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WCH BULLETIN December 2012 VOLUME 3 ISSUE 10

Welcome to the December issue of WCH bulletin! WCH is 2012-2013 Compliant with OMIG http://omig.ny.gov/data

WCH Service Bureau is a proud member of the following professional organizations:


WCH Service Bureau, Inc. would like to take this time to wish you and your family a happy holiday season. It gives us great gratitude and pleasure to express to you our season's greetings and best wishes for the New Year. Thank you for giving us the opportunity for having your trust in our services. May your holiday season and the New Year be filled with much joy, happiness and success. We look forward to working with you in the coming year and hope our business relationship continues for many years to come. WCH would like to consolidate in wishing you health, comfort, and a prosperous New Year ahead! We are always here for you!


INSIDE THIS ISSUE: 4 WCH CORNER 10 Attention Health Professionals: Information Regarding the 2013 Medicare Physician Fee Schedule CREDENTIALING NEWS 11 Office of Inspector General Work Plan FY 2013 14 Credentialing Live Webinar HEALTHCARE UPDATES 15 Electronic Funds Transfer (EFT) 15 Oxford Fined for Failure to Explain Coverage 16 There is no Such Thing as a 10-minute Office Visit 18 Important Changes Effective January 7, 2013 - Correction 19 Early Assessment Finds That CMS Faces Obstacles in Overseeing the Medicare EHR Incentive Program 20 Avoid Untimely Claim Denials 20 Magellan Outpatient Behavioral Health New Model 21 Improper Payments to Providers for Incarcerated Beneficiaries 22 Payments for Alien Beneficiaries Unlawfully Present in the United States on the Dates of Service

23 Medical Necessity Top Reason for RAC Denials 23 Use of Q6 Modifier for Locum Tenens by Providing Performing Provider NPI - Analysis Only CR 24 CMS Fact Sheet: Draft HHS Notice of Benefit and Payment Parameters for 2014 25 Three Steps in Order to Receive EHR Incentive Payment 28 NEWS BY SPECIALTY 29 STATES UPDATES 30 QUESTIONS AND ANSWERS 32 FEEDBACK


WCH CORNER

WCH YEAR RECAP

The 2012 year has been extremely busy for WCH, we would like to let our clients know what results we had achieved this past year.

WCH IS 5010 COMPLIANT! We are officially registered with Medicare program as 5010 compliant vendor, as well as with other insurance companies.Once again, we want to make sure that you know, that WCH is 5010 compliant and your claims are in good hands!

WCH PUBLICATION RECEIVED CEU CREDITS WCH Bulletin and WCH Times have been each approved for 1 CEU credit by AMBA American Medical Billing Association.

Clients will find Registration form on WCH website to receive CEU credit. On your online profile you can review your CEU credits and maintaing full credit list.

From January 1, 2013 all WCH publications will be under package subscription. WCH is proud to offer numerous opportunities for professional growth and certification/licence maintenance. We offer a fast and convenient way to earn CEU credit. Each publication gives you 1 CEU credit.

New CFPC,CPC coder in WCH! WCH Service Bureau, Inc has announced in April edition, that Liz Bannova (Vice-Manager) become CFPC (Certified Family Professional Coder) She showed great determination, knowledge and achieved her goal, WCH is very proud to have first CFPC coder on staff. WCH Times | 4


WCH RELEASED NEW PROGRAM - WEBINAR SERVICE WCH has released program - Webinar service. This program helps our clients with web-conference, online-meeting, seminars and presentations via Internet in real-time mode. Participants can access to the service in the web-browser without long and tiring downloading of software. Service has very convenient, simple and intuitive measuring interface. Service provides possibility of recording webinar for the future downloading and later viewing by webinar users. Webinar is the perfect tool for corporate education.

WCH CONTEST THE WINNER WAS ANNOUNCED! WCH contest finished and winner was announced. The competition was fierce, and it was great to see such amazing, interesting, exciting designs of potential virtual assistant. In nearest future our clients and website visitors can see new virtual assistant with new tools.

WCH ONLINE STORE AT We have started selling our software product Time Management on Amazon. This product received a good attention from buyers. We invite you to visit our Amazon store: http://www.amazon.com/gp/product/B005AKPJA6

NEW CREDENTIALING DEPARTMENT MANAGER From July 1, 2012 WCH has new credentialing department manager Mr. Osipyants. We are confident that with Mr. Osipyants experience in credentialing arena and well established relationship with insurances vendors will streamline all credentialing processes and hopefully relieve our clients from their enrollment headaches.

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WCH WEBSITE NEW DESIGN! We are launched our WEBSITE new design. The site has undergone a fresh lick of paint and some radical new changes. From here you will be able to keep up to date with all the latest news, releases and more. The new site is fully compatible with your mobile devices too! So you can check us out whilst you are on the go! Don't forget to check out WCH new blog where WCH updating and sharing important news from healthcare industry. So head on over to now!

ICD-10 CODE CONVERSION ON WCH WEBSITE WCH have placed on WCH website new ICD-10 Code Conversion just might make your job a little easier. The ICD-10 code translator tool allows you to compare ICD-9 to ICD-10 codes. ICD-9 is being expanded from 17,000 to approximately 141,000 ICD-10 codes, and this online tool can help you map that expansion.

WCH BLOG! In our blog you may find interesting news and fascinating views, interesting news of health care industries. The new Blog section of our website is an exciting new outreach project for us. Our blog focus on a variety of topics related to medical industry. Do not miss interesting news in our blog. We are sure you will be happy to list through our blog. Who wants be a writer, please send your text to us.

WCH Go Green Initiative WCH support Go Green Initiative program We recommend that our clients follow us on this initiative, you can start with simple things first: џ Upgrade to E-Fax џ Set up for electronic funds transfer (EFT) for your insurance payments џ Set your staff's payroll for direct deposit џ Communicate with everyone via email џ Stop printing or copying- purchasing scanner is priority for every office WCH Times | 6

Use Gmail or Hotmail on your mobile device for reminders џ Accept our invitation to receive your Electronic remittances by email џ

WCH will continue to update about our internal Go Green processes every issue. If you need a more personal assistance with the process, please contact us for help.

Think Green and Go Paperless!


WCH offers free website for clients, don't miss a chance Several months ago we offered free-websites for our clients. Now we continue this program Free Websites for Doctors. For clients that do not have a website, we are offering to create one to three page website with information about your practice. You may ask Why you need to create a website? Because 97% of your potential patients use online to find their doctors, laboratories and imaging centers.

WCH became a proud member of RAMA Russian American Medical Association On June 1 WCH became a RAMA member. Russian American Medical Association was founded and incorporated in 2002. It was created to facilitate and enable Russian American physicians and other health care professionals to excel in patient care, teaching and research, and to pursue their aspirations in professional, humanitarian and community affairs. RAMA is not a political organization. The main office of RAMA is located in Cleveland (Ohio) and has regional offices in several U.S. states.

CHANGES IN THE BILLING DEPARTMENT WCH is continuing to grow and expand our departments! The billing department has reached over fifty employees. Our department updated staff is below. Oksana Pokoyeva, CPC, CPMA, Billing Department Manager oksanap@wchsb.com

Elizaveta Bannova, CMRS, CFPC, CPC, Vice Manager lizab@wchsb.com

Victoria Uzakova, Supervisor vikau@wchsb.com

Zukhra Kasimova, CPC, Supervisor zukhrak@wchsb.com

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SOCIAL MEDIA DEPARTMENT Social Media Department promotes WCH services through different channels of marketing: We Invite You To Join Us! Please Visit wchsb.com.

Department pushes the WCH into new social media Valeriya Aksyonova, Designer spaces, drives innovation and online communication Olesya Petrenko, Marketing Manager programming in this arena, provides platform for real-time conversation, collaboration and idea sharing. Plus we can do it all for you! If you want to promote your services, please contact us: olesyap@wchsb.com

WCH PANTHERS-RACE FOR CURE 2012 On September 9, 2012, WCH has taken part in 2012 Komen New York City Race for the Cure in Central Park. We were honored and privileged to take part of such an extraordinary event that not only benefited the foundation by helping them reach the goal of $6 million, but also to promote awareness of local breast cancer screening, education and outreach programs.

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WCH Referral Program for our clients

Refer WCH to Your Colleagues and Friends for billing service! Only happy clients refer others, and we want to make sure we exceed the expectations of every client who passes through our doors. We understand that, we only grow if you are happy with our service. If you know anyone who needs billing service, WCH is here to help. We are grateful for referrals that come our way and pleased to offer a Referral Reward Program. WCH will provide you with 2 complimentary insurances for credentialing, the deal is worth $800, for every client that will sign with us.

For any questions please, contact Olga Khabinskay General Manager 888-924-3973 (x 1201), 718-934-6714 skype: olgakwchsb olgak@wchsb.com


AMA: LAST-MINUTE ACTION TO AVERT CUTS TO PHYSICIANS SHOWS THE NEED FOR MEANINGFUL MEDICARE CHANGES “Congress averted a drastic cut of 26.5 percent from hitting physicians who care for Medicare patients on January 1. This patch temporarily alleviates the problem, but Congress’ work is not complete; it has simply delayed this massive, unsustainable cut for one year. Over the next months, it must act to eliminate this ongoing problem once and for all. “This last-minute action on the part of Congress is a clear example of how the Medicare program is increasingly unreliable for physicians and patients. This instability stalls progress in moving Medicare toward new health care delivery models that can improve value for patients through better care coordination. Physicians want to work with Congress to move past this ongoing crisis and toward a Medicare program that ensures access to care and the best health outcomes for patients and a stable, rewarding practice environment for physicians.” Source: Jeremy A. Lazarus, MD President, American Medical Association

WCH will hold All Medicare claims 2013 claims approximately for 2 weeks till Medicare will update fee schedule

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CREDENTIALING NEWS OFFICE OF INSPECTOR GENERAL WORK PLAN FY 2013 In an effort to promote efficiency and eliminate waste, fraud, and abuse, the Office of Inspector General (OIG) takes a look at Medicare and Medicaid programs every year. In doing so, it provides an annual work plan stipulating areas of these programs that require monitoring and investigation by components of the OIG (Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General). During the fiscal year, these offices typically audit and review Medicare Part A and B claims to determine whether providers billed appropriately for services they furnished. WCHSB credentialing department staff reviewed the 2013 work plan and identified key areas of focus: Onsite Visits for Medicare Provider and Supplier Enrollment and Reenrollment (New) We will determine how often onsite visits occur as part of the Medicare enrollment or reenrollment process. CMS reserves the right, when deemed necessary, to perform onsite inspections of a provider or supplier to verify enrollment information submitted to CMS. (42 CFR § 424.510(d)(8).) Moreover, CMS is authorized to expand the role of unannounced preenrollment site visits. (Affordable Care Act, § 6401(a)(3).) CMS implemented the Affordable Care Act provider and enrollment provisions by requiring onsite visits for provider and supplier types identified by CMS as moderate risk or high risk. (76 Fed. Reg. 5862 (February 2, 2011).) A prior OIG review

found that 33 percent of medical equipment suppliers in South Florida did not maintain physical facilities, a vulnerability that might be reduced by confirming legitimacy of location with onsite visits conducted during the enrollment process. (OEI; 00-00-00000; expected issue date: FY 2014; new start. Affordable Care Act.) Program Integrity—Improper Use of Commercial Mailboxes (New) We will determine the extent to which Medicare Part B providers and suppliers had practice locations that matched commercial mailbox addresses in 2011. Medicare providers and suppliers are required to establish physical business facilities of adequate size and with permanent, visible signs and must provide CMS with specific street addresses (not mailboxes) recognized by the U. S. Postal Service. Recent evidence suggests that individuals attempting to defraud Medicare may be using mailbox rental services to evade enforcement of this requirement, as commercial mailbox services provide a recognized street address without a mailbox number. (OEI; 00-00-00000; expected issue date: FY 2014; new start) Independent Therapists—High Utilization of Outpatient Physical Therapy Services We will review outpatient physical therapy services provided by independent therapists to determine whether they were in compliance with Medicare reimbursement regulations. Prior OIG work found that claims for therapy services provided by independent physical therapists were not reasonable, WCH Times | 11


medically necessary, or properly documented. Our focus is on independent therapists who have a high utilization rate for outpatient physical therapy services. Medicare will not pay for items or services that are not “reasonable and necessary.” (Social Security Act, § 1862(a)(1)(A).) Documentation requirements for therapy services are in CMS's Medicare Benefit Policy Manual, Pub. 100-02, ch. 15, § 220.3. (OAS; W00-11-35220;W-00-12-35220; W-00-13-35220; various reviews; expected issue date: FY 2013; work in progress and new start) Program Integrity—Excluded Individuals Employed by Managed Care Networks We will determine the extent to which OIGexcluded individuals were employed by entities that provide services through MCE provider networks in 2009. We will also determine the extent to which safeguards are in place to prevent excluded individuals and entities from participating in Medicaid managed care provider networks. The Department of Health and Human Services (HHS) and OIG have authority to exclude individuals and entities from all Federal health care programs pursuant to the Social Security Act, §§ 1128, 1156, and 1892. Medicaid and any other Federal health care programs are precluded from paying for any items or services furnished, ordered, or prescribed by an excluded individual or entity, except under specific limited circumstances. (Social Security Act, § 1862(e)(1), and 42 CFR § 1001.1901(b).) The payment prohibition applies to the excluded individual or entity, anyone who employs or contracts with the excluded individual or entity, and any hospital or other provider through which the excluded individual or entity provides services. Recent State WCH Times | 12

Medicaid program integrity reviews by CMS's Medicaid Integrity Group have identified provider enrollment, including the employment of excluded providers, as one of the most common vulnerabilities. (OEI; 07-0900632; expected issue date: FY 2013; work in progress) First Level of the Medicare Appeals Process We will describe redeterminations (the first level of Medicare appeals) processed in 20082011 for Medicare Parts A and B. A Medicare contractor has 60 days to conclude a redetermination regarding a denied claim. We will also assess the processing of redeterminations by Medicare contractors and CMS's monitoring of redeterminations processing. (Social Security Act, § 1869(a)(3)(C)(ii).) (OEI; 01-12-00150; expected issue date: FY 2013; work in progress) Part B Imaging Services—Payments for Practice Expenses We will review Medicare payments for Part B imaging services to determine whether they reflect the expenses incurred and whether the utilization rates reflect industry practices. For selected imaging services, we will focus on the practice expense components, including the equipment utilization rate. Practice expenses are those such as office rent, wages, and equipment. Physicians are paid for services pursuant to the Medicare physician fee schedule, which covers the major categories of costs, including the physician professional cost component, malpractice costs, and practice expenses. (Social Security Act, § 1848(c)(1)(B).) (OAS; W-00-12-35219; W-00-13-35219; various reviews; expected issue date: FY 2013; work in progress and new start)


Diagnostic Radiology—Medical Necessity of High-Cost Tests We will review Medicare payments for high-cost diagnostic radiology tests to determine whether they were medically necessary and the extent to which the same diagnostic tests are ordered for a beneficiary by primary care physicians and physician specialists for the same treatment. Medicare will not pay for items or services that are not “reasonable and necessary.” (Social Security Act, § 1862 (a)(1)(A).) (OAS; W-00-12-35454; W-00-13-35454; various reviews; expected issue date: FY 2013; work in progress and new start) For more detailed information please visit the OIG website at www.oig.hhs.gov

Dora Mirkhasilova, Credentialing Specialist Phone: 718-934-6714 1102 or email credentialing@wchsb.com

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HEALTHCARE UPDATES What You Need to Know The therapy caps for 2013 will be $1900 for physical therapy and speech-language therapy combined and $1900 for occupational therapy

ELECTRONIC FUNDS TRANSFER (EFT) Electronic Funds Transfer, or EFT, allows to send payments to payees electronically,

OXFORD FINED FOR FAILURE TO EXPLAIN COVERAGE: The NYS Department of Financial Services (DFS) has announced that Oxford Health has been fined $665,000 for failing to explain coverage to its health plan members. Oxford was cited for approximately 300,000 instances of failing to provide explanation of benefit statements (EOBs). State law requires that the EOB explain what services the plan covers and how consumers can appeal when they believe claims are improperly denied. The violations are cited in an Examination Report undertaken by the NYS Department of Insurance (the predecessor to DFS) for the period October 1, 2001 through December 31, 2008. Oxford failed to send EOBs for certain claims, and in certain instances failed to provide specific explanation of any denial, reduction or other

rather than printing and mailing a paper check. EFT payments are especially advantageous because payee receives payment faster than with a paper check, and there is no risk of a check getting lost in the mail. EFT is Fast- no making a trip to the bank, Safeno paper check to lose or damage, and less expensive than paper check payments and collections, that means that your money will be confirmed in your bank account quicker than if you have to wait for the mail, deposit your check, and wait for the funds to become available.

reasons for not providing reimbursement for the amount claimed. The two Oxford companies fined are Oxford Health Plans NY, Inc., and Oxford Health Insurance, Inc. Oxford responded that the violations were not the result of any conscious policy to evade the requirements of the Insurance law or regulations. Oxford must submit a corrective action plan to DFS within 60 days of the approval of the Stipulation it agreed to with DFS. See: http://ow.ly/exLFd. Governor Vetoes Bill Amending Self-referral Law: Governor Cuomo has vetoed legislation that would have brought New York's law on the prohibition of financial arrangements and referrals into conformance with the federal WCH Times | 15


Stark Self-Referral Statute. The legislation included certain exceptions to the self-referral prohibition adopted under the federal law but not currently part of New York's law. Regarding self-referral: This bill would amend the Public Health Law which prohibits, subject to certain exceptions, health care practitioners from referring patients to providers of health care services with whom the practitioner or an immediate family member has a financial relationship. This bill could weaken those Public Health Law prohibitions by, among other things, creating additional exceptions to what constitutes a financial relationship, albeit in conformity with federal law. Given the concern with real and apparent conflicts of interest that this change would engender. Generally, the Stark Law prohibits physicians from referring Medicare patients for certain designated health services (e.g., clinical lab, imaging, radiation therapy, and physician therapy services, among others) to an entity with which the physician (or a member of the physician's immediate family) has a financial relationship, unless an exception applies. The State Law by and large mimics the Stark Law, but there are certain distinctions that make the State Law more restrictive. Notably, the

THERE IS NO SUCH THING AS A 10MINUTE OFFICE VISIT I will never forget something a patient told me several years ago when I was covering the front desk in a practice I was managing. If you manage a practice and haven't worked at your check-in and check-out desks recently, I highly recommend it. WCH Times | 16

State Law covers referrals of designated health services regardless of payment source, meaning remuneration from private insurers and managed care plans are covered by the statute. In addition, the Stark Law contains exceptions for the following additional types of arrangements that are not in the State Law, which make it more permissive: џ community-wide health information

systems and e- prescribing items and services and electronic health record items and services (in contrast, the State Law only includes a limited allowance for the provision of computers and related equipment and supplies by a clinical laboratory to a health services purveyor), џ bona fide charitable donations, џ fair market value compensation

arrangements, and џ a “temporary non-compliance” grace

period for arrangements that, but for a ministerial error, otherwise comply with a Stark Law exception.

An insured patient that I checked out was shocked when I said the charge for her visit was $100. She said, “But he was only in the room for ten minutes!“ I was briefly at a loss for words. I recovered, we agreed on a payment plan for her co-pay, I made a note on her encounter form for the billing office and she left.


I've been thinking about our conversation, and thinking about what that $100 – actually the payer would probably only pay about $35 and with her co-pay, the grand total would be $55 – and what that $55 is supposed to cover… 1. First, we scheduled the appointment, which was a work-in, so it took several people to take the message, pull the medical record (paper charts), call the patient to assess the problem, determine the need for the appointment and schedule it. 2. When the patient arrived, we checked to make sure her address and phone were the same, quickly checked her eligibility to make sure the insurance on file was still in force, and asked for a photo ID. An encounter form was generated at the nurse's station to notify her of the patient's arrival. 3. The nurse called her from the reception area, weighed her, and took her into an exam room to take her vitals, take a brief Chief Complaint and History of Present Illness, review the medications she is taking and check to see if she needed any chronic medication refills while she was there 4. The physician came in to see her, asked about any changes since she'd last been seen, reviewed her History of Present Illness and examined her. He talked to her about her illness and described a treatment plan for her upper respiratory infection given her chronic health problems. 5. He prescribed a medication for her problem, updated her medication list and made a copy for her to take with her.

6. He marked the encounter form with the level of service and her diagnoses and gave her the form to take to the checkout desk. 7. He refiled the medication reconciliation in the chart, finished documenting the visit, and placed the chart in the bin to be refiled. The chart was filed, and the encounter form was sent to the billing office. 8. At the billing office the charges and any payment was posted and the claim was filed. If there was no problem with the claim, it electronically passed through two scrubs and a final one at the payer. 9. If payment was not denied for any of a dozen reasons, the payment would arrive at the billing office and would be posted. 10.Since the patient did not pay her co-pay at the check-out desk, the patient balance is billed to the patient. If the patient pays on the very first statement, it has taken the practice from 45 to 60 days to receive the complete payment of $55. I know that patients often say “But he only spent 10 minutes with me.” Checking back with the provider, I find it was typically longer. Patients tend to underestimate the time as it goes very fast. The total visit encompassed the work of the phone operator, the medical records clerk, the triage nurse, the check-in person, the nurse, the doctor, the check-out person and the biller. It took 8 people, and at least 45 minutes of work to make that appointment happen. Plus, that visit had to help pay the expenses for the rent, the utilities malpractice WCH Times | 17


insurance, medical supplies, computers, phones and janitorial services. The practice, the patients and the overseers of healthcare want each visit to be non-rationed, safe, high-quality, error-free, holistic, pleasant, clean, accurate, efficient and reimbursable. It's what we all want. And it isn't cheap. Even though healthcare and healthcare reimbursement have been sizzling hot topics in the past few years, most patients – already anxious and often sick – do not have a strong

REMINDER - IMPORTANT CHANGES EFFECTIVE JANUARY 7, 2013 - CORRECTION Medicare Secondary claims must only contain one iteration of loop 2320 with an AMT01 equal to "D" (primary payer paid amount). Claims containing more than one iteration will be rejected on the 999, not the 277CA as previously indicated. CMS issued Change Request (CR) 7880 edit spreadsheet changes for institutional and professional claims. The edit changes below will be implemented January 7, 2013. New editing that may require changes to how you submit your claims: • Subscriber policy or group number in loop 2000B SBR03 must not be present. If this information is reported you will receive a 999E (acknowledgement with errors) and a claim rejection on the 277CA. • Medicare Secondary claims must only WCH Times | 18

grasp of what actually goes into the services they receive. They see very little of the behind-the-scenes efforts. I don't think the patient visit is necessarily the perfect time to educate patients on what goes into an office visit, but maybe each of us should be prepared to offer a meaningful answer when the patient says “But he only spent 10 minutes with me.” Source: www.managemypractice.com

contain one iteration of loop 2320 with an AMT01 equal to "D" (primary payer paid amount). Claims containing more than one iteration will be rejected on the 999. • Line adjudication information, paid units of service in loop 2430 SVD05 must be greater than or equal to 0 and less than 9,999.9. Claims reporting paid units of service less than 0 or greater than 9,999.9 will be rejected on the 277CA. Attention PC-ACE Pro32 users: Your next quarterly update will be available January 7, 2013. This update will address necessary changes in regards to these edits. Users who do not upgrade will receive errors due to new edits effective January 7, 2013 Source: cms.gov


EARLY ASSESSMENT FINDS THAT CMS FACES OBSTACLES IN OVERSEEING THE MEDICARE EHR INCENTIVE PROGRAM WHY DID THIS STUDY This study is an early assessment of CMS's oversight of the Medicare electronic health record (EHR) incentive program, for which CMS estimates it will pay $6.6 billion in incentive payments between 2011 and 2016. Because professionals and hospitals selfreport data to demonstrate that they meet program requirements, CMS's efforts to verify these data will help ensure the integrity of Medicare EHR incentive payments. HOW DID THIS STUDY This study reviewed CMS's oversight of professionals' and hospitals' self-reported meaningful use of certified EHR technology in 2011, the first year of the program. To address our objective, we analyzed self-reported information to ensure it met program requirements. We also reviewed CMS's audit planning documents, regulations, and guidance for the program and conducted structured interviews with CMS staff regarding CMS's oversight.

reports may contribute to CMS's oversight obstacles. WHAT RECOMMEND We recommend that CMS: (1) obtain and review supporting documentation from selected professionals and hospitals prior to payment to verify the accuracy of their self reported information and (2) issue guidance with specific examples of documentation that professionals and hospitals should maintain to support their compliance. CMS did not concur with our first recommendation, stating that prepayment reviews would increase the burden on practitioners and hospitals and could delay incentive payments. We continue to recommend that CMS conduct prepayment reviews to improve program oversight. CMS concurred with our second recommendation. We recommend that ONC: (1) require that certified EHR technology be capable of producing reports for yes/no meaningful use measures where possible and (2) improve the certification process for EHR technology to ensure accurate EHR reports. ONC concurred with both recommendations. Source: https://oig.hhs.gov

WHAT CMS FOUND CMS faces obstacles to overseeing the Medicare EHR incentive program that leave the program vulnerable to paying incentives to professionals and hospitals that do not fully meet the meaningful use requirements. Currently, CMS has not implemented strong prepayment safeguards, and its ability to safeguard incentive payments postpayment is also limited. The ONC requirements for EHR

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AVOID UNTIMELY CLAIM DENIALS An important message from Novitas Solutions, Inc. (formerly Highmark Medicare Services) All claims for services furnished on January 1, 2010 and after, must be filed with Novitas Solutions, Inc no later than one calendar year (12 months) from the date of service or the claim will be denied as being past the timely filing deadline. Please remember the holiday on the first of the year and submit your claims before one year from the date of service for timely processing.

accepted by Novitas Solutions, Inc after your end of day processing time on Monday, December 31, 2012, will not be considered received until our next business day of Wednesday, January 2, 2013, due to standard system operating hours. We recommend you submit these claims at least 2-3 business days prior to December 31, 2012, to allow time for potential report error resolutions and claim resubmissions. Source: Novitas Solutions, Inc

To avoid receiving an untimely claim denial for services, Novitas Solutions, Inc must receive these claims prior to your end of day processing time on Monday, December 31, 2012. Once received electronically, they must also be accepted on the initial acknowledgment report Office will be closed on Tuesday, January 1, 2013, in observance of the New Year's Day holiday. Therefore, any electronic claims that are received and

MAGELLAN OUTPATIENT BEHAVIORAL HEALTH NEW MODEL Magellan Behavioral Health's new outpatient care management model, which WCH Times | 20

takes effect in January 2013: - Reduces provider administrative tasks - Expedites direct access to care - Identifies and addresses gaps in behavioral health services and coordination Key Components of the Outpatient Care Model: Ń&#x; The model works through:


џ The model works through:

џ A decrease in the time you spend on the

- Removal of administrative processes often perceived as access barriers, such as preauthorization and treatment request forms - Use of proprietary evidence-based, clinically driven claims algorithms to identify only those cases needing care management support or other intervention - Review of all submitted claims against the clinical algorithms

phone or online with Magellan to obtain authorization for routine outpatient care that meets criteria for continuation. џ Reduction of your administrative burden, providing more time for you to spend with your patients and your practice.

What Does it Mean for Providers? џ You can initiate routine outpatient services, including counseling and medication management visits, for members without calling Magellan or obtaining preauthorization through our website.

IMPROPER PAYMENTS TO PROVIDERS FOR INCARCERATED BENEFICIARIES The Office of Inspector General (OIG) of the Department of Health and Human Services advised in the 2013 OIG Work Plan that they would be reviewing Medicare payments for Incarcerated Beneficiaries. Medicare, in general, does not pay for services rendered to incarcerated beneficiaries; however, the regulation does permit Medicare payment where an incarcerated beneficiary has an obligation for the cost of care. (Social Security Act, § 1862, and 42 CFR § 411.4.) The Common Working File will reject claims on which the dates of incarceration (as obtained from the Social Security Administration) and

Services Still Requiring Preauthorization High-risk cases and higher levels of care such as inpatient, residential, and partial hospitalization services. Specialty care such as intensive outpatient treatment, psychological testing, outpatient ECT, transcranial magnetic stimulation (rTMS), hypnotherapy, applied behavior analysis, and biofeedback.

the dates of service on the claim overlap. (The Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual, Medicare Claims Processing Manual (100-04), Chapter 1, § 10.4.) In addition, the Medicare Claims Processing Manual provides instructions for providers who render services to incarcerated beneficiaries who meet the criteria for exception. Audits conducted by the OIG have resulted in overpayments to providers across the country, including those serviced by National Government Services. As a result, CMS has charged National Government Services to begin the process of recouping identified overpayments. The first series of overpayment adjustments have generated. WCH Times | 21


Overpayment letters will begin to be mailed on Monday, December 10. The listing of the claims impacted by this action that you will receive with your letter will indicate that; "This claim adjustment was due to a mass adjustment." The detailed description of the adjustment can be found on the Fiscal Intermediary Standard System. The letters will

PAYMENTS FOR ALIEN BENEFICIARIES UNLAWFULLY PRESENT IN THE UNITED STATES ON THE DATES OF SERVICE The Office of Inspector General (OIG) of the Department of Health and Human Services advised in the 2013 OIG Work Plan that they would be reviewing payments for Alien Beneficiaries Unlawfully present in the United States. The OIG will determine whether Medicare payments were made on behalf of beneficiaries who were unlawfully present in the United States on the dates of services. Medicare payment may not be made for items and services furnished to alien beneficiaries who were not lawfully present in the United States. (The Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual, Medicare Claims Processing Manual (100-04), Chapter 1, ยง 10.1.4.8.) Medicare prohibits payment for services rendered to individuals who are not "qualified aliens." (Personal Responsibility and Work Opportunity Reconciliation Act of 1996, ยง 401.) These audits that have been conducted by the WCH Times | 22

contain the guidelines for applying for an extended repayment plan so that you may research that option if necessary. Source: OIG.com

OIG have resulted in overpayments to providers across the country, including the National Government Services states of business being identified. As a result of these audit findings, the OIG and the CMS have charged National Government Services to begin the process of recouping those overpayments. The first tier of this process has now begun and we have generated the first round of those overpayment adjustments. As with any overpayment situation letters have also been generated. These letters will begin to be mailed on Monday, December 10. The listing of the claims impacted by this action that you will receive with your letter will indicate that; "This claim adjustment was due to a mass adjustment." The detailed description of the adjustment can be found on Fiscal Intermediary Standard System. The letters will contain the guidelines for applying for an extended repayment plan so that you may research that option if necessary. Source: OIG.com


MEDICAL NECESSITY TOP REASON FOR RAC DENIALS

administrative time on RAC activity. Medical record requests jumped by a fifth (21 percent) this quarter.

Recovery auditors (better known as RACs) denied 23 percent more Medicare claims in the third quarter of this year, compared to the previous quarter, according to the American Hospital Association.

Medical necessity is the most common reason for denials and has been since the first quarter of 2010, according to the more than 2,300 surveyed hospitals since AHA started monitoring denials. Sixty-one percent of hospitals said the RAC claimed treatment took place in the wrong setting and not that the care was medically unnecessary. Forty percent of them are appealing the decisions at a 74 percent success rate.

The RACTrac results signal not only more denials but also more associated costs. Denials cost providers 26 percent more this quarter. More than half of hospitals (58 percent) said they are spending more than $10,000 for managing the RAC process, while 41 percent spent more than $25,000. Twelve percent said they spent more than $100,000.

Source: CMS. Gov

Hospitals say they also are spending more

USE OF Q6 MODIFIER FOR LOCUM TENENS BY PROVIDING PERFORMING PROVIDER NPI ANALYSIS ONLY CR Locum tenens policy states that “Physicians may retain substitute physicians to take over their professional practices when the regular physicians are absent for reasons such as illness, pregnancy, vacation or continuing medical education, and for the regular physician to bill and receive payment for the substitute physician's services as though he performed them himself … These substitute physicians are generally called 'locum tenens' physicians.” Substitute services are indicated with the HCPCS Q6 modifier. The locum tenens physician is not allowed to substitute for more than 60 days, which currently can

only be validated through medical record review; the locum tenens physician does not appear on claims and is not required to be formally enrolled in Medicare. Professional practices may also bill locum tenens for “regular physicians” who have left the practice with no intention of returning. During any circumstance when the locum tenens physician is billing under the NPI of the regular physician the locum tenens physician's NPI shall also be on submitted claims to allow transparency into the identities of these physicians. This is a statutory requirement under SSA section 1842: “the claim form submitted to the carrier for such services includes the second physician's unique identifier.” Source: CMS. Gov WCH Times | 23


CMS FACT SHEET: DRAFT HHS NOTICE OF BENEFIT AND PAYMENT PARAMETERS FOR 2014 Earlier this year, CMS published the Patient Protection and Affordable Care Act: Standards Related to Reinsurance, Risk Corridors and Risk Adjustment Final Rule (Premium Stabilization Rule) (77 FR 17220) and the Establishment of Exchanges and Qualified Health Plans; Exchange Standards for Employers Final Rule (77 FR 18310). These rules implement standards for Affordable Insurance Exchanges (Exchanges), States, and health insurance issuers related to the reinsurance, risk adjustment, and risk corridors programs established by the Affordable Care Act and the establishment of Exchanges and qualified health plans. These programs are designed to provide consumers with affordable health insurance coverage, to reduce incentives for health insurance issuers to avoid enrolling sicker people, and to stabilize premiums in the individual and small group health insurance markets inside and outside Exchanges. The draft HHS Notice of Benefit and Payment Parameters is a proposed rule released today that expands upon the standards set forth in these earlier rules, and provides further information related to policies such as the risk adjustment, reinsurance and risk corridors programs, advance payments of the premium tax credit, and cost-sharing reductions. Key proposals include: Ń&#x; Reducing the incentives for health

insurance issuers to avoid enrolling people with pre-existing conditions: The permanent risk adjustment program will assist health plans that cover individuals with higher health care costs and will help WCH Times | 24

ensure that those who are sick have access to the coverage that they need. CMS proposes a risk adjustment methodology to use when operating risk adjustment on behalf of a State. CMS also outlines the agency's proposed approach to validating risk adjustment data to instill confidence in the program. States that are running an Exchange and their own risk adjustment program can propose a different methodology. Ń&#x; Stabilizing premiums in the individual

market for health insurance: The transitional reinsurance program is a threeyear program designed to reduce medical risk for issuers and thereby reduce premiums for enrollees in the individual market to ensure market stability with the implementation of new consumer protections in 2014. The statute sets a fixed, national amount for the reinsurance program. To improve efficiency and reduce administrative burden, CMS proposes uniform reinsurance payment parameters for this program. CMS proposes that a State may supplement the HHS reinsurance payment parameters, but must pay for those supplementary parameters with additional State reinsurance collections or State funds (instead of funds collected by HHS under the national contribution rate). CMS also proposes: a per capita rate under which contributions would be collected annually by HHS from all applicable health insurance issuers and group health plans; exclusion of certain types of plans from the reinsurance contribution requirement; and standards governing the calculation of contributions. Ń&#x; Protecting health insurance issuers against

uncertainty in setting premium rates:


The temporary risk corridors program protects qualified health plans from uncertainty in rate setting from 2014 to 2016 by having the Federal government share risk in losses and gains. CMS proposes to account for profits and taxes in the calculations and to align this program with the MLR program. Ń&#x; Assisting low and moderate-income

Americans in affording health insurance on Exchanges: CMS proposes further clarification regarding the administration of advance payments of the premium tax credit and cost-sharing reductions. To help eligible individuals pay their premiums and make coverage purchased through an Exchange affordable for low- and middleincome consumers, CMS is proposing to make advance payments of the premium tax credit to issuers on behalf of certain individuals. The cost-sharing reduction program will further reduce the out-ofpocket spending for health services for

THREE STEPS IN ORDER TO RECEIVE EHR INCENTIVE PAYMENT The EHR Incentive Programs are available for Medicare and Medicaid eligible professionals. These programs started to work in 2011 year. The total maximum incentive amount that can be paid under the Medicare EHR Incentive Program is $44,000 over five consecutive years of program participation and under the Medicaid EHR Incentive Program is $63,750 over six years of program participation. Eligible professional can receive

low- and middle-income individuals, and Indians. CMS is proposing that issuers provide cost sharing reductions at the point of service for eligible individuals and that CMS directly reimburse issuers for these payments. Ń&#x; Exchange User Fees: Under the Affordable

Care Act, Exchanges are self-sustaining entities. CMS proposes a user fee for health insurance issuers participating in a Federally-facilitated Exchange that would be commensurate with fees charged by State-based Exchanges. Source: CMS. Gov

the maximum incentive under the Medicare EHR Incentive Program by starting in 2011 or 2012, if eligible professional don't start by 2014, he/she is not eligible to receive any incentive payment. Under the Medicaid EHR Incentive Program eligible professional can receive the maximum incentive by starting in 2016. Under the Medicare EHR incentive program payment adjustments will take place in 2015 for providers who are eligible but decide not to participate. Adjustments to Medicare reimbursements will start at 1% per year, up to a maximum 5% annual WCH Times | 25


adjustment. No payment adjustments under the Medicaid EHR Incentive Program. Three steps in order To receive EHR incentive payment: 1) Provider must be eligible. Incentive payments are made to individual providers, not to practices or medical groups. Provider can be eligible for both Medicare and Medicaid EHR Incentive Programs but can participate in one only. The following are considered “eligible professionals” who can participate in the Medicaid EHR Incentive Program: Physicians (primarily doctors of medicine and doctors of osteopathy); Nurse practitioners; Certified nurse-midwives; Dentists; Physician assistants who furnish services in a federally qualified Health Center or Rural Health Clinic that is led by a physician assistant. To qualify for participation in the Medicaid EHR Incentive Program, an eligible professional must also meet one of the following criteria: • Have a minimum 30% Medicaid patient volume • Have a minimum 20% Medicaid patient volume, and be a pediatrician • Practice predominantly in a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) and have a minimum 30% patient volume attributable to needy individuals The following are considered “eligible professionals” who can participate in the Medicare EHR Incentive Program: Doctors of medicine or osteopathy; Doctors of dental surgery or dental medicine; Doctors of podiatry; Doctors of optometry; Chiropractors. WCH Times | 26

As an option provider can check eligibility through web site https://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentiveProgra ms/Eligibility.html There are specific Eligibility Requirements for Hospitals. To learn which hospitals are eligible to participate in the program, visit http://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentiveProgra ms/Eligible_Hospital_Information.html 2)To get an incentive payment, provider must use an EHR that is certified specifically for the EHR Incentive Programs. You can find a complete list of certified EHR technology at the Certified Health IT Product List (CHPL) website, http://healthit.hhs.gov/CHPL. 3) To receive an EHR incentive payment, providers have to show that they are “meaningfully using” their EHRs by meeting thresholds for a number of objectives. CMS has established the objectives for “meaningful use” that everyone must meet to receive an incentive payment. All required objectives that should be reported are the same for both Medicare and Medicaid EHR Incentive Programs. For the first year of participating, eligible professionals have to meet the requirements for and report data on a continuous 90-day period during the calendar year (any 90 days from January 1st to December 31st). For the remaining years of participating, eligible professionals have to meet the requirements for the entire calendar year. For the first year of participating


under Medicaid EHR Incentive Program, eligible professionals have the option to report adopting, implementing, or upgrading to a certified EHR system and not to report meaningful use objects. “Meaningful use� is reporting thorough web site. The EHR Incentive Program consists of 3 stages. Each stage has own requirements. We are currently in Stage 1. Medicare EHR Incentive Program runs by CMS and Medicaid EHR Incentive Program runs by state. To see if your state's program has launched go to the Medicaid State Information section of the EHR website state. To see if your state's program has launched go to the Medicaid State Information section of the EHR website https://www.cms.gov/Regulations-andGuidance/Legislation/EHRIncentivePrograms/ MedicaidStateInfo.html You can also look at the State EHR Incentive Program Milestones and Web Resources https://www.cms.gov/apps/files/statecontact s.pdf , which provides individual websites for each state's Medicaid EHR Incentive Program. . If you eligible professional and you have decided to participate in the Medicare/Medicaid EHR Incentive Program you can register online at:

https://ehrincentives.cms.gov/hitech/login.ac tion For Medicaid eligible professionals CMS will then send information to the individual state. Twenty-four hours after successfully registering through the CMS website, eligible professional will need to log in to his/her state program's website to verify registration and provide additional eligibility information. How do you register? Use Registration User Guide that will give you step-by-step directions on how to register online. For Medicaid EHR Incentive Program https://www.cms.gov/EHRIncentivePrograms/ Downloads/EHRMedicaidEP_RegistrationUser Guide.pdf Medicare EHR Incentive Program https://www.cms.gov/EHRIncentivePrograms/ Downloads/EHRMedicareEP_RegistrationUser Guide.pdf.

WCH Times | 27


NEWS BY SPECIALTY 78320 (bone imaging; SPECT).

Cardiology Rubidium is used with the following cardiac PET scan 78491 Myocardial imaging, positron emission tomography (PET), perfusion; single study at rest or stress 78492 multiple studies at rest and/or stress The level II cod e for rubidium is A9555 (rubidium 82Rb, diagnostic, per study dose, up to 60 millicuries). If “supervision, interpretation and report” also is performed, one or more codes from the 93015–93018 range would be appropriate. Note that, the American Medical Association revised codes 93015 and 93016 in the 2013 CPT manual to eliminate the word “physician” when connected to supervision. Changes are shown below. 93015 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with supervision, interpretation and report 93016 supervision only, without interpretation and report.

Radiology For 2013, effective January 1, the Centers for Medicare & Medicaid Services (CMS) will implement two other primary changes related to the multiple procedure payment reduction (MPPR) policy. џ CMS has added the following to the list of

nuclear medicine codes covered by the MPPR policy: CPT code 78306 (bone imaging; whole body) when followed by WCH Times | 28

џ The technical component (TC) and TC

portion of global services for certain diagnostic cardiovascular and ophthalmology procedures will be reduced when the service is furnished by the same physician (or same physicians in the same group practice) to the same patient in the same session on the same day. For diagnostic ophthalmology services, a 20percent reduction will apply. For diagnostic cardiovascular services, a 25-percent reduction will apply. For codes affected by the new multiple procedure payment reduction (MPPR), see Tables 10–15 in the in the Medicare physician fee schedule final rule at http://www.gpo.gov/fdsys/pkg/FR-2012-1115/pdf/2012-26902.pdf Some Medicare payers will allow code V71.1, especially for PET for the initial treatment strategy. According to the Medicare national coverage determination (NCD) for PET for oncologic indications, this scan may be allowed for tumors that are “strongly suspected” based on diagnostic tests and clinical history. If the PET is done with negative results, V71.1 could be used to indicate that the physician suspected a malignant neoplasm. Some payers also allow V71.1 for subsequent treatment strategy when the physician suspects a recurrence or metastasis that is subsequently disproven by PET. The bottom line then: Check your payer’s local coverage determination (LCD) to see whether V71.1 is allowed. Source: panaceahealthsolutions.com


STATES UPDATES Aetna aims for accountable cancer care in Michigan Aetna, Hartford is introducing a program in Michigan that aims to reduce costs and improve outcomes in oncology treatment. The program will be available to in-network oncologists who are part of Physician Resource Management, a doctor-owned consulting group for oncology practices. Aetna and Cardinal Health earlier this year introduced a pathways program in Florida. They also introduced similar initiatives last year in Washington, D.C., Maryland and Northern Virginia. Source: Cigna

Florida Blue, healthcare system team for accountable care organization NCH Healthcare System, Naples, Florida, will participate in an accountable care program with Florida Blue, the state's Blue Cross and Blue Shield company. In its first year, the accountable care organization will use a "value-based payment structure" and will include only Florida Blue members in the Naples market, but it is expected to expand in the future.

Anthem Blue Cross announced it was expanding its ACO network via care-coordination programs with providers in Southern California, and it launched a new primary-care initiative with six large physician groups in Virginia. Other payers also are aligning themselves with local providers in ACO arrangements.

Partners HealthCare marks $42 million for Massachusetts tax One prominent Boston health system plans to pay $42 million under a tax in Massachusetts' healthcare cost-containment law. The money from Partners HealthCare, which totals less than one-half of 1% of the system's 2012 expenses, will help finance a state trust fund for investment in healthcare reform initiatives by distressed Massachusetts hospitals. The Massachusetts law, an ambitious and widely watched attempt to contain rising healthcare costs, includes provisions to promote health information technology, accountable care and new payment models. The tax could raise $135 million from Partners, other large hospital operators and insurers. The tax is limited to hospital operators with at least $1 billion in assets and less than half their revenue from public payers. Source: modernhealth

WCH Times | 29


QUESTIONS AND ANSWERS

Question: t Hi, I am a Pediatrician and I am planning to open PC in Bronx. Currently I am working on submitting documents. I would really appreciate if you can advice me what exact documents I need to include to get a permission.

Answer: t You must submit a Certificate of Incorporation with a $90.00 filing fee. We also will need a copy of your Board Certification in Pediatrics from the American Medical Board of that specialty. Also provide your NYS Medical License number. Send that to NYS Education Department. Dora Mirkhasilova, Credentialing Specialist

Question: t Should PC be billed in the same location where the TC was performed as government identified due to the geographic locations?

Answer: t If the global diagnostic service code is billed, the biller (either the entity that took the test, physician who interpreted the test, or separate billing agent) must report the address and ZIP code of where the test was furnished on the bill for the global diagnostic service code. In WCH Times | 30

other words, when the global diagnostic service code is billed, for example, chest x-ray as described by HCPCS code 71010 (no modifiers), the locality is determined by the ZIP code applicable to the testing facility, i.e. where the TC of the chest x-ray was furnished. The testing facility (or its billing agent) enters the address and ZIP code of the setting/location where the test took place. This practice location is entered in Item 32 on the claim. As explained above, in order to bill for a global diagnostic service code, the same physician or supplier entity must furnish both the TC and the PC of the diagnostic service and the TC and PC must be furnished within the same MPFS payment locality. A listing of the current PFS locality structure, including state, locality area (and when applicable, counties assigned to each locality area) may be accessed from http://www.cms.gov/Medicare/Medicare-Feefor-ServicePayment/PhysicianFeeSched/index.html on the CMS website.(Select “Medicare PFS Locality Configuration� from the menu on left.) Separate Billing of Professional Interpretation If the same physician or other supplier entity does not furnish both the TC and PC of the diagnostic service, or if the same physician or other supplier entity furnishes both the TC and PC but the professional interpretation was furnished in a different payment locality from where the TC was furnished, the professional interpretation of a diagnostic test must be separately billed with modifier -26 by the interpreting physician. Victoria Uzakova, Supervisor


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December 2012  

December 2012

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