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March 2011

Volume 2 Issue 2

WCH Bulletin

WCH service Bureau, Inc Is the proud member of the following professional organizations

Welcome back readers!

Welcome back doctors and office managers to this, our second issue of the year. We hope our February Bulletin was informative, and wish the same for our current issue. In our March 2011 issue

Member of AHIMA http://www.ahima.org/ National Association of Healthcare Consultants

we will focus on the on one of the prevalent issues in the Healthcare industry, Healthcare Fraud and Abuse. We will provide information on the importance of documentation compliance, what to do when your claims are denied and the top provider types to engage in fraud.

WCH Panthers on the Run Again!

Inside this issue:

Member of NAMSS http://www.namss.org/

WCH: Bringing you the Best

Its that time again! WCH Panthers will be par- Passover Closing Dates ticipating in this year’s 10K Run For ASPIRE on National Billers Day Sunday April 3, 2011 kicking off at H.B Mattlin Middle School in Plainview, NY at 9 Am. The What Does “practicing Medicine” mean? 10K run, sponsored by the Greater Long Island Finding new Collection Agency Running Club, is Long Island's Oldest continuous held 10K, and seeks to support the ASPIRE Time management Ad program with its proceed going towards fund- Chart Audit Ad ing its rehabilitative program for young ampu- What is HealthCare Fraud? tees, and ASPIRE’s Stanley Kramberg Memorial What is Medical Necessity? Scholarship Fund. Prizes include a pair of Mizuno running shoes for the top male and female runners, and every registrant will receive a long sleeve “Run for ASPIRE” t-shirt as well as a free massage. To help support the ASPIRE program and its efforts, please sponsor our team by visiting the website at www.GLIRC.org. See you on the course!

Pg 2 Pg 2 Pg 2 Pg 2 Pg 2 Pg 3 Pg 3 Pg 4 Pg 4

Why contract with Insurance/Health Plans?

Pg 5

What does the RAC (Recovery Audit Contractors) review?

Pg 5

Top Allegations

Pg 6

Did you know Medicaid covers Cessation Pharmacotherapies?

Pg 7

Radiology management program for New York Medicaid Fee-For –Service

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HIPAA Compliant Sign-in sheet

Pg 8

Rules for ordering Ambulette transportation

Pg 9

Medical Director Agreements: Doctor Beware

Pg 10, 11

Medicaid beneficiaries Cannot be Billed

Pg 12, 13

Update On FMAP Contingency Reduction—provider restoration payments

Pg 13

Physicians to get relief from Medicare Lab paperwork rule

Pg 14, 15

Assistance for the people of Japan

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WCH Bulletin

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WCH: Bringing You The Best. It brings us great joy and pride to announce that three of our dedicated staff members, Elizaveta Bannova, Natalie Leontyeva and Ekaterina Sobakina have successfully passed the AMBA (American Medical Billing Association) CMRS (Certified Medical Reimbursement Specialist) exam. The WCH staff stands together and congratulates Elizaveta, Natalie and Ekaterina on a job well done! What Does CMRS mean? A Certified Medical Reimbursement Specialist is an experienced and knowledgeable individual in the areas of HCPCS coding, Medical terminology, Insurance Claims & Billing, HIPAA, OIG Compliance, Information & Web Technology, Reimbursement among quite a few other things. Being a certified specialist is not mandatory, but only seeks to improve our level services and prove WCH’s dedication to making our clients’ rest easier. Ask yourself, don’t you feel relieved knowing that your billing/reimbursements are being taken care of by a certified specialist?

In observance of

NATIONAL BILLER’S DAY MARCH 26, 2011

Passover, WCH will be closed April 19, 20, 25 and 26.

New York has placed great emphasis on quality health care and recognizes that medical billers are a vital part of the health industry. As proof of this March 26 will forever be known in the state of New York as National Biller’s Day. Join us as we wish all our fellow medical billers a happy National Biller’s Day!

What does “practicing medicine” mean? To Practice medicine mean that a licensed physician is using his medical skills and knowledge acquired in a medical setting. This is not limited to direct care, and a physician is still considered to be practicing medicine in the state of New York if, for example, he is employed as a Medical Director. The physician however, must maintain valid credentials. Source: Office of the Professions; New York State Educational Department. (518) 474-3817

WCH has been receiving many complaints from our clients about the current collection company/credit bureau that we are using, and we taking this matter very seriously. WCH has begun interviewing new debt collection companies to assume this role. We sincerely appreciate your feedback and we are working to improve our patient payment collection process.


Volume 2 Issue 2

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Feeling overwhelmed? Can’t keep track of your employees’ time schedules? Let WCH’s Time management software work for you! Economical, Efficient, Effective! Call us today and stay organized forever.

We Remind and Encourage You To Let A WCH Professional Chart Auditor Review Your Charts

“FED up with Insurance denials for lack of medical necessity and overpayment recovery? Feeling anxious before your documentation review? Correct your mistakes and save your reputation and funds with WCH Chart Auditors. Contact us today - tomorrow may be too late…" Slava Kurdov, CPC


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WCH Bulletin

What is Healthcare Fraud HealthCare fraud is the deliberate submittal of false claims to private or public health care plans. The real difference between fraud and abuse is the person’s intent. Inspector General Levinson recently told Congress, "Health care fraud schemes commonly include billing for services that were not provided or were not medically necessary, purposely billing for a higher level of service than what was provided, misreporting costs or other data to increase payments, paying kickbacks, and/or stealing providers' or beneficiaries' identities." So just how much money has Medicare lost? The National Insurance Crime bureau guesses that the amount is more than $130, 000 billion annually, while investigations in the past year alone have resulted in 500 Medicare fraud convictions, and an estimated $3 billion in recovered funds. Who are these perpetrators? They’re not just street criminals and big companies, they’re the working professionals;

♦ ♦ ♦ ♦ ♦

DME providers Home Health Care Agencies, Infusions Medical transportations companies and Podiatrists

But this is just the short list. Providers involved in the healthcare industry from all specialties have been found committing these fraudulent acts. What has the government to protect Medicare, other providers and most importantly the tax payers’ money? The FBI’s HealthCare Fraud unit is working hand in hand with Health Care Fraud Prevention and Enforcement Action Team, or HEAT as well as Medicare , the DEA ( Drug Enforcement Administration) and the FDA (Food and Drug Association) to bring healthcare fraud to a minimum. Also, in 2007 Medicare implemented its Medicare Strike Force that has been trying to stem the flood of taxpayer dollars flowing to illegal operations. Just this past February 17 the FBI has taken down and brought charges against 111 defendants nationally in eight cities, including right here in Brooklyn, New York. Among the perpetrators? Chiropractors, medical doctors, nurses and therapists. Sources: 1) http://abcnews.go.com/Politics/federal-agents-raided-health-care-facilities-states-morning/story?id=12940819 2) http://www.fbi.gov/news/stories/2011/february/hcf_takedown_021711/health-care-fraud-takedown 3) Health Care Fraud and Abuse: Law Enforcement Viewpoint: CAC-PIAC meeting October 2009, Janet Simon, DPM

What is Medical Necessity? Documentation should support that the care provided was needed to reasonably treat and care for the pt and problems that are being addressed during that encounter. Benefits are restricted to those drugs, devices, txmts or procedure for which the safety and efficacy have been proven procedures to be comparable or superior to conventional therapies. Supporting Medical Necessity:

• • • • • •

The final Dx The presenting signs/symptoms Unconfirmed dxs (rule out and vs) Any dx tests ordered ( V-codes can be used) The specificity of the dx Coexisting and chronic conditions.

Co-morbidities/underlying dx should only be considered in the E/M level when their presence significantly increases the complexity of the medical decision making. If chronic conditions are listed in PMH area the dx should be listed in the A/P area. Higher levels of medical decision making (MDM) can be supported when the affect that the chronic condition has on the encounter is clearly documented. Source: Health Care Fraud and Abuse: Law Enforcement Viewpoint: CAC-PIAC meeting October 2009, Janet Simon, DPM.


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Volume 2 Issue 2

Healthcare News

Why Contract with Insurance/Health Plans? Contracts – READ THEM ! Specific provisions: Timely filing, penalties, timeliness of receipt of payment. Predeterminations of benefits or pre-authorizations should be written in contract that these services need to be paid. (May have State Consumer protection laws that cover this.) Insurance violations – UHC/PacifiCare Wrongful denials of covered claims • Incorrect payment of claims • Lost documents/medical records • Failure to timely acknowledge receipt of claims • Failure to respond to appeals • Failure to resolve provider disputes PROS AND CONS OF CONTRACTING WITH INSURANCE/HEALTH PLANS PROS • Fixed fees –may be able to negotiate • Direct payment to provider from co. • Marketing benefit-web site, provider directory • Paid for add. codes • Less collection issues? • Increase referrals from Health Plan docs NON-CONTRACTED PROVIDERS (NCP) PROS • No fee limit • Able to balance bill pt. • No egregious contract provisions • No Silent PPO’s • Able to practice at will • May be ALLOWED a higher amount by HP Source: Health Care Fraud and Abuse: Law Enforcement Viewpoint: CAC-PIAC meeting October 2009, Janet Simon, DPM. Denied or Modified Claims?

What does the RAC (Recovery Audit Contractors) review? • • • •

Review claims and medical records on a post payment basis Review Claims paid after October 1, 2007 RACs will be able to review medical records three years from the date the claims were paid Collect overpaid claims

This firm has handled a number of Medicare, OMIG and private payer audits. A knowledgeable legal counsel can be indispensable, particularly when the amounts that the payers are trying to recover are significant. WCH highly recommends the services of this firm. Contact them at (518) 462-3000 Marcia B. Smith, Esq.


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WCH Bulletin

TOP ALLEGATIONS Physician Audits: 454 – Top specialties: Podiatry, Internal Medicine & Gastroenterology Most Commonly Audited Codes; 11720/11721 (nail debridement) E/M Codes – all (-25 modifier) 11730 (nail avulsion) 11040 series (ulcer debridement) 11060/11061 (I&D of abscess) 11050 series (paring of skin lesions) 99241 series (consultations) When the auditors identify a under coded or over coded claim, rarely will the claim be paid without the physician appealing the auditor decision. RAC audits – Have not been seen frequently for podiatry – YET ! 2 types: Automated review (w/o medical record) Complex review (w/ Medical record) Generally smaller dollar amounts at issue. Reforms implemented in July 2008: • Recouping before appeal is done • RAC contingent fees would be lost if appeal is found in favor of the physician. Program Safeguard Contractors have taken over most of the audit functions previously performed by carriers. • Often do statistical sampling and extrapolated overpayments. • Review personnel often are poorly trained as to podiatry coding and billing.


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Volume 2 Issue 2

Did You Know?

Medicaid Covers Smoking Cessation Pharmacotherapies Smoking cessation therapy consists of prescription and non-prescription agents. Covered agents include nasal sprays, inhalers, Zyban (bupropion), Chantix (varenicline), over-the-counter nicotine patches and gum. Two courses of smoking cessation therapy per recipient, per year are allowed. A course of therapy is defined as no more than a 90-day supply (an original order and two refills, even if less than a 30-day supply is dispensed in any fill). If a course of smoking cessation therapy is interrupted, it will be considered one complete course of therapy. Any subsequent prescriptions would then be considered the second course of therapy. Some smoking cessation therapies may be used together. Professional judgment should be exercised when dispensing multiple smoking cessation products. Duplicative use of any one agent is not allowed (i.e., same drug and same dosage form and same strength). For all smoking cessation products, the recipient must have an order. A prescription is the terminology for an order of a prescription product. A fiscal order refers to an order, which looks just like a prescription—written on a prescription blank, for an overthe-counter product. Prescription nicotine patches will no longer be reimbursed. New York State Medicaid will only reimburse for over-the counter nicotine patches. For more information on the New York State Medicaid Smoking Cessation policy, please call (518) 486-3209. Source: www.nyhealth.gov; New York Medicaid Update, February 2011, Volume 27, Number 3, page 12

Radiology Management program for New York Medicaid Fee-For-Service Effective April 4, 2011, New York State Medicaid fee-for-service will implement a radiology management program to ensure that beneficiaries receive the most clinically appropriate imaging studies. The program will be applied to non-emergency outpatient CT, CTA, MRI, MRA, cardiac nuclear and PET procedures, for fee-for-service beneficiaries. Beneficiaries who are eligible for both Medicaid and Medicare (dual eligible) or beneficiaries who are enrolled in a managed care plan are not included. RadConsultTM, administered by HealthHelp, is a consultative, educational program that improves quality and reduces the cost of care by providing expert peer consultation and the latest evidence based medical criteria for diagnostic imaging. It provides access to consultations with subspecialists affiliated with academic radiology departments. Ordering practitioners will be required to obtain prior approval. Requests will be reviewed against guidelines, and an approval number will be issued. Approvals will be required for claims payment. If you are interested in attending an upcoming educational webinar, please email kurczj@healthhelp.com with the following information: ♦ Facility or practice name and NPI; ♦ Address of practice; ♦ Number of providers in the practice; ♦ First and last name of the main point of contact; and ♦ Contact phone, fax and email. To learn more about this new program, please visit: www.eMedNY.org. Source: www.nyhealth.gov; New York Medicaid Update, February 2011, Volume 27, Number 3, page 7


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WCH Bulletin

HIPAA Compliant Sign-in Sheet We all know how hectic the front office at the doctor’s can be, and at times it can be quite stressful trying to keep patients’ information organized. With this easy and simple sign-in sheet, receptionists can minimize this chaos with just a tap of a pen. To obtain your own copy please visit http://www.medicalartspress.com. It’s the best format you can use for the patient sign-in sheet! Its HIPAA Complaint, secure and its regulated to protect your practice.


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Rules for Ordering Ambulette Transportation Per 18 NYCRR Section 505.10(c)(2), a request for prior authorization for transportation by an ambulette/invalid coach must be supported by the order of a practitioner who is the Medicaid enrollee’s: • Attending physician; • Physician’s assistant; • Nurse practitioner; • Dentist; • Optometrist; • Podiatrist or

Other type of medical practitioner approved by the department.

A diagnostic and treatment clinic, hospital, nursing home, intermediate care facility, long term home health care program, home and community based services waiver program, or managed care program may order nonemergency ambulance transportation services on behalf of the ordering practitioner.

Rules for Ordering New York City Livery Transportation A request for prior authorization for transportation via New York City livery service must be supported by the order of a practitioner who the Medicaid enrollee’s: • Attending physician; • Physician’s assistant; • Nurse practitioner; • Dentist; • Optometrist; • Podiatrist or • Other type of medical practitioner approved by the Department. A diagnostic and treatment clinic, hospital, nursing home, intermediate care facility, long term home health care program, home and community based services waiver program, or managed care program may order nonemergency ambulance transportation services on behalf of the ordering practitioner.


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WCH Bulletin

"Medical Director Agreements: Doctor Beware" Given the current financial challenges physicians face from skyrocketing overhead costs and declining reimbursement rates, many are seeking alternative sources of income to bolster the revenues they generate from medical services they personally perform. One of the ways in which physicians are attempting to do this is to serve as medical directors for other entities. In record numbers, physicians are agreeing to serve as medical directors for freestanding clinics, outpatient and ambulatory surgical centers, nursing homes and long-term care facilities, clinical labs, diagnostic imaging centers and other health care entities and organizations. However, while medical director agreements and positions can be lucrative, they are also fraught with legal and regulatory pitfalls that can have unforeseen negative effects on the physicians who serve in these roles. Therefore, it is imperative that doctors to try to protect themselves through proper structuring of medical director agreements and business relationships. The potential to violate health care regulatory laws presents the first danger. In many instances, entities offering physicians medical director positions do so as part of an attempt to garner referrals from those physicians. In these situations, compensation arrangements are often structured either to directly or indirectly influence a physician's referral patterns. These types of arrangements can not only come under scrutiny through several federal and Florida health care regulatory laws, but also quite frankly violate them. For instance, if a federal or Florida health care regulator felt that a medical director agreement was structured in order to induce a physician to refer their patients to the entity with which the physician was contracting, the regulator could possibly assert violations of the federal Anti-Kickback Statute, the Florida Patient Brokering Act, or the federal Stark Law. Physicians should be aware that these statutes carry with them draconian and severe consequences such as fines and civil monetary penalties ranging from $10,000 to $50,000 per occurrence; exclusion from the Medicare and Medicaid programs; possible criminal action, including incarceration; and possible disciplinary action taken against the physician's license. Additionally, emergency medicine physicians who serve as medical directors through either an employment or independent contractor relationship with a basic life support transportation service or advanced life support service must meet and comply with the requirements of Section 401.265, Florida Statutes. These requirements include: (1) supervising and assuming the direct responsibility for the medical performance of emergency medical technicians and paramedics; (2) performing duties such as advising, consulting, training, counseling and overseeing the services provided by such entities; (3) ensuring appropriate quality assurance and establishing a quality assurance committee that provides for quality assurance review of all emergency medical technicians and paramedics operating under the medical director's supervision; (4) disciplining emergency medical technicians and paramedics as necessary; and (5) reporting certain incidents and disciplinary matters to appropriate state agencies when required by Section 401.265, Florida Statutes. Failure to meet and comply with these requirements could result in disciplinary action being taken against a medical director's medical or osteopathic medicine license. Another significant pitfall physicians need to be aware of involves the potential medical malpractice and professional liability issues that may arise due to the physicians' performance of their duties as medical directors. In medical director agreements, physicians are often asked to supervise other personnel such as nurse practitioners, physician assistants, physical therapists, nursing assistants, radiology technicians and even other physicians. In addition, physicians serving as medical directors are often required to review clinical, patient care and risk management policies and procedures as part of their duties and obligations. In some cases, plaintiffs who alleged that they may have been injured by the negligence of an entity or another licensed health care professional under the supervision of a medical director have asserted both direct and vicarious liability claims against a physician serving as a medical director. In many cases, physicians often overlook medical malpractice insurance and indemnification provisions that are either not included in their medical director contracts or are poorly written provisions. Physicians serving as medical directors (due to their busy schedules or lack of knowledge about an entity or facility) also often fail to provide the necessary supervision and review of both personnel and policies and procedures. More and more, when they bring medical malpractice or professional negligence lawsuits, plaintiffs' attorneys are asserting claims for these alleged failures against physicians serving as medical directors. A third pitfall involves the requirements physicians must meet when supervising ancillary personnel and health care providers while Continued on next page


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serving as medical directors. Specifically, many Medicare and Medicaid billing regulations require certain levels of supervision by a physician in order for an entity or health care provider to be able to bill for the services being rendered by an ancillary health care provider. Failure to provide the appropriate supervision can result in allegations of false claims being made to the Medicare or Medicaid programs. While the entity or the health care provider filing these claims will be primarily responsible for any such alleged false claims, in many instances government agencies and regulators are asserting similar claims against physicians serving as medical directors and seeking to hold them liable for either administrative, civil or criminal violations. Finally, in March 2004, Florida implemented The Health Care Clinic Act (the "Act") in Part XIII of Chapter 400, Florida Statutes. The Act provides that each clinic governed by the Act must have a medical director who has a full and unencumbered license as either a medical doctor, osteopathic physician, podiatric physician or chiropractic physician. It is important to note that the Act requires a clinic's medical director to be authorized under Florida law to supervise all of the services provided at the applicable clinic. Therefore, a clinic providing general medical care cannot be supervised by a chiropractic or podiatric physician due to the limited scope of practice of their professional licenses. As a result, many clinics that offer a diverse range of services including general medical care are seeking medical doctors and osteopathic physicians to serve as their medical directors. However, serving as a medical director in accordance with the Act can be extremely risky for medical doctors and osteopathic physicians. Specifically, Section 400.9935, Florida Statutes, requires that a medical director must accept, in writing, the legal responsibility for certain activities and duties that must be performed by the clinic. This Section states that a medical director shall: (1) ensure that signs identifying the medical director are posted in a conspicuous location in the clinic; (2) ensure that all practitioners providing health care services or supplies to clinic's patients maintain a current, active and unencumbered Florida license; (3) review any patient referral contracts or agreements executed by the clinic; (4) ensure that all health care practitioners at the clinic have active appropriate certification or licensure for the level of care or treatment they are providing; (5) serve as the clinic's medical records owner in accordance with Section 456.057, Florida Statutes; (6) ensure the clinic's compliance with all record keeping, physician office surgery, and adverse incident reporting requirements under applicable Florida statutes, rules and regulations; and (7) conduct systematic reviews of the clinic's claims submissions and billings in order to ensure that the billings and claims submissions are not fraudulent or unlawful, and upon discovery of any unlawful claim or charge take immediate corrective action. Under the Act, additional responsibilities are imposed on clinics and their medical directors when clinics provide radiology services. Medical directors for clinics requiring licensure under the Act are faced with a plethora of responsibilities for which they can be held legally responsible if the clinic fails to meet all of its legal requirements. In other words, a medical director for clinic license under the Act could face civil, administrative and licensure actions and penalties if they fail to ensure that a clinic meets all of the requirements set forth in Section 400.9935, Florida Statutes. In these situations, physicians serving as medical directors have a heightened standard of both supervision and legal responsibility that most physicians serving as medical directors have not experienced prior to the implementation of the Act. Medical doctors and osteopathic physicians who chose to serve as a medical director of a clinic license under the Act must be aware of and completely understand the significant responsibility and potential liability that they are undertaking when entering into medical director agreements with such clinics. Consequently, any medical doctor or osteopathic physician considering entering into an agreement to serve as a medical director should carefully review any proposed agreement and consider retaining qualified legal counsel in order obtain a complete and thorough review of their agreements and the potential duties, responsibilities and liabilities which come with such agreements. Michael R. Lowe, Esq. is a Board-Certified Health Law Attorney and shareholder at Michael R. Lowe, P.A., 407-332-6353. Contact the firm online.

Source: http://www.lowehealthlaw.com/CM/Articles/Medical-Director.asp


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WCH Bulletin

Medicaid Beneficiaries Cannot Be Billed By enrolling in the Medicaid program, a provider agrees to accept payment under the Medicaid program as payment in full for services rendered. A provider may not make a private pay agreement with a beneficiary to accept a Medicaid fee for a particular covered service and then provide a different upgraded service (usually a service that is beyond the scope of the Medicaid program) and agree to charge the beneficiary only the difference in fee between two services, in addition to billing Medicaid for the covered service. It is an unacceptable practice to knowingly demand or collect any reimbursement in addition to claims made under the Medicaid program, except where permitted by law. ACCEPTANCE AND AGREEMENT

When a provider accepts a Medicaid beneficiary as a patient, the provider agrees to bill Medicaid for services provided or, in the case of a Medicaid managed care or Family Health Plus (FHPlus) enrollee, the beneficiary’s managed care plan for services covered by the contract.

The provider is prohibited from requesting any monetary compensation from the beneficiary, or their responsible relative, except for any applicable Medicaid co-payments.

The provider is prohibited from requesting any monetary compensation from pregnant women or children who have been found to be presumptively eligible for Medicaid.

A provider may charge a Medicaid beneficiary, including a Medicaid or FHPlus beneficiary enrolled in a managed care plan, only when both parties have agreed prior to the rendering of the service that the beneficiary is being seen as a private pay patient.

• •

This agreement must be mutual and voluntary. If, for example, a provider sees a beneficiary, and advises them that their Medicaid card is valid, eligibility exists for the date of service and treats the individual, the provider may not change their mind and bill the beneficiary for that service or any part of that service.

It is suggested that providers keep the beneficiary’s signed consent on file so that they may be treated as a private pay patient. A provider who participates in Medicaid fee-for-service may not bill Medicaid fee-for-service for any services included in a beneficiary’s managed care plan, with the exception of family planning services, when the provider does not provide such services under a contract with the recipient's health plan. A provider who does not participate in Medicaid fee-for-service, but who has a contract with one or more managed care plans to serve Medicaid managed care or FHPlus members, may not bill Medicaid fee-for-service for any services. Nor may any provider bill a beneficiary for services that are covered by the beneficiary’s Medicaid managed care or FHPlus contract, unless there is prior agreement with the beneficiary that they are being seen as a private pay patient as described above. The provider must inform the beneficiary that the services may be obtained at no cost from a provider that participates in the beneficiary’s managed care plan. Note: Due to the requirement that PRIOR agreement be made for reimbursement, Medicaid beneficiaries may never be charged for services rendered in an Emergency Room (except applicable Medicaid co-payments). CLAIM SUBMISSION The prohibition on charging a Medicaid or FHPlus recipient applies:

When a participating Medicaid provider or a Medicaid managed care or FHPlus participating provider fails to submit a claim to Computer Sciences Corporation (CSC) or the recipient's managed care plan within the required timeframe; or

When a claim is submitted to CSC or the recipient's managed care plan, and the claim is denied for reasons other than that the patient was not eligible for Medicaid or FHPlus on the date of service.

COLLECTIONS A Medicaid beneficiary, including a Medicaid managed care or FHPlus enrollee, must not be referred to a collection agency for collection of unpaid medical bills or otherwise billed, except for applicable Medicaid co-payments, when the provider has accepted the enrollee as a Medicaid or FHPlus patient. Providers may, however, use any legal means to collect applicable unpaid Medicaid co-payments.


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EMERGENCY MEDICAL CARE A hospital that accepts a Medicaid beneficiary as a patient, including a Medicaid or FHPlus recipient enrolled in a managed care plan, accepts the responsibility for making sure that the patient receives all medically necessary care and services. Other than for legally established co-payments, a Medicaid or FHPlus recipient should never be required to bear any out-of-pocket expenses for:

• •

Medically necessary inpatient services; or, Medically necessary services provided in a hospital- based emergency room (ER).

This policy applies regardless of whether the individual practitioner treating the beneficiary in the facility is enrolled in the Medicaid program. When reimbursing for ER services provided to Medicaid managed care or FHPlus enrollees, health plans must apply the:

• • •

Prudent Layperson Standard; Provisions of the Medicaid Managed Care/FHPlus Model Contract; and, Department Directives.

CLAIMING PROBLEMS If there is a problem with a claim submission, the provider must first contact CSC. If the claim is for a service included in the Medicaid managed care or FHPlus benefit package, the enrollee's managed care plan must be contacted. Questions? Please call the Office of Health Insurance Programs at (518) 473-2160. Source: New York State Medicaid update, February 2011, Volume 27—number 3

Update on Federal Medical Assistance Percentage (FMAP) Contingency Reduction— Provider Restoration Payments The State implemented a 1.1% across the board reduction to Medicaid payments that were processed on or after September 16, 2010. Subsequent concerns expressed by the Center for Medicare and Medicaid Services have led to a change in implementation to claims with dates of service beginning on or after September 16, 2010. Therefore, a reconciliation has been prepared to refund monies collected on claims with a date of service prior to September 16 but paid after that date, and for exempt providers who had been inadvertently reduced.

The State began distribution of restoration payments in billing cycle 1746 (checks dated 2/7/2011, released 2/23/2011). The paper remittance includes a single line containing the lump sum payment identified by Financial Reason Code 'LSF'. Electronic remittances reflect the lump sum payment in the PLB segment with the qualifier 'LS'. Any questions may be directed to: b1191@health.state.ny.us. Please include your provider name and Medicaid number in the email so that questions can be reviewed and responded to in an orderly manner. As additional information becomes available, it will be posted online at: http://www.health.ny.gov/health_care/ state/fmap_contingency_plan/. The modified reduction will remain in effect for claims with dates of service on or after September 16, 2010, which are paid by March 31, 2011.. Source: New York State Medicaid update, February 2011, Volume 27—number 3


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WCH Bulletin

Physicians To get Relief From Medicare Lab Paperwork Rule The AMA and groups representing clinical laboratories had urged CMS to rescind a new requirement that doctors sign off on lab tests. Washington -- Responding to pressure from the American Medical Association and others, the Centers for Medicare & Medicaid Services has indicated that it will rescind a new Medicare rule requiring physicians to provide their signatures on requisitions for laboratory tests. Doctors had warned that the rule would have created paperwork headaches for medical professionals ordering and fulfilling lab test requests, ultimately having an adverse impact on patient care. The signature policy has been on the books since Jan. 1, but it was never enforced by the Medicare agency. CMS finalized the rule in its 2011 physician fee schedule in November 2010. However, citing concerns about lack of awareness of the change in the health care industry, the agency delayed enforcement of the policy until April 1. Lawmakers soon became involved, requesting an additional nine-month enforcement delay. Reps. Michael Burgess, MD (R, Texas) and Bill Pascrell Jr. (D, N.J.) wrote a Feb. 10 letter to the agency stating, "We worry about how the rule could affect Medicare beneficiaries where such lab services are necessary for a physician to make critical decisions that affect patients' health and well-being, often under significant time constraints, and urge CMS to consider these situations as they examine this policy." The letter was signed by 87 other lawmakers. A group of 34 senators sent a similar letter to CMS on Feb. 11. But the AMA, along with several other members of organized medicine, called for the agency to abolish the signature rule permanently. "We clearly communicated to CMS that the added administrative hassles this rule would impose on physicians were burdensome and unnecessary," said AMA President Cecil B. Wilson, MD. "CMS' decision to reverse this policy will allow physicians to spend less time on paperwork and more time on patient care. This decision is an important step as the administration works to ease regulatory burdens for businesses, including physician practices." CMS spokeswoman Ellen Griffith would not comment on how the agency would go about rescinding the rule. "All I can confirm is that the agency is taking another look at the policy and considering next steps," she said. Not a new concept The lab signature policy had been in development for several years. CMS proposed the rule in 2009, but it chose not to finalize it because of concerns raised during a public comment period. In 2010, agency officials had enough confidence that they had ironed out those details that they decided to include a signature requirement in the 2011 fee schedule. The rule would not create an extra burden for physicians, CMS had said, because in most instances a physician already is annotating the patient's medical record with either a signature or an order, as well as with any paperwork needed to identify the lab test. The agency also noted that a signature in ink would not be required for similar requisitions made over the phone or through an electronic medical record system.

C o n t in u e d o n ne xt p a ge


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Volume 1, Issue 1

In the final fee schedule rule, CMS further defended its decision by stating that the policy would make it easier for lab technicians to know whether a test was appropriately requested. Also, "potential compliance problems would be minimized for laboratories during the course of a subsequent Medicare audit because a signature would be consistently required." But physicians argued that the signature requirement would create an additional barrier between them and their patients. The policy could interfere with a physician's ability to practice medicine professionally and efficiently, said Jeff Terry, MD, a urologist in Mobile, Ala. He said physicians can't be in front of patients to sign requisitions all of the time. For instance, Dr. Terry said, a scenario might exist where a physician performing surgery in the operating room receives an urgent call for another patient. The doctor already is aware of the second patient's problem, so he wants the patient to get an x-ray immediately, then follow up with the physician in the office later. The physician's nurse could provide the patient with the requisition needed to obtain the xray, expediting the process in a way that benefits both patient and physician, he said. This handoff would not be possible if a physician signature requirement were in place. "Patients with kidney stones don't want to wait another day for me to sign the paper before they can do a test," he said. Before the most recent rule change, CMS had been very clear that doctor sign-offs weren't required, said JoAnne Glisson, senior vice president of the American Clinical Laboratory Assn. in Washington, D.C. Consequently, almost all requisitions arrive at labs without signatures. The new policy had left labs facing a choice between two unpleasant options if they wanted to be paid by Medicare for all the services they provide, said Richard Daly, CEO of Laboratory Partners, a large fullservice lab company based in Cincinnati that runs about 5.5 million tests a year. "One would be to not provide the test -- or provide the test and chase the physician or facility for a signature," he said. "Neither was a great solution." Glisson said senior CMS officials informed the lab association that they were going to rescind the policy. She said the agency would need to issue an interim final rule to undo the requirement before April 1, but the new document had not been released at this article's deadline. Source: http://www.ama-assn.org/amednews/2011/02/28/gvl10228.htm


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Wch bulletin march  

Welcome back doctors and office managers to this, our second issue of the year. We hope our February Bulletin was informative, and wish the...

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