claims and handling accounts receivable follow-up from home is essential to keep cash coming in. Critical infrastructure elements needed to support secure, remote revenue cycle operations include: - Robust work-at-home platforms - Encryption both for data at rest and data in flight - Multifactor authentication - Secure operating environments Internal encryption capabilities built into laptops and remote workstations are essential to reduce or eliminate breach risks surrounding the transfer of protected health information.

Also important are virtual private networks and multi-factor logon authentication.

TRUSTED AND TIM ELY THIRD-PARTY ASSISTANCE Whether hospitals and other providers elect to shift revenue cycle staff to the home setting or not, they should consider partnering with a trusted third-party capable of taking over elements of the revenue cycle for the duration of the crisis.

Par aRev provides a full range of outsourced AR follow-up services, including aging claims resolution, denial management and bad debt mitigation to help ensure claims are clean and paid the first time around to mitigate any delays. More than 98% of the company?s workforce is now deployed remotely and all of Par aRev ?s remote work processes are HITRUST CSF® -certified.

Par aRev additionally uses data analytics and intelligent automation to expedite claims resolution, often without human touchpoints.

And for clients using the PARA Dat a Edit or , our services are built for remote access, so organizations can continue business as usual regardless of where personnel are working. Most importantly, Par aRev has the ability to scale up quickly to handle additional workflow. With assistance from the client, we can be up and running to manage aging AR and denials in a few days?time. Your organization can minimize or avoid cash flow disruptions while concentrating valuable employee resources in other areas.

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PARA Weekly eJournal: March 9, 2022

CHARGEMASTER AUDIT PROCESS: A COMPREHENSIVE REVIEW The Par aRev enuechar gemast er audit pr ocess ut il izes t hePARA Dat a Edit or (PDE) t o cr eat ea ser ies of f ocused scr eens and r epor t s ut il ized by t he Par aRev enueHIM Coding St af f t o ident if y and cor r ect char gemast er er r or s, compl iance issues, and missing char ges.

The PARA Dat a Edit or is the main tool used for the review; the PDE is available 24/7 to all Hospital Users.

There are 7 phases to the Par aReven u e Ch ar ge M ast er Com pr eh en sive Review process: -

Checking Invalid HCPCS and Revenue Codes Checking Line Items for Charge Compliance and Modifiers Checking Valid Code Assignment Claim review Department interviews with revenue-generating department managers Checking pricing against the Medicare fee schedules and APC reimbursement Reporting and implementing updates

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PARA Weekly eJournal: March 9, 2022

CHARGEMASTER AUDIT PROCESS: A COMPREHENSIVE REVIEW All query results in the PDE CDM t ab are color coded: - Red? Invalid code - Blu e? Code, procedure number, NDC, OE mnemonic or description which matches the filter query - Wit h in a code box?Par aReven u e / Hospital recommended changes - Pu r ple?Par aReven u e advisory recommended changes, to be reviewed by Hospital prior to implementation

The detail CDM Tab allows Par aReven u e and the Hospital User a view of all data tables tied to the charge items for a ?one stop? all encompassing review.

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PARA Weekly eJournal: March 9, 2022

CHARGEMASTER AUDIT PROCESS: A COMPREHENSIVE REVIEW Deliver ables -

Par aReven u e Chargemaster Analysts complete a desk review of the charge master line items with quantity prior to department manager interviews to identify items that may need further discussion with Department Managers. A complete package of reports indicating items that require update or further discussion is delivered, along with assistance in prioritizing and implementing the appropriate charge master changes

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A Par aReven u e Senior Revenue Cycle Consultant will conduct individual interactive discussions with each revenue generating department manager to review active charge line items for correct code use, charge capture, and compliant charge practices, generating a written report with specific recommendations listed for client consideration

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Par aReven u e coders select and review 100 outpatient claims to identify missing charges, accurate HCPCS and modifier use, units of service, and other compliance problems or billing issues

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Par aReven u e chargemaster analysts ensure that the charge master line coding is updated with each annual and quarterly CPT® /HCPCS release to ensure compliance with Medicare HCPCS coding requirements

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Par aReven u e provides support throughout the term of the contract for all coding, billing compliance questions through monthly client meetings and the Post-a-Question feature on the PARA Dat a Edit or .

Par aReven u e reviews and facilitates appropriate approvals for all charge master changes using the Charge Maintenance tab functionality in the PDE.

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PARA Weekly eJournal: March 9, 2022

CHARGEMASTER AUDIT PROCESS: A COMPREHENSIVE REVIEW Ph ase I ? Ch ar ge M ast er Desk Review The first portion of the charge master audit will be a review of CDM line items using the following filters:

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In valid- This filter will list each line item which has an incorrect code. The codes will be identified in red font, with any recommended changes displaying in the box provided

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Un it of ser vice ? per m l/ sq cm ? This filter will find all items in the charge master which should be billed using a unit of service identified in the HCPCS code description.The Par aReven u e service includes a detailed review of each pharmacy line NDC to determine if the charge process is set to calculate the correct units of service

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Ph ar m acy ? Self Adm in Dr u gs ? J Codes? This filter identifies Self-Administered Drugs to ensure compliance with Medicare coverage. The filter will allow the User to review each line, verify the code is correct, update the code, and then to be sure the line is coded correctly to be processed as Patient Liability in keeping with Medicare SAD rules.

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PARA Weekly eJournal: March 9, 2022

CHARGEMASTER AUDIT PROCESS: A COMPREHENSIVE REVIEW -

Ph ar m acy ? Self Adm in Dr u gs ? Iden t if ied f or r eview - This is a keyword search filter to identify lines in the charge master which are likely to be SAD and are not coded correctly in the system. The User can then review the line items and assign the correct code for billing

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DM E ? OPPS Exem pt ID f or Review ? This keyword filter identifies line items in the charge master which may be billed using a DME code under the 0274 revenue code. The User will be able to create a report to be reviewed by Materials Management to determine the correct ?L? code to be applied if a HCPCS is not readily identified from the description alone

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Con sist en cy? In some of the more complex patient accounting systems there are opportunities to maintain a number of different ?third party indicators?, all of the ?indicators? are mapped to a code type (CPT® , Medicare, Medicaid, Workers Comp, or Other), within the PARA PDE. This filter will assist the User in making sure the codes and segments within a code type are internally consistent. This filter allows the User to identify the ?background? codes which are different from the main upfront displayed codes and make appropriate corrections

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Blood? Review of blood charges to be sure that the Hospital does not incur a blood deductible for products billed using the 038X rev code series

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ED, Ur gen t Car e, Pr ovider Based Clin ics, an d Nu r sin g Pr ocedu r es? Review of the department charges to be sure the hospital is billing for the technical portion of physician procedures, and all separately billable nursing procedures are captured, charged, and correctly coded

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Radiology In t er ven t ion al Pr ocedu r es? Review the imaging departments to be sure all surgical procedures are coded appropriately and charged

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Im plan t s?Par aReven u e reviews all line items which contain key words in the charge description to be sure the implant revenue codes are assigned correctly.

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PARA Weekly eJournal: March 9, 2022

CHARGEMASTER AUDIT PROCESS: A COMPREHENSIVE REVIEW Ph ar m acy J code an d Un it of Ser vice Review ? This review utilizes the CMS National Drug Code (NDC) to HCPCS J-code audit file, ensuring that the correct units of service are reported, especially for expensive status K and G drugs.

Par aReven u e processes the Pharmacy clinical NDC data table into the PDE and then audits the currently assigned Jcodes and unit of service.

Par aReven u e will identify all invalid NDC codes, incorrectly assigned Jcodes, and incorrect units of service.

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Com plian ce ? Iden t if ied f or Review ? The compliance ID for review filter is driven by the ?Wheatlands? Medicare billable item PDF.This document can be found in the Hospit al Dow n loadssection of the PDE Advisor t ab. The filter will search the charge master forcompliance-related keywords and identify the items which should not be billed to the Program Com plian ce ? M odif ier s? With the focus on modifiers, this filter and review allows the User to review all modifiers ?hard coded? in the charge master to be absolutely sure the auto application of the modifier is correct.

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PARA Weekly eJournal: March 9, 2022

CHARGEMASTER AUDIT PROCESS: A COMPREHENSIVE REVIEW

The third portion of the charge master review is to identify items which are coded incorrectly, but the code is a valid code, or if the service assigned to the code is inconsistent with other services assigned to the same code. The process utilized for this review will be contained in the Au dit Repor t section on the right side of the Filt er s Tab.

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PARA Weekly eJournal: March 9, 2022

CHARGEMASTER AUDIT PROCESS: A COMPREHENSIVE REVIEW

The service line filters and audit reports are based on CPT® /HCPCS codes contained in the CMS Addendum B. Each of the codes are tied to a service line, in some cases a single code can be tied to several service lines.

By listing the codes in CPT® /HCPCS code sequence the codes are grouped together and allow a fast and efficient review. The Ser vice Lin e Filt er s and Au dit Repor t s can be utilized to identify any codes which are not currently contained in the charge master or where codes, prices or usage is incorrect.

The Ser vice Lin e Filt er s and Au dit Repor t s are very useful for multi-hospital groups to tie similar codes across different hospitals and departments, for consistent coding, charge descriptions and pricing.

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PARA Weekly eJournal: March 9, 2022

CHARGEMASTER AUDIT PROCESS: A COMPREHENSIVE REVIEW Par aReven u e will review 100 Medicare Outpatient claims to identify system, charge process capture issues, coding and compliance errors. The review will identify missing or inaccurate codes, units of service, inappropriate modifier usage, missing or incorrect pharmacy codes and pharmacy J-code units.

The PARA Dat a Edit or Claim Evalu at or sub tab is utilized in this review.

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PARA Weekly eJournal: March 9, 2022

CHARGEMASTER AUDIT PROCESS: A COMPREHENSIVE REVIEW If the claims are built in the Par aReven u e system utilizing the transaction data set on file, the detail transactions are available for access and review.

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PARA Weekly eJournal: March 9, 2022

CHARGEMASTER AUDIT PROCESS: A COMPREHENSIVE REVIEW Each of the ?corrections? to a claim is assigned a error code for reporting.

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PARA Weekly eJournal: March 9, 2022

CHARGEMASTER AUDIT PROCESS: A COMPREHENSIVE REVIEW The number of claims and supporting documentation for each type of claim is noted in the table below.

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PARA Weekly eJournal: March 9, 2022

CHARGEMASTER AUDIT PROCESS: A COMPREHENSIVE REVIEW Number of claims by type and supporting documentation, continued.

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PARA Weekly eJournal: March 9, 2022

CHARGEMASTER AUDIT PROCESS: A COMPREHENSIVE REVIEW There are several reports which can be generated ad hoc by the User, with two different sort options.

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PARA Weekly eJournal: March 9, 2022

CHARGEMASTER AUDIT PROCESS: A COMPREHENSIVE REVIEW The reports present all data elements, corrections and descriptions, in Detail or Summary view.

Par aReven u e can accept claims for review in a number of formats: - Submission of claims from an electronic 837 file import (recommended method) - Submission of claims in hard copy (paper) format, (extra charge to be billed for keying the claims by hand) - Reconstruction from an account header and transaction file, in addition to submitting the diagnosis ICD-9/ICD-10 and the billing HIM assigned HCPCS information and claims data, either in a data table or hard copy (paper) format 24

PARA Weekly eJournal: March 9, 2022

MEDICARE MENTAL HEALTH: A HELPFUL BOOKLET CM S n ow of f er s a com pr eh en sive r eview of M edicar e cover ed beh avior al h ealt h ser vices. Beh avior al h ealt h ser vices, t ypically r ef er r ed t o as m en t al h ealt h ser vices an d in clu des su bst an ce abu se, af f ect s a pat ien t ?s over all w ell-bein g. It ?s im por t an t t o u n der st an d M edicar e cover age of t h ese ser vices. Th is book let in clu des in f or m at ion on cover ed an d n on -cover ed ser vices, eligible pr ovider s, M edicar e Advan t age an d M edicar e dr u g plan cover age, as w ell as m edical r ecor d docu m en t at ion an d codin g.

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PARA Weekly eJournal: March 9, 2022

REQUIRED CALIFORNIA LABORATORY PAYMENT REPORTING TheCal iforniaDepartment of HealthCareServiceshaspubl ishedthel ist of hundredsof providers, many of which arecommunity hospital s, that arerequired toreport detail edpayment rates receivedfor l aboratory services during cal endar 2021. Thedataisdueby June30, 2022. Fail uretoreport thedatacan result insuspensionfromparticipationintheMedi-Cal program. https://www.dhcs.ca.gov/provgovpart/Pages/CLLS.aspx

Similar to Medicare?s Lab PAMA private payer rate reporting requirements, this state obligation poses a tough problem for hospitals which do not post remittances for outpatient lab services at the line item level.

PARAREV can help. Please contact your Account Executive for a proposal to mine data from the hospital?s electronic claim and remittance files, which may substantially advance the hospital?s compliance with the data submission requirement.

Providers which are required to report can expect a letter from DHCS informing the organization of the requirement in the coming days. In addition, the list of 438 NPIs (and associated provider names) is available at the following link: https://www.dhcs.ca.gov/provgovpart/Documents/CL-2021-Data-Collection-NPI-List.xlsx

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PARA Weekly eJournal: March 9, 2022

REQUIRED CALIFORNIA LABORATORY PAYMENT REPORTING

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PARA Weekly eJournal: March 9, 2022

REQUIRED CALIFORNIA LABORATORY PAYMENT REPORTING Links and excerpts from the State regulations which impose this requirement are provided below: http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201120120AB1494 Assem bly Bill No. 1494 CHAPTER 28 SEC. 9.

Section 14105.22 of the Welfare and Institutions Code, as added by Section 64 of Chapter 230 of the Statutes of 2003, is amended to read: 14105.22. (a) (1) Reimbursement for clinical laboratory or laboratory services, as defined in Section 51137.2 of Title 22 of the California Code of Regulations, may not exceed 80 percent of the lowest maximum allowance established by the federal Medicare Program for the same or similar services.

(2) This subdivision shall be implemented only until the new rate methodology under subdivision (b) is approved by the federal Centers for Medicare and Medicaid Services (CMS). (b) (1) It is the intent of the Legislature that the department develop reimbursement rates for clinical laboratory or laboratory services that are comparable to the payment amounts received from other payers for clinical laboratory or laboratory services. Development of these rates will enable the department to reimburse clinical laboratory or laboratory service providers in compliance with state and federal law.

(2) (A) The provisions of Section 51501(a) of Title 22 of the California Code of Regulations shall not apply to laboratory providers reimbursed under the new rate methodology developed for clinical laboratories or laboratory services pursuant to this subdivision.

(B) In addition to subparagraph (A), laboratory providers reimbursed under any payment reductions implemented pursuant to this section shall not be subject to the provisions of Section 51501(a) of Title 22 of the California Code of Regulations for 12 months following the date of implementation of this reduction.

(3) Reimbursement to providers for clinical laboratory or laboratory services shall not exceed the lowest of the following: (A) The amount billed.

(B) The charge to the general public.

(C) Eighty percent of the lowest maximum allowance established by the federal Medicare Program for the same or similar services.

(D) A reimbursement rate based on an average of the lowest amount that other payers and other state Medicaid programs are paying for similar clinical laboratory or laboratory services.

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PARA Weekly eJournal: March 9, 2022

REQUIRED CALIFORNIA LABORATORY PAYMENT REPORTING http://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201320140AB1124 Assem bly Bill No. 1124, CHAPTER 8 (3) Reimbursement to providers for clinical laboratory or laboratory services shall not exceed the lowest of the following: (A) The amount billed.

(B) The charge to the general public.

(C) Eighty percent of the lowest maximum allowance established by the federal Medicare Program for the same or similar services.

(D) A reimbursement rate based on an average of the lowest amount that other payers and other state Medicaid programs are paying for similar clinical laboratory or laboratory services.

Assem bly Bill No. 1124, CHAPTER 8 - con t in u ed (4) (A) In addition to the payment reductions implemented pursuant to Section 14105.192, payments shall be reduced by up to 10 percent for clinical laboratory or laboratory services, as defined in Section 51137.2 of Title 22 of the California Code of Regulations, for dates of service on and after July 1, 2012. The payment reductions pursuant to this paragraph shall continue until the new rate methodology under this subdivision has been approved by CMS. (B) Notwithstanding subparagraph (A), the Family Planning, Access, Care, and Treatment (Family PACT) Program pursuant to subdivision (aa) of Section 14132 shall be exempt from the payment reduction specified in this section.

(5) (A) For purposes of establishing reimbursement rates for clinical laboratory or laboratory services based on the lowest amounts other payers are paying providers for similar clinical laboratory or laboratory services,laboratory service providers shall submit data reports within 11 months of the date the act that added this paragraph becomes effective and annually thereafter.

The data initially provided shall be for the 2011 calendar year, and for each subsequent year, shall be based on the previous calendar year and shall specify the provider ?s lowest amounts other payers are paying, including other state Medicaid programs and private insurance, minus discounts and rebates.

The specific data required for submission under this subparagraph and the format for the data submission shall be determined and specified by the department after receiving stakeholder input pursuant to paragraph (7).

(B) The data submitted pursuant to subparagraph (A) may be used to determine reimbursement rates by procedure code based on an average of the lowest amount other payers are paying providers for similar clinical laboratory or laboratory services, excluding significant deviations of cost or volume factors and with consideration to geographical areas.

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PARA Weekly eJournal: March 9, 2022

REQUIRED CALIFORNIA LABORATORY PAYMENT REPORTING The department shall have the discretion to determine the specific methodology and factors used in the development of the lowest average amount under this subparagraph to ensure compliance with federal Medicaid law and regulations as specified in paragraph (10).

(C) For purposes of subparagraph (B), the department may contract with a vendor for the purposes of collecting payment data reports from clinical laboratories, analyzing payment information, and calculating a proposed rate.

(D) The proposed rates calculated by the vendor described in subparagraph (C) may be used in determining the lowest reimbursement rate for clinical laboratories or laboratory services in accordance with paragraph (3).

(E) Data reports submitted to the department shall be certified by the provider ?s certified financial officer or an authorized individual.(F) Clinical laboratory providers that fail to submit data reports within 30 working days from the time requested by the department shall be subject to the suspension provisions of subdivisions (a) and (c) of Section 14123.

http://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode =WIC&division=9.&title=&part=3.&chapter=7.&article=3.

Welf ar e an d In st it u t ion s Code - WIC DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.8]( Division 9 added by Stats. 1965, Ch. 1784. ) PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771]( Part 3 added by Stats. 1965, Ch. 1784. ) CHAPTER 7. Basic Health Care [14000 - 14199.56]( Chapter 7 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) ARTICLE 3. Administration [14100 - 14124.14]( Article 3 added by Stats. 1965, 2nd Ex. Sess., Ch. 4. ) 14123.

Participation in the Medi-Cal program by a provider of service is subject to suspension in order to protect the health of the recipients and the funds appropriated to carry out this chapter.(a) (1) The director may suspend a provider of service from further participation under the Medi-Cal program for violation of any provision of this chapter or Chapter 8 (commencing with Section 14200) or any rule or regulation promulgated by the director pursuant to those chapters. The suspension may be for an indefinite or specified period of time and with or without conditions, or may be imposed with the operation of the suspension stayed or probation granted.

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REQUIRED CALIFORNIA LABORATORY PAYMENT REPORTING The director shall suspend a provider of service for conviction of any felony or any misdemeanor involving fraud, abuse of the Medi-Cal program or any patient, or otherwise substantially related to the qualifications, functions, or duties of a provider of service.

(2) If the provider of service is a clinic, group, corporation, or other association, conviction of any officer, director, or shareholder with a 10 percent or greater interest in that organization, of a crime described in paragraph (1) shall result in the suspension of that organization and the individual convicted if the director believes that suspension would be in the best interest of the Medi-Cal program. If the provider of service is a political subdivision of the state or other government agency, the conviction of the person in charge of the facility of a crime described in paragraph (1) may result in the suspension of that facility. The record of conviction or a certified copy thereof, certified by the clerk of the court or by the judge in whose court the conviction is had, shall be conclusive evidence of the fact that the conviction occurred. A plea or verdict of guilty, or a conviction following a plea of nolo contendere is deemed to be a conviction within the meaning of this section.

(3) After conviction, but before the time for appeal has elapsed or the judgment of conviction has been affirmed on appeal, the director, if he or she believes that suspension would be in the best interests of the Medi-Cal program, may order the suspension of a provider of service. When the time for appeal has elapsed, or the judgment of conviction has been affirmed on appeal or when an order granting probation is made suspending the imposition of sentence irrespective of any subsequent order under Section 1203.4 of the Penal Code allowing a person to withdraw his or her plea of guilty and to enter a plea of not guilty, or setting aside the verdict of guilty, or dismissing the accusation, information, or indictment, the director shall order the suspension of a provider of service.

The suspension shall not take effect earlier than the date of the director ?s order. Suspension following a conviction is not subject to the proceedings required in subdivision (c). However, the director may grant an informal hearing at the request of the provider of service to determine in the director ?s sole discretion if the circumstances surrounding the conviction justify rescinding or otherwise modifying the suspension provided for in this subdivision.(4) If the provider of service appeals the conviction and the conviction is reversed, the provider may apply for reinstatement to the Medi-Cal program after the conviction is reversed.

Notwithstanding Section 14124.6, the application for reinstatement shall not be subject to the one-year waiting period for the filing of a reinstatement petition pursuant to Section 11522 of the Government Code. (b) Whenever the director receives written notification from the Secretary of the United States Department of Health and Human Services that a physician or other individual practitioner has been suspended from participation in the Medicare or Medicaid programs, the director shall promptly suspend the practitioner from participation in the Medi-Cal program and notify the Administrative Director of the Division of Workers?Compensation of the suspension, in accordance with paragraph (2) of subdivision (e).

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REQUIRED CALIFORNIA LABORATORY PAYMENT REPORTING This automatic suspension is not subject to the proceedings required in subdivision (c). No payment from state or federal funds may be made for any item or service rendered by the practitioner during the period of suspension. (c) The proceedings for suspension shall be conducted pursuant to Section 100171 of the Health and Safety Code.The director may temporarily suspend any provider of service prior to any hearing when in his or her opinion that action is necessary to protect the public welfare or the interests of the Medi-Cal program.The director shall notify the provider of service of the temporary suspension and the effective date thereof and at the same time serve the provider with an accusation. The accusation and all proceedings thereafter shall be in accordance with Section 100171 of the Health and Safety Code. Upon receipt of a notice of defense by the provider, the director shall set the matter for hearing within 30 days after receipt of the notice. The temporary suspension shall remain in effect until such time as the hearing is completed and the director has made a final determination on the merits. The temporary suspension shall, however, be deemed vacated if the director fails to make a final determination on the merits within 60 days after the original hearing has been completed. This subdivision does not apply where the suspension of a provider is based upon the conviction of any crime involving fraud, abuse of the Medi-Cal program, or suspension from the federal Medicare program. In those instances, suspension shall be automatic. (d) (1) The suspension by the director of any provider of service shall preclude the provider from submitting claims for payment, either personally or through claims submitted by any clinic, group, corporation, or other association to the Medi-Cal program for any services or supplies the provider has provided under the program, except for services or supplies provided prior to the suspension.

No clinic, group, corporation, or other association which is a provider of service shall submit claims for payment to the Medi-Cal program for any services or supplies provided by a person within the organization who has been suspended or revoked by the director, except for services or supplies provided prior to the suspension.

(2) If the provisions of this chapter, Chapter 8 (commencing with Section 14200), or the regulations promulgated by the director are violated by a provider of service that is a clinic, group, corporation, or other association, the director may suspend the organization and any individual person within the organization who is responsible for the violation. (e) (1) Notice of the suspension shall be sent by the director to the provider ?s state licensing, certifying, or registering authority, along with the evidence upon which the suspension was based.

(2) At the same time notice is provided pursuant to paragraph (1), the director shall provide written notification of the suspension to the Administrative Director of the Division of Workers?

Compensation, for purposes of Section 139.21 of the Labor Code. (f) In addition to the bases for suspension contained in subdivisions (a) and (b), the director may suspend a provider of service from further participation under the Medi-Cal dental program for the provision of services that are below or less than the standard of acceptable quality, as established by the California Dental Association Guidelines for the Assessment of Clinical Quality and Professional Performance, Copyright 1995, Third Edition, as periodically amended. The suspension shall be subject to the requirements contained in subdivisions (a) to (e), inclusive.(Amended by Stats.

2016, Ch. 852, Sec. 3. (AB 1244) Effective January 1, 2017.)

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Up d at ed 1/ 12 / 2 2

2022 c o mp r eh en s i v e COV ID-19 Gu ide

Click an yw h er e on t h is page t o be t ak en t o t h e f u ll on lin e docu m en t .

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PARA Weekly eJournal: March 9, 2022

TUESDAY WEBINARS: COMPLYING WITH THE NO SURPRISES ACT

t ime is r unning out .

PARA exper t s ar e pr ovidin g a f r ee w ebin ar each Tu esday design ed t o h elp h ospit als u n der st an d an d com ply w it h t h e r equ ir em en t s u n der t h e No Su r pr ises Act .

Ever y Tu esday 11:30 am PST

Sign Up By Click in g HERE, Or Scan Th e QR Code

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PARA Weekly eJournal: March 9, 2022

DID YOU MISS IT? NO SURPRISES ACT WEBINARS? CATCH UP HERE! Did you miss t hev er y impor t ant "No Sur pr ises aCt " Webinar s and Q&A's? If you did you still have a chance to participate in the live versions (see previous page for links). And if you can't participate live, here are the links for the NSA Tool Demo Video , Webinars, Q&A sheets, and the Specific NSA Forms.

Our PARAREV team is always available to help.

Please reach out on our website.

DEM O -

NSA No Surprises Act Tool Demonstration Video

WEBINARS -

NSA No NSA No NSA No NSA No

Surprises Act Surprises Act Surprises Act Surprises Act

Update Webinar- 12/21/21 Update Webinar- 12/28/21 Update Webinar- 1/04/22 Update Webinar- 1/11/22

Q&A -

NSA No Surprises Act Update Q & A? 12/21/21 NSA No Surprises Act Update Q & A? 12/28/21 NSA No Surprises Act Update Q & A? 1/11/22

-

PARA - NSA Update Q&A 1.18.22.pdf (para-hcfs.com) PARA - NSA Q&A 2022.2.1.pdf (para-hcfs.com)

FORM S -

PARA - NSA Template for Convening Facility or Provider Good Faith Estimate - updated 12.28.21 PARA - NSA Template for Right to Receive a Good Faith Estimate of Expected Charges - updated 12.28.21 PARA - NSA Template for Disclosure Notice - updated 12.28.21

LOGINS - If you already have a PDE login ? you have access to the NSA Tool by logging into the PDE and clicking on the PTT/NSA Tab and NSA Link Tab - Please make sure we have an updated email address for you ? Fill out this FORM to confirm your email and to be added/updated onto the Distribution List.

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PARA Weekly eJournal: March 9, 2022

CHARGE PROCESS: BEDSIDE PROCEDURES

Bedsidepr ocedur es may consume bot h suppl ies and ext r a r esour ces f r om var ious depar t ment s, incl uding unit st af f , sur ger y and/ or r adiol ogy, wound car e, r espir at or y t her apy, and PICCl ine t eam member s.

While these departments provide support to the care of the patient, it is not always possible to recognize that support with revenue generated by the service for the department providing the care.

Add-on charges for staff services assisting in bedside procedures must be carefully considered.

For inpatients, the daily room and board charge represents the nursing support of staff regularly assigned to the hospital unit. No additional charge is appropriate if regularly assigned unit staff offer the support required by the physician in performing the bedside procedure.

How ever , bedside pr ocedu r es ar e of t en per f or m ed u sin g n on -u n it st af f w h ich t r avel on an as-n eeded basis t h r ou gh ou t t h e h ospit al. In these cases, a separate charge for the assistance of the non-unit staff may be an appropriate representation of the non-unit resources.The difficulty is finding an appropriate revenue code and HCPCS to enable charges for traveling staff to be reported on both inpatient and outpatient claims.

On outpatient claims, charges for services are reported in revenue codes which require a valid HCPCS to accurately describe the service performed.For this reason, PARAREV r ecom m en ds billin g bot h in pat ien t an d ou t pat ien t bedside pr ocedu r e on ly f or ser vices w h ich m ay be accu r at ely descr ibed by a valid CPT® / HCPCS code. Services which do not meet this test should not generate charges above the basic evaluation and management charge for outpatients, or the daily room and board rate for inpatients. The PARAREV Dat a Edit or offers information on the acceptable revenue codes for each valid HCPCS on the Calculator HCPCS report.

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PARA Weekly eJournal: March 9, 2022

CHARGE PROCESS: BEDSIDE PROCEDURES

Inpatient claims do not report CPT® /HCPCS codes; charges under the revenue code for the department providing the service may be reported and no claims processing issues will result.

Obser vat ion st at u s pat ien t s pr esen t u n iqu e bedside pr ocedu r e ch ar ge ch allen ges.The hourly charge for observation care (G0378) includes regular nursing care, evaluations, and monitoring.When performing another billable service for a patient in observation status, the hours reported as observation time must not accrue during a period when the patient is actively monitored for the other service(s). Time in patient care required to provide separately reimbursed services which include active monitoring should be carved out of the hours billed for observation care.

On the following CMS FAQ provides guidance for hospitals in determining which procedures include ?active monitoring?: https://questions.cms.gov/faq.php?id=5005&faqId=2725

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PARA Weekly eJournal: March 9, 2022

CHARGE PROCESS: BEDSIDE PROCEDURES

PARAREV offers a more thorough discussion on observation charging and billing at the following link: https://apps.para-hcfs.com/pde/documents/Observation_Charge_Process.pdf In addition, PARAREV papers are available in the ?Advisor ? repository on the PARAREV Dat a Edit or :

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PARA Weekly eJournal: March 9, 2022

CHARGE PROCESS: BEDSIDE PROCEDURES

PARAREV offers concise guidance on billing for supplies in the institutional setting; the PARAREV Data Editor Advisor tab may be queried for the term ?Supplies? and a link to the resource is returned:

The link to the supplies paper is provided below: https://apps.para-hcfs.com/pde/documents/Billing_For_Supplies_April_2014.pdf

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PARA Weekly eJournal: March 9, 2022

FAQ: GOOD FAITH ESTIMATES IMPLEMENTATION

CMShas publ ished a compr ehensiv e f r equent ly asked quest ions document cov er ing t he impl ement at ion of good fait h est imat es f or unisur ed and sel f - pay pat ient s. cl ick on t heimagebel ow t o v iew t heent ir e, inf or mat iv edocument .

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PARA Weekly eJournal: March 9, 2022

UPCOMING "ASK THE CONTRACTOR" TELECONFERENCES Q1, 2022

Most Part A and B Medicare Administrative Contractors offer ?Ask the Contractor ? (ATC) teleconferences to provide hospitals and other providers an opportunity to ask questions about Medicare policies and procedures.

Some MACs permit providers to submit questions to their Medicare Administrative Contractor in advance.

Each MAC may hold separate ATC teleconferences for Part A, Part B, and DME suppliers; furthermore, each MAC mayfocus on certain topics during each ATC webinar.Not all MACs follow the same format.

Her e ar e dat es an d lin k s f or u pcom in g ATC con f er en ces f or Par t A M ACs: WPS Ju r isdict ion 5 - Iowa, Kansas, Missouri, and Nebraska - Next ATC 1/25/2022 - Topic:Outpatient Rehabilitation Updates http://wpsghalearningcenter.com/confirm-course?courseid=AM2awu6Lzvg1 NGS Ju r isdict ion 6 an d K - J6: Illinois, Minnesota, and Wisconsin; - JK: Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, and Vermont - Last meeting held 12/16/2021 https://www.ngsmedicare.com/web/ngs/-/ af_ask-the-contractor-teleconference_091421?lob=93617&state=97206&region=93624 - 2022 ATC conferences have not yet been announced WPS - Ju r isdict ion 8 - Indiana and Michigan - Past ATC conference recordings are available, but 2022 session schedule not yet announced WPS J8 Part A Training Guides and Resources Nor idian Ju r isdict ion E - M edicar e Par t A - California, Hawaii, Nevada, American Samoa, Guam, Northern Mariana Islands - Next ATC March 23, 2022 https://med.noridianmedicare.com/web/jea/education/act 41

PARA Weekly eJournal: March 9, 2022

UPCOMING "ASK THE CONTRACTOR" TELECONFERENCES Q1, 2022

Nor idian Ju r isdict ion F - Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming - Next ATC March 23, 2022 https://med.noridianmedicare.com/web/jfa/education/act Novit as Ju r isdict ion H - Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, Texas, Indian Health & Veteran Affairs - Next ATC scheduled for February 23, 2022 - Topics will include Novitas Initiatives, Acute Hospital Provider Liable Billing, and Acute Hospital Outpatient Billing https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00008196 Palm et t o - Ju r isdict ion J - Alabama, Georgia, and Tennessee - January 12, 2022; April 13, 2022 https://palmettogba.com/palmetto/jja.nsf/DID/AU9QTU8307 Novit as Ju r isdicat ion L - Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania - Next ATC February 23, 2022 - Topics will include Novitas Initiatives, Acute Hospital Provider Liable Billing, and Acute Hospital Outpatient Billing https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00008196 Palm et t o - Ju r isdict ion M - North Carolina, South Carolina, Virginia, and West Virginia - Next ATC January 12, 2022; April 13, 2022 https://palmettogba.com/palmetto/jma.nsf/DID/89BJAR3017 Fir st Coast Ser vice Opt ion s - Ju r isdict ion N - Search for ?Ask the Contractor ? found no results https://medicare.fcso.com/FAQs/0453634.asp

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PARA Weekly eJournal: March 9, 2022

2022 REQUIREMENTS -- UPDATED

unpacking t he"no sur pr ises act ".

The No Surprises Act (NSA) is a federal law which went into effect on January 1, 2022. The law bans surprise medical bills for emergency services and elective care when the patient does not have a choice of ancillary service providers in an in-network facility.

The Department of Health and Human Services (HHS) has realized that not all aspects of the NSA will be able to be implemented by providers and facilities by January 1, 2022, so they have elected to exercise ?enforcement discretion? on portions of the act in 2022. To be in compliance in 2022, healthcare providers and health care facilities must be prepared to: 1. Publicize and disseminate a ?Disclosure Notice? which informs beneficiaries of group health plans of their rights under the No Surprises Act; and 2. Publicize and disseminate a ?Right to Receive a Good Faith Estimate? to uninsured or self-pay patients; and 3. Provide uninsured or self-pay patients with a good faith estimate (within a $400 threshold) of services that will be billed by the ?convening? provider or facility.

4. Present a Notice and Consent form, with an estimate of charges, to a beneficiary of a group health plan who chooses to receive services from an out-of-network facility or provider and submit a claim to the health plan.

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PARA Weekly eJournal: March 9, 2022

2022 REQUIREMENTS -- UPDATED

DISCLOSURE NOTICE As of January 1, 2022, the disclosure notice must be prominently displayed on websites, in public areas of an office or facility, and on a one-page (double-sided) notice provided in-person or through mail or e-mail, as chosen by the patient. The disclosure notice must be provided to all commercially insured patients after January 1, 2022, or before that date if the elective service will be provided after January 1, 2022. The notice must be provided before requesting a payment from the insured or before a claim is submitted on behalf insured. eCFR :: 45 CFR Part 149 ? Surprise Billing and Transparency Requirements

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PARA Weekly eJournal: March 9, 2022

2022 REQUIREMENTS -- UPDATED

In states where there are state laws that protect patients against surprise billing, providers and facilities can use a state disclosure notice if it meets or exceeds the federal guidelines. If a provider or facility drafts their own disclosure notice it must include these three points: 1. Restrictions on providers and facilities regarding balance billing in certain circumstances 2. Any applicable state laws protecting against balance billing 3. Contact information for appropriate state and federal agencies if the individual their rights have been violated

believes

RIGHT TO RECEIVE A GOOD FAITH ESTIM ATE NOTICE All uninsured or self-pay individuals must be made aware, both orally and in writing, of their right to receive a good faith estimate for any services that will be rendered beginning January 1, 2022. The form must be prominently displayed on websites, in offices, and where scheduling or questions about the cost of health care may occur.

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PARA Weekly eJournal: March 9, 2022

2022 REQUIREMENTS -- UPDATED

GOOD FAITH ESTIM ATES TO UNINSURED/ SELF PAY When discussing the good faith estimate it is important to know a few terms: - A h ealt h car e pr ovider (pr ovider ) is defined as a physician or other health care provider who is acting within the scope of practice of that provider ?s license or certification under applicable State law.

- A h ealt h car e f acilit y (f acilit y) is defined as a hospital or hospital outpatient department, critical access hospital, ambulatory surgical center, rural health center, federally qualified health center, laboratory, or imaging center that is licensed as an institution pursuant to State laws or is approved by the agency of such State or locality responsible for licensing such institution as meeting the standards established for such licensing.

- The con ven in g pr ovider or f acilit y is the one who receives the initial request for a good faith estimate from an uninsured or self-pay individual and who is or, in the case of a request, would be responsible for scheduling the primary item or service.

- A co-pr ovider or co-f acilit y furnishes items or services that are customarily provided in conjunction with the convening provider.

An uninsured patient is an individual who does not have benefits for an item or service under a group health plan; whereas a self-pay patient is an individual who has benefits under a group health plan but chooses not to have a claim submitted to their plan. The good faith estimate presented to an uninsured or self-pay patient must include services reasonably expected to be provided by the convening provider or facility.

At t h is t im e, est im at es f or ser vices pr ovided by co-pr ovider s an d co-f acilit ies do n ot h ave t o be pr ovided by t h e con ven in g pr ovider or f acilit y.

The following list was provided in the interim final rule published in the Code of Federal Regulations. CMS followed up with a Fact Sheet that clarifies HHS will not be enforcing the requirement of including services provided by co-providers or co-facilities.

A good faith estimate must include: - Patient name and date of birth - Description of the primary item or service - Itemized list of items or services reasonably expected to be furnished - Items or services reasonably expected to be furnished by the convening provider or convening facility for the period of care; and - Items or services reasonably expected to be furnished by co-providers or co-facilities 46

PARA Weekly eJournal: March 9, 2022

2022 REQUIREMENTS -- UPDATED

- Applicable diagnosis codes, expected service codes, and expected charges associated with each listed item or service - Name, National Provider Identifier, and Tax Identification Number of each provider or facility represented in the good faith estimate, and the State(s) and office or facility location(s) where the items or services are expected to be furnished by such provider or facility - List of items or services that the convening provider or convening facility anticipates will require separate scheduling eCFR :: 45 CFR Part 149 ? Surprise Billing and Transparency Requirements

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PARA Weekly eJournal: March 9, 2022

2022 REQUIREMENTS -- UPDATED

Requirements Related to Surprise Billing; Part II Interim Final Rule with Comment Period | CMS The Good Faith Estimate process that requires facilities and providers to transmit estimates to health plans, is still on hold.

NOTICE AND CONSENT The Notice and Consent is being enforced for those rare instances when the patient has a choice of providers and chooses to receive services from an out-of-network facility or provider.

Situations when a patient does not have a choice of providers and cannot be requested to sign a consent waiving their balance billing protections in an in-network facility are: - When receiving services that are considered ancillary services: - Items and services related to emergency medicine, anesthesiology, pathology, radiology, and neonatology - Items and services provided by assistant surgeons, hospitalists, and intensivists - Diagnostic services, including radiology and laboratory services - Items and services provided by a nonparticipating provider if there is no participating provider who can furnish such item or service at such facility Balance billing is prohibited in all emergency situations, even those that arise during a service that is being provided under a written consent. Any charges related to that emergency cannot be balance billed until the patient is deemed stable, as defined in the NSA ? able to transport to another facility by non-medical transportation.

In the event the patient requires a higher level of care that requires transport, the EMTALA guidelines take precedence. A patient admitted to an out-of-network facility from an emergency department who is then considered stable, must be presented with a notice and consent if they choose to continue treatment in the out-of- network facility. If the consent is signed, the out-of-network facility can balance bill for charges incurred after the provider documents that patient is stable, as defined in the NSA ? able to transport to another facility by non-medical transportation. Ancillary services cannot balance bill even after the patient is considered stable.

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2022 REQUIREMENTS -- UPDATED

eCFR :: 45 CFR Part 149 Subpart E ? Health Care Provider, Health Care Facility, and AirAmbulance Service Provider Requirements

The Notice and Consent form, with an estimate of all charges, must be presented to the patient for a signature.

- This form must be available in the 15 most common languages in the geographical area. If the individual?s preferred language is not among those 15, a qualified interpreter must be made available to assist the patient with understanding their rights.

- The form must be provided at least 72 hours prior to scheduled services, when they are scheduled at least 72 hours out. When services are scheduled and performed on the same day, the document is required to be presented at least 3 hours before the services are rendered.

- The patient must be provided with a signed copy and a signed copy must be maintained in the medical record in the same manner as all other required documented.

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PARA Weekly eJournal: March 9, 2022

FIVE WAYS TO UNCOVER LOST REVENUE

TheCOVID- 19 pandemic has had a dr amat ic impact on many pr ov ider s?r ev enuecycl es, wit h shar ply l ower pat ient And pr ocedur evol umes t r igger ing maj or cash f l ow pr obl ems acr oss a r angeof or ganizat ions. Al t hough t he sit uat ion has st abil ized f or most , f inding ways t o r educe denial s and ensur eyou?r e paid ev er y dol l ar you?r e ent it l ed has nev er been mor eimpor t ant .

DENIAL REALITY Even before the pandemic, denials were a major and costly problem in healthcare.

Consider: - Denial volume increased by 79% for the average hospital between 2011 to 2017 [1] - A recent survey of hospital executives found that 30% of responding facilities had bad debt of between $10 million and $50 million, while 6% reported bad debt of greater than $50 million [2] - 9% of $3 trillion in U.S. hospital claims ($270 billion) were initially denied in 2016 [3] - Hospitals expend $9 billion annually in administrative costs for rework denials [4] - It takes 5-12 minutes per claim to check status manually [5] - The average cost of each claim status check by providers is $5.40 [6]

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PARA Weekly eJournal: March 9, 2022

FIVE WAYS TO UNCOVER LOST REVENUE

Despite the growing prevalence of denials, the fact remains that 90% of claims are preventable and 66% are recoverable. Even so, 65% of claim denials are never corrected and resubmitted for reimbursement. [7]

Here are five ways to take control of your denial problem: STEP 1: OPTIM IZE THE EFFECTIVENESS OF YOUR CURRENT AR PROCESS While hospitals continue to face rising accounts receivable (AR) balances due to denied, unpaid and underpaid commercial insurance claims, adding staff to pursue denials can be costly and may still result in many low-dollar, high-volume claims going unworked.

A virtual extension of your central billing office?s resources can help bolster your efforts with a dedicated, knowledgeable, and responsive team of experts who have specific experience with your payers. This additional capability, integrated seamlessly with your systems, can decrease cycle time, and help ensure all claims, no matter the age or balance, are effectively worked to 100% resolution.

STEP 2: DEVELOP A HARD DOLLARS COLLECTION STRATEGY An effective AR management strategy should incorporate processes to pursue claims at key aging intervals, so no denials fall through the cracks. Typically, hospitals can task their primary AR management firm with claims that have aged from 30 to 90 days before sending older claims to the pre-write-off insurance collection specialist. Alternatively, hospitals can task internal staff with new claims, then turn any remaining inventory over to a pre-write-off insurance collection vendor.

Ultimately, you want to develop a strategy to collect the extremely aged hard dollars or dollars already written off (zero balance) so that you can improve collections and verify that claims are truly un-collectable and may be removed from the balance sheet.

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FIVE WAYS TO UNCOVER LOST REVENUE

STEP 3: PURSUE PRE-WRITE-OFF INSURANCE COLLECTION Secondary assigned accounts or second placement AR services for pre-write-off insurance collections provide a critical safeguard to ensure no insurance payments legitimately due to the hospital go uncollected, regardless of age. The benefits of enlisting this kind of outsource capability include: - The establishment of an AR management process that offers a systematic approach to obtaining 100% claims resolution - A reduction in write-offs, a commensurate increase in cash flow and a decrease in bad debt reserves caused by aging accounts - The creation of incentives that push primary AR vendors to optimize their processes - Greater transparency to enable hospitals to evaluate performance across the entire revenue cycle

STEP 4: CONDUCT ZERO-BALANCE REVIEWS Specialized, forensic audits of written-off (zero balance) claims compare payments received to anticipated revenue based on episode-of-care specifics, coding best-practices, and payer-provider contractual terms. Any underpaid claims are resubmitted, per the payer ?s terms, for reimbursement.

Recovered underpayments from zero-balance reviews can total up to 1% of a hospital?s annual Net Patient Revenue, an amount that may be significant for large hospitals and health systems that generate hundreds of millions of revenue annually.

A zero-balance audit and recovery process should include training or education to help hospital staff mitigate systemic or reoccurring coding and process errors uncovered during the initial review.

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FIVE WAYS TO UNCOVER LOST REVENUE

STEP 5: DEVELOP A PROCESS TO IDENTIFY THE ROOT CAUSE OF ALL DENIALS No matter where collections are pursued in the revenue cycle, one of the most important steps you can take in developing a robust accounts receivable strategy is determining the root cause of delayed, underpaid or denied claims.

Unfortunately, hospital personnel and many primary vendors frequently don?t have the time or technology to determine the precise underlying reason for the denial.Partnering with a vendor that utilizes intelligent automation can help systematically isolate denials by type, age and size before all claims are worked to resolution.

This time-saving process also helps identify exactly where in the revenue cycle the initial problem occurred so proactive measures can be taken to prevent it from happening again.

While it?s best to resolve and collect outstanding accounts receivable before they become highly aged, this isn?t always practical in today?s challenging reimbursement environment.

By adopting a comprehensive and aggressive accounts receivable strategy to ensure hospitals receive all the money they?re due from payers, facilities can experience significant reductions in bad debt and write-offs and a corresponding increase in cash flow and margins.

Pararev can help you progress toward the goal of zero-percent write-offs through our comprehensive AR solutions. We?re able to resolve all claims, regardless of size or age quickly, and conduct zero-balance reviews to ensure you?re collecting every dollar you deserve.

Contact us today to learn more.

1. Kelly Gooch, ?4 ways hospitals can lower claim denial rates,? Becker ?s Hospital CFO Report, Jan. 5, 2018.

2. ?Bad Debt Exceeds $10M at a Third of Organizations, But Lack of Confidence Exists in How Much is Recoverable,? Cision PR Newswire. June 19, 2918.

3. Philip Betbeze, ?Claims Appeals Cost Hospitals Up to $8.6B Annually? HealthAffairs, March 16, 2021.

4. ibid.

5. ibid.

6. ibid.

7. Chris Wyatt, ?Optimizing the Revenue Cycle Requires a Financially Integrated Network,? HFMA, July 7, 2015.

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PARA Weekly eJournal: March 9, 2022

MLN CONNECTS

PARA in vit es you t o ch eck ou t t h e m ln con n ect s page available f r om t h e Cen t er s For M edicar e an d M edicaid (CM S). It 's ch ock f u ll of n ew s an d in f or m at ion , t r ain in g oppor t u n it ies, even t s an d m or e!

Each w eek PARA w ill br in g you t h e lat est n ew s an d lin k s t o available r esou r ces. Click each lin k f or t h e PDF!

Th u r sday, M ar ch 3, 2022

New s -

Ambulance Prior Authorization Model Expands April 1 Nutrition-related Health Conditions: Recommend Medicare Preventive Services

Claim s, Pr icer s, & Codes -

HCPCS Application Summaries & Coding Decisions: Drugs and Biologicals

Even t s -

ICD-10 Coordination & Maintenance Committee Meeting ? March 8?9

M LN M at t er s® Ar t icles -

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An Omnibus CR Covering: (1) Removal of Two National Coverage Determination (NCDs), (2) Updates to the Medical Nutrition Therapy (MNT) Policy, and (3) Updates to the Pulmonary Rehabilitation (PR), Cardiac Rehabilitation (CR), and Intensive Cardiac Rehabilitation (ICR) Conditions of Coverage The Supplemental Security Income (SSI)/Medicare Beneficiary Data for Fiscal Year (FY) 2020 for Inpatient Prospective Payment System (IPPS) Hospitals, Inpatient Rehabilitation Facilities (IRFs), and Long Term Care Hospitals (LTCHs)

Pu blicat ion s -

Medicare Payment Systems ? Revised

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PARA Weekly eJournal: March 9, 2022

r a n s mi t t a l s

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Ther e w er e FIVE new or r evised Tr ansmittal s r el eased this w eek .

To go to the ful l Tr ansmittal document simpl y cl ick on the scr een shot or the l ink .

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TRANSMITTAL 11289OTN

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TRANSMITTAL R11269CP

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TRANSMITTAL R11282CP

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TRANSMITTAL R11288CP

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TRANSMITTAL R11285OTN

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PARA Weekly eJournal: March 9, 2022

ed l ea r n s

Ther e w er e THREE new or r evised MedLear ns r el eased this w eek .

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MEDLEARN MM12631

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MEDLEARN MM12543

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MEDLEARN MM12626

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