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Summer 2007

WCH Times Page 1

Volume 3

WCH TIMES Phone Directory 718-934-6714 Department Billing Management Credentialing Tech support

Ext 111 101 101 104

WCH E-MAILS: Alexandr Romanychev: Olga Khabinskaya: Dmitriy Bobkov: Marina Bakina:

We invite you to join our WCH Community Visit our website to learn more. Member of National Association of Healthcare Consultants

Welcome to the third edition of WCH TIMES! WCH is continuing to provide our clients with latest healthcare news and upcoming changes taking place in the healthcare community. Since the last two newsletters released, we had received numerous positive responses from our readers. On behalf of WCH Service Bureau, I would like to thank all of our clients for continuing trust and support they have expressed. This summer issue includes a variety of important events taking place in the healthcare insurance industry. We are also adding a new topic to the newsletter called WCH Corner, which will provide helpful information for your practice. In WCH Corner, we will discuss questions asked by our readers. Also, provide you with interesting feedback about WCH progress and offer interesting publications from the Department of Health, CMS and other state organizations.

Please enjoy Summer 2007 edition! In this volume: WCH CORNER: 2 Claim Processing Cost 2 Weekly Reports 2 Explanation of Benefit – EOB 2

WAYS TO EDUCATE YOUR PATIENTS: 3 New York Health Insurance Program – Healthy NY 3 Social Security Services 3

USEFUL INFORMATION FOR YOUR PRACTICE: 4 NPI Registry 4 Introduction to Medicare 4 Overview of CLIA guidelines 5 Board Certifications Requirements 5 Courtesy to your patients 5 Physical Therapy Treatment 6

INSURANCE NEWS 6 Multiplan 6 Oxford 6 Neighborhood 6 Medicare 6 Latest Medicare Scams 7 Aetna 7 Atlantis Health Plan 8

6814 18th Ave. 2 Fl. Brooklyn, NY 11204 Phone: 718 934-6714 Fax: 718 504-6072 E-Mail: Web:

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Volume 3

WCH CORNER: Claim Processing Cost In the past newsletter, we had discussed the claim process performed by WCH billing and account representative departments. I hope that discussion had made you more aware of how WCH structures the claim process and the result of you receiving highest possible reimbursements. I would like to now speak about cost of creating and working with the claim. On the recent invoices, you might have notice that we had begun charging our clients $3.00 for denied claims. We were holding back for long time, deciding weather we can work out some kind of arrangement with our clients to eliminate these problems. Unfortunately, only few clients took our advice to change their office routine work, which lead to better results and more paid claims for them and for us. In the past few weeks, I had received few phone calls from our clients asking about the claim charges on their billing invoices. I would like to make it clear once again, we are charging denied claims only for our work. Everyone can make a mistake: these claims are not being charged for mistake. They are charged $3.00 for the work the biller and account representative performed on your claims. In addition, this brings up next interesting point we had noticed. Since the claim charges begun to appear on invoices, doctors, managers and receptionists started to ask question and working towards eliminating these problems. Whereas before, we has send out reports to doctors advising them of the denied claims and we rarely received back response from the office about these claims. Please realize that none of us want and will work free. We hope that those clients that have more then three charged claims on their invoices, give us call and we will see what can we can do together to change the process of work in your office.

Weekly Reports During the first week of this month we had begun sending to each client reports showing denied or pending claims processed with in that particular week. Please review this report it contains necessary information about your claims. The report has the patient name, date of service, insurance name, charges submitted and WCH account representative notes. This report generates on weekly basis.

Explanation of Benefit - EOB EOB is short term for statements you receive from insurance companies, which provide information about your claims. Paid claims arrive with attached payment check on the EOB. We have been archiving 2006 data and noticed that we have a large amount of outstanding claims, which all have been paid, but WCH never received these statements from your office. WCH has checked all claims and has retrieved the payment information (check #, date and amount); we are posting this payment to your claims and adding these charges to the current billing invoice. If you will notice that your invoice includes check dated in 2006, these checks are correct. We are urging all clients to retrieve WCH Billing Agreement and review the requirements set in the agreement about providing EOB on time.

6814 18th Ave. 2 Fl. Brooklyn, NY 11204 Phone: 718 934-6714 Fax: 718 504-6072 E-Mail: Web:

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Volume 3

WAYS TO EDUCATE YOUR PATIENTS: New York Health Insurance Program – Healthy NY What is Healthy NY? New health insurance option provided by the state of NY. Healthy NY brings affordable Health insurance to those who need it most. Healthy NY is for uninsured small business and working individuals. What is covered? Important medical services such as regular medical check ups, prescription drugs, diagnostic care, maternity care, specialty referrals and hospital care. Eligibility Criteria: You may participate with Healthy NY if You: • • • •

were employed during the past year have been without health insurance for 12 months or lost coverage are ineligible for Medicare of employer coverage household income within the limitations

For more information about Healthy NY eligibility requirements and other application questions, please contact the office of Healthy NY at 866-432-5849 or visit their website: Source of information obtained through New York State Insurance Departments Health Resource Center

Social Security Services New online services provided by social security! Please advise your patients that some of the important updates to individual social security files can be done online. This new service eliminates travel time and can be accessed 24 hours a day. The Online service can be found at , here is just a brief list of things that can be done: • • • •

Retire online Sign up for free news updates Benefit Planner Social Security statements

Another excellent feature being offer by the social security services is Multi – Language gateway. An individual can get their social security information in 14 different languages. Source of information obtained through SSA publications No. 05-10605 ICN 473245

6814 18th Ave. 2 Fl. Brooklyn, NY 11204 Phone: 718 934-6714 Fax: 718 504-6072 E-Mail: Web:

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USEFUL INFORMATION FOR YOUR PRACTICE: NPI Registry August 01, 2007 NPI registry is going public. What does this mean for the providers? Well it means that all healthcare providers that had obtained their NPI must update their profile to make sure it reflects correct information. The new NPI registry will be working similar to the UPIN registry site. This site will provide NPI numbers and locations of the providers. The UPIN registry will shut down on the same day. WCH will keep you updated on the progress of the new NPI website within next month. Also, please be advised since June 29, 2007, CMS has discontinued assigning UPINs to new Medicare providers. Source of information obtained through CMS National Provider Stand

Introduction to Medicare As a provider, you are already exposed to the Medicare basic procedural policies such as patient rights, medical and reimbursement policies. In brief, I would like to speak about Medicare program in itself. Who runs the Medicare Program? The Centers for Medicare & Medicaid Services (CMS) is the Federal agency that runs Medicare. CMS is part of the U.S. Department of Health and Human Services. What is Medicare? Medicare is health insurance for people age 65 and older, under age 65 with certain disabilities, and any age with permanent kidney failure. Medicare provides the following plans: Part A – Hospital Part B – Medical Part C – Medicare Advantage Plans, like HMOs and PPO’s Part D – Medicare prescription drug coverage Since the majority of WCH clients submitting claims for Part B plan, I would like to explain some important aspects of this plan. What is Medicare Part B? This plan covers medical services like doctor’s services, outpatient care and medical service that are not covered by other plans. It also pays for items that are medically necessary. Part B also covers some preventive services. These include a one-time “Welcome to Medicare” physical exam, bone mass measurements, flu shots, cardiovascular screenings, diabetics screening and more. The cost for Part B is based on the premium. Most people pay standard monthly Part B premium. ($93.50 in 2007). What Medicare Part B doesn’t cover? Medicare does not cover everything. Cosmetic surgery, health care patients get while traveling outside of the United States, hearing aids, most hearing exams, and more. For more information about Medicare plans, please use the following phone numbers: Members: 800-633-4227 Providers: 866-837-0241 To Report Medicare Fraud: 877-678-4697 Source of information obtained through CMS Pub No. 11082

6814 18th Ave. 2 Fl. Brooklyn, NY 11204 Phone: 718 934-6714 Fax: 718 504-6072 E-Mail: Web:

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Volume 3

Overview of CLIA guidelines What is CLIA? Clinical Laboratory Improvement Amendments (CLIA) was passed in 1988 by Congress in effort to establish quality standards for all non-research laboratory where testing is performed. CLIA required that the Secretary of the Department of Health and Human Services certify laboratories performing these types of tests. CMS administers the CLIA laboratory certificates to health care providers. CLIA standards are national and are not Medicare/ Medicaid exclusive. How can a medical practice enroll with CLIA? A facility can enroll two ways with CLIA. One option is to contact CLIA program to request application or have WCH perform the process on your behalf. The enrollment process is rigorous and requires knowledge of the CLIA enrollment guidelines. The enrollment requirements are - complete application, pay applicable fees, be surveyed and become CLIA certified. Upon completion of the enrollment process, each laboratory is assigned an individual and unique CLIA number. For more information, please visit Source of information obtained through CMS CLIA Information Page

Board Certifications Requirements Currently insurance companies are emphasizing that all healthcare providers joining insurance panels must be Board Certified by the appropriate American Board. Many times when WCH performs credentialing services for new clients, their applications put on hold because they are not Board Certified in their specialty. Having several thousands of new doctor’s graduate school every year, the pressure of getting into the insurance companies is increasing. If you a provider looking to join insurance companies, we are recommending to become Board Certified in your scope of specialty.

Courtesy to your patients A patient refuses to pay at the time of service, is there anything you can do? A patient says they do not have any money to pay. What can we do? The patient becomes angry and belligerent when asked to pay. Is there anything we can do? The patient says they are financially needy and cannot pay; what can we do? If you are a doctor or healthcare facility faced with these questions, we would like to tell you that there is answer to all of the above questions. What is patient courtesy and how much of it can you allow in your practice? Patient courtesy refers to the provision of free or discounted medical care services to patients. Over the years, the tradition of providing courtesy discount has become deeply ingrained in many medical practices. The provided medical service does not always have to be free but many times, it is provided at discounted rate. For example, co-pays, deductibles and coinsurances are overlooked or eliminated for patients that are not able to pay for the services. Despite the fact that both Federal and private payers have made it increasingly clear that such conduct could constitute a crime and / or may represent breach of contract. WCH urges our clients to discontinue extend waivers and discount to patients. As early as 1991, OIG issued a “Special Fraud Alert” emphasizing that the “routine’ waiver of co-pay, deductibles is equivalent to misstating the actual charges submitted to Medicare for payment. Under the Federal Anti-Kickback Stature, it is a crime to engage in the knowing and willful solicitation, receipt, offer or payment of anything of value in exchange for, or to induce, Medicare, Medicaid or another Federal funded health care program, may make the referral of business for which payment. Violations of the stature can result in fines of up to $25,000, five years imprisonment of both. 6814 18th Ave. 2 Fl. Brooklyn, NY 11204 Phone: 718 934-6714 Fax: 718 504-6072 E-Mail: Web:

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Volume 3

Source of information obtained through Liles Parker PLLC Attorney & Counselors at Law

Physical Therapy Treatment Some of our physical therapy clients have been asking us, about not receiving referrals from physicians and impact it has on their provided services. WCH has found official guidelines issued by physical therapy board. The law, Chapter 298 of the Laws of 2006, allows physical therapists with three years of practical experience to treat patients without a referral beginning November 23, 2006. It also requires that patients will be aware that there is a possibility that their health plan will not cover expense of this treatment. If you have any additional questions, you may contact the State Board by calling 518-474-3817 ext 180 or emailing

INSURANCE NEWS Multiplan June 2007, Multiplan has announced acquisition of PHCS health plan. Provider relations department has sent out letters to all providers’ relationship with Multiplan will be governed by the PHSC agreement. The reimbursement will begin at the current Multiplan contracted rate for service provided for both PHCS and Multiplan members. Source of information obtained through

Oxford New Oxford’s Radiology policy states that participating Primary Care Physicians and Specialists will be reimbursed for radiology services performed in outpatient setting. The following services can be provided and reimbursement to PCP (Internal medicine / family provider): 71010-71030, 77080- Chest Imaging 77081, 0028T – Bone Densitometry 73620, 73630, 73650, 73660 – Lower extremity imaging For the full policy description and list of other covered specialist tests, please contact WCH. Source of information obtained from Oxford policy# RADIOLOGY 013.t0

Neighborhood Specialty referral policy update: Effective June 01, 2007, Neighborhood Health Plan will no longer require acquiring a specialty referral ID number in order for service to be reimbursed. The new change requires that referring physician information must specify on the submitted claims. WCH is requesting that all specialists such as physical therapist, podiatrist...etc must provide referring physician full name and NPI. Finally, Neighborhood Health plan conform more closely with specialty referral process. Source of information obtained from Neighborhood Health Plan June 2007 update

Medicare Evaluation and Management Documents – Most missed items During ongoing review performed by Medicare Audit department, the following listed information is not well documented or missed in patients charts. It is important to maintain accurate and well comprehensive record on all E/M services. Here is what Medicare needs to see: • History 6814 18th Ave. 2 Fl. Brooklyn, NY 11204 Phone: 718 934-6714 Fax: 718 504-6072 E-Mail: Web:

Summer 2007 • •

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Physical Exam Your Medical Decision Making (provide copy of x-ray, labs and describe complexity of each case)

Choosing correct codes base on the time spent with the patient (provide time spent for consultation and coordination of care Other general information to support the patients condition (hospital record, and any other consultation reports from specialists) WCH has provided our clients in the past with needed information for E/M services; please review the key elements of E/M service billing. Source of information obtained from National Government Services file PET1210 (05/07)

Latest Medicare Scams National Government Services is asking to inform your patients to protect themselves from ongoing calling scams. Medicare patients are at risk of having their personal information stolen. Here are some of the current phone scams: Individuals identify themselves as employees of the Social Security Administration. The callers indicate that SSA is sending out replacement Social Security and Medicare cards and they need to verify a beneficiary’s personal information. Caller states that Medicaid is raising their premiums and offering fewer benefits. Caller states they are offering a National Health Card for one time fee of $89 that would be good for a lifetime. The Medicare member usually agrees and provides bank account information. Please inform your patients about these frauds in effort to reduce these risks and provide awareness. To report any suspected fraud call State & Federal Workgroup at 877-678-4697 Source of information obtained from Centers for Medicare & Medicaid Services MED 2024 (01/07)

Aetna Introducing Aetna Health Network Option Effective January 01, 2008 new open access plan will launch. Aetna Health Network Option and Aetna Health Network are HMO Based plans. For these plans, referrals will not be required for members to access care from participating specialists. PCP selections will not be required as well. In a way, this plan will allow the same flexible benefits as any Aetna’s PPO plans today. Provider reimbursement will be also the same as other Aetna HMO base plans. You can recognize this new plan on the member’s ID cards. The word “Health Network Only” will displayed on cards that are part of this new HMO plan. These plans will be offered to new employers in all current HMO states except California and Washington.

Terminating Provider Agreement: Aetna is requesting that all providers that are wishing to terminate their provider agreement must inform Aetna immediately. Therefore, Aetna will have enough time to inform the members and assign patients to new providers. At this time, Aetna does not state the termination required period, which means if the provider wishes to leave Aetna they can put in the request any time during their contract period.

6814 18th Ave. 2 Fl. Brooklyn, NY 11204 Phone: 718 934-6714 Fax: 718 504-6072 E-Mail: Web:

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Volume 3

Patients Social Security Number: Effective September 07, 2007 patient’s Social Security numbers will no longer be listed on Explanation of Benefits. The EOB will contain patient account number that will be linked in internal Aetna file to patient profile.

Electronic Statements format of EOB: In the last week of June, WCH had sent out notices to all of our clients advising to switch back to paper statements. Effective June 01, 2007, all Aetna participating providers have stopped receiving paper statements. Now only Aetna sends out paper statements to credentialing Group providers. All individually credentialing practices must send a letter requesting to reopen their file to paper statements. WCH has sent a sample of this letter to all clients. Some of you have already responded back to Aetna and requested the change. Those that have not yet done this, we are urging you to submit your requests to Aetna. We all benefit from this letter!

Laboratory Update: Effective July 1, 2007 Quest Diagnostic will provide full laboratory services to all Aetna members. Quest offers a physician portal through which you can transmit lab orders and received results electronically. Effective the same day, LABCORP will no longer service Aetna members. Source of information obtained from Aetna Office link update June 2007

Atlantis Health Plan Atlantis is not contracted with Quest Diagnostics. All Atlantis members must be referred to Quentin Medical Labs, Shield Medical Labs, LabCorp, and Bio-Reference Labs. If out of network lab will be used the patient will have financial responsibility to pick up the bill. For more information, please direct your administration staff to Source of information obtained from

Have a wonderful summer and we will see you again in fall 2007!!!!

6814 18th Ave. 2 Fl. Brooklyn, NY 11204 Phone: 718 934-6714 Fax: 718 504-6072 E-Mail: Web:

Summer 2007 newsletter  

WCH is continuing to provide our clients with latest healthcare news and upcoming changes taking place in the healthcare community. Since th...

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