Physicians Dropped by Health Plans for Overutilization

By Averel B. Snyder, MD from Physicians Practice

After United Healthcare dropped 15 percent of its provider panel, I was not surprised. I actually thought something like that would occur sooner. It is clear that for Medicare to survive and to decrease healthcare costs in this country, healthcare delivery needs to change. Most believe that fee-for-service reimbursement is no longer an option and there seems to be a shift toward pay for performance. Clearly, increasing quality, decreasing costs, and increasing patient satisfaction are goals both payer and provider would strive for.

There are certain services in place to help meet these goals. One such example is the Medicare Annual Wellness Visit (AWV). The AWV, by delivering evidence-based preventive services, helps keep patients healthier and prevents over-utilization of services. The visit also helps satisfy quality measures for PQRS reporting. Despite all these advantages only approximately 12 percent of Medicare beneficiaries have had their AWV.

Another way to increase quality and decrease costs is to identify those patients that are at increased risk of overutilization. The current methodology to identify risk is the CMS HCC method. In addition to identifying risk by assigning a risk score to each patient, the codes are necessary for Medicare Advantage (MA) plans to get paid from CMS. The majority of physicians do an incomplete job of coding, making it necessary for MA plans to use third-party providers for risk assessments and retrospective chart reviews. There are now automated software solutions that provide all the components of the AWV and calculate the CMS HCC risk score real time.

The point is that fee-for-service overutilization, no coding, and not providing quality measures will not be and should not be tolerated. Those plans with strong executive leadership will identify those top 15 percent physician over-utilizers and not allow them to participate in the MA plan. If I was one of those executives I would make the same decision. It is time to make the paradigm shift and provide the highest quality care as cost efficiently as possible. It is to the providers' advantage to provide wellness visits for all their Medicare patients, and to understand the nuances of HCC coding.

Article By Averel B. Snyder, MD from Physicians Practice

http://www.physicianspractice.com/blog/physicians-dropped-health-plans-overutilization?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=19112013

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Revenue Cycle Efficiencies and ICD-10

By Rachel V. Rose, JD, MBA from Physicians Practice

According to a Bank of America Merrill Lynch Executive Insight Report, Opportunities From Financial Efficiencies, produced in collaboration with HealthLeaders Media, financial leaders indicated that the "revenue cycle is where they could find the most efficiencies. The revenue cycle has been a focus of the industry for years, but the need for improvement is increasing given the payment model shifts that will come as a result of healthcare reform." (p. 2).

Given the upcoming October 1, 2014, transition to ICD-10, the revenue cycle is being scrutinized more closely than ever in preparation for the greatest impact on healthcare billing since the transition to prospective-payment, diagnosis-related groups (DRGs) in the early 1980s. Currently, physicians and other healthcare providers are considering how to contend with the decrease in claim-submission productivity due to the increased specificity, as well as potential denials and the effect on the revenue cycle.

Given the multiple aspects of ICD-10 transition, which could be focused on, I am going to provide some suggestions in the area of coding and compliance, which I have addressed directly with providers. First, like HIPAA, all entities are required to meet the ICD-10 requirements, regardless of their size. In light of this, coding and compliance policies and procedures should be established based upon state, federal and regulatory agency guidelines. Moreover, private payers may be implementing similar standards, especially those involved with Medicare Part C claims submissions.

For these private payers, state prompt-pay laws may be in effect that will enable providers to collect for untimely billing practices by private payers. Second, educating everyone throughout the revenue cycle proactively will enable efficiencies to be captured now and reduce the cash gap during the October 2014 transition. Third, regular compliance audits, including medical necessity, are critical to reducing adverse outcomes from RAC and ZPIC audits, as well as diverting the billing departments' efforts from clean claims submissions to reactively dealing with legal processes. Finally, the caliber of coders is crucial. It is inadvisable for providers to skimp on coder certification, training, and input. Outsourcing is also an option, but make sure that the appropriate HIPAA and Health Information Technology for Economic and Clinical Health, or HITECH, Act business associate requirements are in place.

In sum, "revenue cycle issues … caused the most anxiety among [the BAML] survey respondents, with 25 percent saying they felt 'very' exposed to potential losses." (Ibid. at p. 5). By being proactive and implementing effective compliance programs, healthcare providers can reduce their anxiety and potentially mitigate significant losses on the revenue cycle.

By Rachel V. Rose, JD, MBA from Physicians Practice
http://www.physicianspractice.com/blog/revenue-cycle-efficiencies-and-icd-10?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=19112013

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Physicians and the Financial Challenge of Providing an Interpreter

By Melissa Young, MD from Physicians Practice

I’ve written before about unexpected expenses, and we recently ran into another one.

Practices are required to provide access to care to patients regardless of their ability to speak the same language as the physician, and the practice must provide a reliable way to communicate with the patient. That means for patients who do not speak English (and in our practice, instead speak Filipino or Urdu), a translating service must be available.  Patients may decline and use a family member, but the service must be available. There are different options for such a service. If there is a staff member who speaks the same language as the patient, the staff member can do it. Or the practice can contract with a translator service. As a less-expensive alternative, there is software that can translate, although that doesn’t always work as well. There are also telephone-based translating services. Well, it isn't just the non-English speakers who need a translator. We recently had a patient come in who is hearing-impaired. When his appointment was confirmed, he reminded us (through a representative) that it is our responsibility to provide a sign-language interpreter.
We had never needed the services of a signer before.  Fortunately, he provided us with the number of someone we could call. It turns out, such services cost between $150-200 in our area. At least, that was the quote we got.

At $150-200 a visit, that pretty much means that, at best, we break even for the visit, and more likely, we lose money each time we see him. Since it is a requirement, I thought, "maybe there is a CPT code for 'use of a translator.'" Maybe we could get reimbursed for hiring someone. Alas, there is no such code, at least not that I could find.  Now, this patient legitimately needed to see an endocrinologist. He wasn’t one of those people who just think they have an endocrine disorder because they are tired. He needed to be seen, and he will need follow up. And every time he comes, he needs an interpreter. Unless (according to the regulation) there will not be a significant amount of communication involved. What kind of doctor visit doesn’t entail communication? My biller/husband said we should be able to say we can't see him, but (aside form it being the right thing to do) we have to, otherwise it violates a whole bunch of regulations. The exception to the rule is if it places "undue strain" on the practice. And according to previously filed lawsuits, one patient doesn’t break the bank. So, we will continue to see him and provide him with an interpreter and take a loss each time. I was curious to know what the experience has been in other practices.

Article from Physicians Practice By Melissa Young, MD
http://www.physicianspractice.com/blog/physicians-and-financial-challenge-providing-interpreter?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=19112013

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Pleasing Patients Best Marketing Strategy for Medical Practices

Making your medical practice easy to do business with will differentiate it from others, establish a competitive advantage, and make it highly appealing to patients. Here are some of the many ways that physicians can make it happen.

1. Create convenient hours

Many people have workloads or requirements that limit their availability for doctors' appointments during the traditional 9 a.m. to 5 p.m. work day. To accommodate this population, many physicians have office hours beginning at 6 a.m. or 6:30 a.m. to accommodate "early risers" on their way to work, or those coming off night. Others have evening hours ending at 8 p.m., 9 p.m., or 10 p.m. to accommodate commuters and others for whom daytime appointments are inconvenient or impossible.

There are also pediatric practices that are open from 5p.m. to 5a.m. The premise is that the need for healthcare services often occurs after doctors' offices are closed —necessitating a costly trip to the emergency room or a night of worry waiting until doctor's office reopens.

"Availability" for a target population that needs the convenience of extended hours, is a strategy that works.

2. Increase phone availability

Many practices have telephone access only from 9 a.m. to 5 p.m. and are "closed" for lunch. This makes no sense if early morning callers are working men and women who do not want, or are unable, to call from work. Others prefer not to have their coworkers overhear their medical problems (or birth date when asked for it) or may not have access to a phone at work. For similar reasons, some patients may prefer to call you during their lunch break or at the end of their workday after 5 p.m. New-patient callers (with any of the above restrictions) are not likely to call back.

Recommendation: Have an employee available to answer the phones approximately one hour before the office opens, one hour after it closes, and during the hour your office might be closed for lunch. The calls that you might otherwise miss (and the goodwill you'll generate by being available) will be worth it.

3. Use electronic health records

Utilize EHRs to reduce the need for patients to fill out the same forms at each office visit, provide electronic referrals allowing easier access to follow-up care with specialists, and have the convenience of e-prescriptions electronically sent to patients' pharmacies, among other benefits.

4. Establish a Web portal

Provide an easy-to-use Web portal so patients can schedule, reschedule, or if necessary, cancel appointments, and access and print health history forms that can be filled out prior to coming to the office. A portal will also allow your practice to view and update patients' contact, insurance, and other personal information. Patients can also make electronic payments, request prescription refills, receive test results, and exchange secure messages with doctors about lab-test results (eliminating telephone tag).

To make these interactions even more convenient, give patients the freedom to connect to your practice from their smartphones via a mobile app.

Recommendation: Make sure your website is HIPAA compliant and as secure as possible.

5. Provide Wi-Fi

Provide Wi-Fi, it's a nice extra. Patients can then use their smartphones, iPads, laptops, etc., while waiting. It doesn't eliminate the inconvenience of long waits but it does make them more tolerable.

The great jazz pianist and composer Fats Waller knew about being easy to do business with. He said, "Find out what people want, and how they want it, and then give it to them just that way." He was spot on.

Courtesy of Physician Practice By Bob Levoy, the author of seven books and hundreds of articles on human resource and practice management topics. His newest book is "222 Secrets of Hiring, Managing and Retaining Great Employees in Healthcare Practices" published by Jones & Bartlett. He can be reached at blevoy@verizon.net.


http://www.physicianspractice.com/patient-relations/pleasing-patients-best-marketing-strategy-medical-practices?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=21112013

READ MORE - Pleasing Patients Best Marketing Strategy for Medical Practices

Improve Your Patients’ Health with the Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV) Medicare Part B/Noridian

MLN Matters® Number: SE1338
Related Change Request (CR) #: NA
Related CR Release Date: NA
Related CR Transmittal #: NA
Effective Date: NA
Implementation Date: NA

Provider Types Affected

 All health care professionals who care for Medicare patients.

What You Need to Know

Medicare covers an annual preventive visit for all Medicare patients. These visits are:

• The Initial Preventive Physical Examination (IPPE); and
• The Annual Wellness Visit (AWV).

These examinations allow you to assess your patients' health on an annual basis to help you determine if they have any risk factors and if they are eligible for other preventive services and screenings that Medicare covers.

These examinations are a great way for you to detect illnesses in their earliest stages when treatment works best. The average reimbursement level for the AWV is about $107 and about $150 for the IPPE with no patient deductible or co-pay. These are cost-effective services as well as a good way to keep in touch with your patients every year.

Note: Please check the physician fee schedule for the exact amount of reimbursement for your locality and setting. You can view the physician fee schedule by visiting http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PFSlookup/index.html  on the Centers for Medicare & Medicaid Services (CMS) website.

The Initial Preventative Physical Exam IPPE (Welcome to Medicare physical)
Medicare covers an IPPE for all patients who have newly enrolled in Medicare Part B.

• The patient must receive this service within the first 12 months after the effective date of their Medicare Part B coverage.
• The IPPE is a one-time benefit.
• There are 7 components in every IPPE:
  • Review the patient's medical and social history;
  • Review potential risk factors for depression and other mood disorders;
  • Review functional ability and level of safety;
  • An examination of the patient;
  • End-of-life planning;
  • Education, counseling and referral based on the previous 5 components; and
  • Education, counseling and referral for other preventive services.

For more information about the IPPE, including a more detailed description of the 7 elements, please see "Quick Reference Information: The ABCs of the IPPE" at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf  on the CMS website.

The AWV or Annual Wellness Visit

Medicare covers an annual AWV for patients:

• Who are no longer within 12 months of the effective date of their first Part B coverage period; and
• Who have not gotten either an IPPE or AWV within the previous 12 months.

Medicare pays for only one first AWV. Medicare will pay for a subsequent AWV for each patient annually. Note: The elements in first and subsequent AWVs, and the codes to bill them, are different.

• There are 6 elements in a first AWV:
  • An assessment;
  • Establishment of a current list of provider and suppliers;
  • Detection of cognitive impairment the patient may have;
  • Establishment of a written screening schedule;
  • Establishment of a list of risk factors; and
  • Providing personalized health advice and referral to appropriate health education or other preventive services.
• There are 8 elements in a subsequent AWV:
  • Update health risk assessment;
  • Update medical and family history;
  • Assessment;
  • Update of list of current providers and suppliers;
  • Detection of cognitive impairment the patient may have;
  • Update of the written screening schedule;
  • Update of the list of risk factors; and
  • Provision of personalized health advice and referral to appropriate health education or other preventive services.

As long as a physician is providing supervision, appropriately trained members of your office staff can provide the components of the AWV.
For more information about the AWV, including a more detailed description of the elements of the AWV, please see

• "Quick Reference Information: The ABCs of the AWV" at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AWV_Chart_ICN905706.pdf  or
• "Providing the Annual Wellness Visit" at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AnnualWellnessVisit-ICN907786.pdf  on the CMS website.

Additional Information

The Medicare Learning Network® has published a variety of additional educational material on Medicare-covered Preventive Services, including:

• Preventive Services Educational Products: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/education_products_prevserv.pdf;
• The Preventive Services MLN page: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/PreventiveServices.html;  and
• MLN Matters® Articles Related to Medicare-Covered Preventive Benefits http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/MLNPrevArticles.pdf.

For general information about Medicare-covered preventive services, visit the CMS Prevention page at http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/index.html  on the CMS website. For information to share with your Medicare patients, please visit http://www.medicare.gov  on the Internet.

Last Updated Nov 18, 2013

READ MORE - Improve Your Patients’ Health with the Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV) Medicare Part B/Noridian

Update to Medicare Deductible, Coinsurance, and Premium Rates for 2014

MLN Matters® Number: MM8527
Related Change Request (CR) #: CR 8527
Related CR Release Date: November 15, 2013
Related CR Transmittal #: R82GI
Effective Date: January 1, 2014
Implementation Date: January 6, 2014

Provider Types AffectedThis MLN Matters® Article is intended for physicians, other providers, and suppliers submitting claims to Medicare contractors (Fiscal Intermediaries (FIs), carriers, Regional Home Health Intermediaries (RHHIs), Durable Medical Equipment/ Medicare Administrative Contractors (DME/MACs) and A/B Medicare Administrative Contractors (A/B MACs)) for services to Medicare beneficiaries.

Provider Action NeededThis article is based on Change Request (CR) 8527 which details the new Calendar Year (CY) 2014 Medicare premium, coinsurance, and deductible amounts. Make sure that your billing staffs are aware of these changes.

BackgroundBeneficiaries who use covered Part A services may be subject to deductible and coinsurance requirements. A beneficiary is responsible for an inpatient hospital deductible amount, which is deducted from the amount payable by the Medicare program to the hospital, for inpatient hospital services furnished in a spell of illness. When a beneficiary receives such services for more than 60 days during a spell of illness, he or she is responsible for a coinsurance amount equal to one-fourth of the inpatient hospital deductible per-day for the 61st-90th day spent in the hospital. An individual has 60 lifetime reserve days of coverage, which they may elect to use after the 90th day in a spell of illness. The coinsurance amount for these days is equal to one-half of the inpatient hospital deductible. A beneficiary is responsible for a coinsurance amount equal to one-eighth of the inpatient hospital deductible per day for the 21st through the 100th day of Skilled Nursing Facility (SNF) services furnished during a spell of illness.
Most individuals age 65 and older, and many disabled individuals under age 65, are insured for Health Insurance (HI) benefits without a premium payment. The Social Security Act provides that certain aged and disabled persons who are not insured may voluntarily enroll, but are subject to the payment of a monthly premium. Since 1994, voluntary enrollees may qualify for a reduced premium if they have 30-39 quarters of covered employment. When voluntary enrollment takes place more than 12 months after a person's initial enrollment period, a 10 percent penalty is assessed for 2 years for every year they could have enrolled and failed to enroll in Part A.
Under Part B of the Supplementary Medical Insurance (SMI) program, all enrollees are subject to a monthly premium. Most SMI services are subject to an annual deductible and coinsurance (percent of costs that the enrollee must pay), which are set by statute. When Part B enrollment takes place more than 12 months after a person's initial enrollment period, there is a permanent 10 percent increase in the premium for each year the beneficiary could have enrolled and failed to enroll.
The updated rates are as follows:

2014 PART A - HOSPITAL INSURANCE (HI) RATES

Deductible

• $1,216.00

Coinsurance

• $304.00 a day for 61st-90th day
• $608.00 a day for 91st-150th day (lifetime reserve days)
• $152.00 a day for 21st-100th day (Skilled Nursing Facility coinsurance)

Base Premium (BP)

• $426.00 a month

BP with 10% surcharge

• $468.60 a month

BP with 45% reduction

• $234.00 a month (for those who have 30-39 quarters of coverage)

BP with 45% reduction and 10% surcharge

• $257.40 a month

2014 PART B - SUPPLEMENTARY MEDICAL INSURANCE (SMI) RATES

Standard Premium

• $104.90 a month

Deductible

• $147.00 a year

Pro Rata Data Amount

• $114.99 1st month
• $32.01 2nd month

Coinsurance

• 20 percent

Additional InformationThe official instruction, CR 8527 issued to your MAC regarding this change may be viewed at http://www.cms.hhs.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R82GI.pdf  on the CMS website.

If you have any questions, please contact your MAC at their toll-free number, which may be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/provider-compliance-interactive-map/index.html   on the CMS website.

READ MORE - Update to Medicare Deductible, Coinsurance, and Premium Rates for 2014

A little known rule in the ACA could pose financial risk to doctors

A little known rule published by CMS to implement the Affordable Care Act (ACA) could pose a significant financial risk for doctors, hospitals and other healthcare providers. The rule requires health plans participating in the exchanges to provide individuals purchasing insurance through the exchanges a grace period before terminating the coverage for non payment of the premiums. Doctors and other healthcare providers will continue to provide care during the grace period, but the insurance plan will not be required to pay the claims incurred during most of the grace period. The result could be that physicians and other healthcare providers would provide a significant amount of uncompensated care.

Details of the rule

The CMS rule provides individuals that purchase subsidized coverage through the exchanges a 90-day grace period before their coverage is cancelled for non payment. The insurance plan is required to pay any claims incurred during the first 30 days of the grace period, but the insurance plan is not required to pay the claims incurred during the last 60 days of the grace period if the individual’s coverage is terminated. The insurance plan is allowed to place all the claims during the last 60 days of the grace period in a pending status. The rule requires the insurance plan to notify the healthcare providers when an insured individual is in the last 60 days of the grace period.

Risk falls on healthcare professionals and providers

The rule imposes a significant risk for uncompensated care on the healthcare providers. The rule does require insurers to tell healthcare providers when patients are behind on their premium payments, but he rule does not specify how the health plan will provide that notice to the providers. The only notice some providers receive will probably be the pending status placed on the unpaid claims by the insurance plan.
Many doctors and hospitals are reluctant to participate in insurance plans offered on the exchanges due to the increased financial risk associated with the CMS rule. The result could be that individuals enrolling in insurance plans through the exchanges may find it difficult to find a healthcare provider willing to accept them as patients. CMS has been asked to modify the rule so that insurers are required to pay claims during the entire 90-day grace period.

How grace period can be manipulated to benefit patients

The CMS rule may also result in individuals manipulating the system. Some individuals may intentionally pay premiums for only part of the year and become serial abusers of the 90 day grace period. Another unintended consequence of the ACA is that individuals that choose not to pay their premiums and have their coverage terminated can reenter the exchange and enroll in a plan regardless of their pre-existing conditions so there is little incentive for some individuals to maintain their coverage.

Were you aware of the 90-day grace period? As a healthcare professional or provider, are you worried you don’t have adequate financial protection?

Michael L. Smith is an attorney and George F. Indest, III is president and managing partner, both at The Health Law Firm.
Courtesy of: http://www.kevinmd.com/blog/2013/11/rule-aca-pose-financial-risk-doctors.html

READ MORE - A little known rule in the ACA could pose financial risk to doctors

New CMS-1500 Medi-Cal (California Medicaid) Guide for Use Beginning January 6, 2014

Medi-Cal has created a New CMS-1500 Medi-Cal Guide to show providers the fields that have changed on the new 02/12 version of the CMS-1500 claim form. Information submitted in the fields will be the same as information submitted previously on the old 08/05 version of the claim form.

Providers can refer to the CMS-1500 Completion or CMS-1500 Completion for Vision Care section in the appropriate Part 2 provider manual for claim completion instructions by field number. Side-by-side comparisons of the current and upcoming claim fields are available in the New CMS-1500 Medi-Cal Guide, which can be downloaded from the new Claim Form Updates page of the Medi-Cal website.

Old and New Claim Versions: Dates of Use
Beginning January 6, 2014, the Medi-Cal claims processing system will be able to accept and process the new 02/12 version of the CMS-1500. The old 08/05 version of the CMS-1500 will continue to be accepted and processed also, but only for three months, through March 31, 2014. Beginning April 1, 2014, only claims submitted on the 02/12 version will be accepted and processed.

Provider Manual Update Plan
The CMS-1500 claim form has been revised to accommodate the ICD indicator that will be required on claims in 2014 with the ICD-10-CM code rollout. Rather than update the entire provider manual to announce claim updates and then next year release the manual pages again with ICD-10 information, Medi-Cal has determined to approach provider manual updates as follows:

• To serve the immediate need for claim completion instructions, the CMS-1500 Completion and CMS-1500 Completion for Vision Care manual sections will be updated. The sections are slated for release in the December 2013 Medi-Cal Update bulletins. A set of instructions for completing the new 02/12 version of the CMS-1500 will be added at the front of each section. The older 08/05 instructions will be retained at the back of the section.
• Claim field names in the provider manual will continue as they appear on the 08/05 version of the CMS-1500. For example, Reserved for Local Use field (Box 19) will be retained and not changed to Additional Claim Information field (Box 19) until later in 2014.
• Billing examples will be retained, as is, in the 08/05 version of the CMS-1500.
• If it is determined that claim instructions must be updated before ICD-10-related manual pages are released in 2014, an analysis will be performed to decide if select manual pages should be updated and released.

The above cost-saving approach will allow several hundred manual sections to be updated only once.

Courtesy of: http://files.medi-cal.ca.gov/pubsdoco/Claims/Articles/claims_21966.asp?utm_source=iContact&utm_medium=email&utm_campaign=Medi-Cal%20NewsFlash&utm_content=21966

READ MORE - New CMS-1500 Medi-Cal (California Medicaid) Guide for Use Beginning January 6, 2014

New Influenza Virus and Hepatitis B Virus Vaccine Codes: Noridian/Medicare

MLN Matters® Number: MM8249
Related Change Request (CR) #: CR 8249
Related CR Release Date: May 2, 2013
Effective Date: November 20, 2012 (For code 90661); January 1, 2013 (For codes 90653, 90672, 90685, 90686, 90687, 90688, 90739, and Q2033)
Related CR Transmittal #: R2693CP Implementation Date: October 7, 2013

Provider Types Affected
This MLN Matters® Article is intended for physicians, providers, and suppliers submitting claims to Medicare contractors (carriers, Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs), carriers and A/B Medicare Administrative Contractors (MACs)) for services to Medicare beneficiaries.

What You Need to Know
This article is based on Change Request (CR) 8249, which provides instructions for payment and Common Working File (CWF) edits to be updated to include influenza virus vaccine codes 90653, 90672, 90685, 90686, 90687, 90688, and Q2033; and hepatitis B virus vaccine code 90739 for claims with dates of service on or after January 1, 2013, but processed on or after October 7, 2013. The CR also provides instructions for payment and Medicare Common Working File (CWF) edits to be updated to include influenza virus vaccine code 90661 for claims with dates of service on or after November 20, 2012, processed on or after October 7, 2013. Make sure that your billing staffs are aware of these updates.

Background
Vaccines that are described by codes 90653, 90685, 90687, 90688, and 90739 are currently pending Food and Drug Administration (FDA) approval. Vaccines that are described by codes 90661, 90672, 90686, and Q2033 have already been approved.
The Centers for Medicare & Medicaid Services (CMS) will notify Medicare contractors once FDA approval is obtained for the vaccines that are described by codes 90653, 90685, 90687, 90688, and 90739. In addition, Medicare contractors are adding Q2033 as an acceptable influenza vaccine code. As a result of CR8249:

• Effective for claims with dates of service on or after January 1, 2013, vaccine codes 90653, 90672, 90685, 90686, 90687, 90688, 90739, and Q2033 will be payable by Medicare.
• Effective for claims with dates of service on or after November 20, 2012, code 90661 will be payable by Medicare.

Annual Part B deductible and coinsurance amounts do not apply. All physicians, non-physician practitioners and suppliers who administer the influenza virus vaccination must take assignment on the claim for the vaccine.

On professional claims, for dates of service between January 1, 2013 and September 30, 2013, Medicare contractors shall use local pricing guidelines to determine payment rates for influenza virus vaccine codes 90653, 90672, 90685, 90686, 90687, 90688, and Q2033; and hepatitis B virus vaccine code 90739. For dates of service on or after October 1, 2013, Medicare contractors will use Medicare Part B payment limits for these codes. Effective for dates of service between November 20, 2012, and September 30, 2013, contractors shall use local pricing guidelines to determine payment rates for influenza virus vaccine code 90661.

On institutional claims, hospitals (type of bill (TOB) 12X and 13X), skilled nursing facilities (TOB 22X and 23X), home health agencies (TOB 34X), hospital-based renal dialysis facilities (72X), and critical access hospitals (85X), payment will be based on reasonable cost for codes 90653, 90672, 90685, 90686, 90687, 90688, 90739, and Q2033 with dates on service on or after January 1, 2013. For the same facilities billing code 90661 on or after November 20, 2012, the payment is also based on reasonable cost.

For Indian Health Services (IHS) facilities (including IHS critical access hospitals), comprehensive outpatient rehabilitation facilities, and independent renal dialysis facilities, payment will be based on the lower of the actual charge or 95% of the Average Wholesale Price (AWP).
Medicare contractors shall deny claims for vaccines containing codes 90653, 90685, 90687, 90688, and 90739 if vaccines described by these codes have not obtained approval from the FDA by October 1, 2013. In doing so, they will use:

• Claims Adjustment Reason Code (CARC) 114: Procedure/product not approved by the Food and Drug Administration.
• Remittance Advice Remark Code (RARC) M51: Missing/incomplete/invalid procedure code.
• Group Code: CO

Contractors shall also deny claims containing vaccine codes 90653, 90685, 90687, 90688, and 90739 if no product is located as a result of utilizing local pricing guidelines.

Additional Information
The official instruction, CR 8249, issued to your Medicare contractor regarding this change, may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2693CP.pdf  on the CMS website.

Last Updated Nov 07, 2013

Courtesy of: https://med.noridianmedicare.com/web/jeb/article-detail/-/view/10525/new-influenza-virus-and-hepatitis-b-virus-vaccine-codes

READ MORE - New Influenza Virus and Hepatitis B Virus Vaccine Codes: Noridian/Medicare

Back to School: Identify How ICD-10 Will Affect Your Practice

In order to be fully prepared for the October 1, 2014, ICD-10 transition, you need to know exactly how ICD-10 will affect your practice. Although many people associate coding with submitting claims, in reality, ICD codes are used in a variety of processes within clinical practices, from registration and referrals to billing and payment.
The following is a list of important questions to help you think through where you use ICD codes and how ICD-10 will affect your practice. By making a plan to address these areas now, you can make sure your practice is ready for the ICD-10 transition.

• Where do you use ICD-9 codes? Keep a log of everywhere you see and use an ICD-9 code. If the code is on paper, you will need new forms (e.g., patient encounter form, superbill). If the code is entered or displayed in your computer, check with your EHR and/or practice management system vendor to see when your system will be ready for ICD-10 codes.
• Will you be able to submit claims? If you use an electronic system for any or all payers, you need to know if it will be able to accommodate the ICD-10 version of diagnoses and hospital inpatient procedures codes. If your billing system has not been upgraded for the current version of HIPAA claims standards—Version 5010—you will not be able to submit claims. Check with your practice management system or software vendor to make sure your claims are in the HIPAA Version 5010 format and that your system or software can include the ICD-10 version of diagnoses and hospital inpatient procedures codes.
• Will you be able to complete medical records? If you use any type of electronic health record (EHR) system in your office, you need to know if it will capture ICD-10 codes. Look at how you enter ICD-9 codes (e.g., do you type them in or select from a drop down menu) and talk to your EHR vendor about your system’s capabilities for ICD-10. If your EHR system does not capture ICD-10 codes and you use another terminology (SNOMED), you will still need ICD-10 codes to submit claims.
• How will you code your claims under ICD-10? If you currently code by look up in ICD-9 books, purchase the ICD-10 code books in early 2014. Take a look at the codes most commonly used in your office and begin developing a list of comparable ICD-10 codes. Alternatively, check your software for an ICD-10 look up functionality.
• Are there ways to make coding more efficient? For example, develop a list of your most commonly used ICD-9 codes and become familiar with the ICD-10 codes you will use in the future; and invest in a software program that helps small practices with coding.

Want more information about ICD-10?
Visit the CMS ICD-10 website for the latest news and resources to help you prepare for the October 1, 2014, deadline. Sign up for CMS ICD-10 Industry Email Updates from CMS.

Courtesy of: Centers for Medicare & Medicaid Services (CMS) Weekly Digest Bulletin

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How Late Payments, Patients can Throw off a Medical Biller's Day

By Marsha Sosebee from Physicians Practice

Dear Diary, even though it’s Monday, today started out with much promise of being a good day. The end of month collection percentage totals for last month looked great. The percentage of money in the over-120-day-and-aging bucket was down to 0.2 percent and the overall amount due on the accounts receivable report was down by $32,000. I had high hopes that the day would end as well as it began.

My first task of the day was to review the schedule to see which of today’s patients had a past due balance. Finding four such patients, I began to review their history and send necessary alerts to the receptionist. The first two patients had balances from surgeries and were making regular monthly payments as promised. So far so good. The third patient had owed a balance for almost two months and had not yet set up a payment plan, even though he had been back for a recheck appointment just last week. That’s where my hopes for the day began to sag a bit.

The fourth patient had been the victim of a car accident and one of our doctors had been called from the emergency room to do surgery. The hospital had not given us any insurance information on this patient, so I looked to see what information the patient had given at his first recheck appointment in our office. Nothing was written in the section for insurance. Great. As I read through the note history, I found a note from the receptionist that said, "At checkout, asked patient to pay on surgery balance. Patient responded that the accident was the other guy’s fault and that’s who would have to pay the bill." Further notes revealed his adamancy that he was not going to pay this surgery balance. We were at an impasse because our doctor was on main ER call that day and we were required to continue seeing him until treatment was complete. At this point, my hopes for the day were swinging mighty low.

I called the car insurance claims adjustor only to be told that the hospital bills had exhausted the MedPay limits on the patient’s automobile policy and the at-fault driver did not have car insurance. The patient’s attorney had already been in contact with them about a settlement but in all reality, it would probably end up going to court. The adjustor said that if a settlement was reached, it would be paid to the patient who would be responsible for using it to pay the remainder of his medical bills.

I added my note to the history and inserted a pop-up note that I needed to speak with the patient when he arrived. Judging by the previous encounter our staff had with him, I was not looking forward to his arrival at 10:30.

The next order of business on the “to do list” was to check status of pre-certs that had been requested last week. I called ABC insurance company first because three of the precertifications were theirs. I don’t know how so much changes in one week at insurance company, but apparently it can. I dialed the same number I had called the week prior to begin the precert process. After going through the maze of prompts, a person answered who informed me that I had reached the wrong department. I assured her I had chosen all prompts carefully. She asked for the number I had dialed originally. I told her 800-000-0000. She said that was the problem; that number was not for precerts at all. She agreed to transfer me to the correct department. The person in that department would have loved to help me, but they don’t handle precerts for that employer group. Again, I was transferred to the correct department. Four transfers later, I finally connected with a representative who said that if I had just dialed 800-000-0000 I would have reached her directly and avoided all of this unnecessary frustration. I’m glad she couldn’t see my expression through the phone.

Confident that I had at last reached the right person, I gave her the patients' information for whom I had requested precertifications. Two were in process she said, but the third request was not on file.

"Why not?" I demanded to know. I had sent all three sets of clinical information and photographs in the same envelope. If two were there, what happened to the third one, I wanted to know. The rep suggested that maybe I had forgotten to include the third one. I knew I had put all three in there. After 20 minutes of back and forth and being put on hold so she could check with other departments, she finally came back to the line to let me know it was found in the mail room. She informed me that I would have to send the photographs again because she was not able to locate them.

At this point, I gave up all hope for the day ending on a good note and I was pretty sure this was a good indication of how my week was going to be. It was also at this point that I wondered if other billers really faced the same frustrations as me. I also contemplated whether or not billers should automatically have a prescription of Prozac. Like some people have a jar of peppermints on their desk, maybe billers need a little jar of happy pills.

Signed,

A frustrated biller

Article courtesy of Physicians Practice http://www.physicianspractice.com/blog/How-Late-Payments-Patients-Throw-off-Medical-Billers-Day?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=07112013

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Improve Patient Education to Improve Medical Practice Collections

Often patients misinterpret how, and how much, they will be billed for their visits.

Take for example, the copay. When patients pay a copay at time of service, they sometimes believe this is all they will owe. So when they receive a bill in the mail a few weeks later, they complain.  They call and say something like, "I was told I only had a $10 copay, and that's ALL I am paying!”
Addressing a patient concern like this one takes up staff time and hinders the collection process. Staff may feel so bad when speaking with a patient that they may even adjust off the patient's balance.

Problems due to payment misinterpretations, however, are avoidable if your front-office staff spends a few minutes prior to a patient's appointment explaining how the billing process works. 
A front-office person should come out to the lobby, sit with the patient, and explain each policy the patient will need to sign, including your practice's privacy policy, payment policy, and cancellation policy. This will indicate to the patient that he is valued and cared for.

Explaining the payment policy and how benefits work in a calm and professional manner will provide the patient with a much greater understanding of how his policy works. Over the years I have seen firsthand how many patients have a poor understanding of these important elements.   Although this one-on-one patient explanation might seem like a concierge-type service, it's a sound investment to make in your practice. 
Patients will no longer misunderstand how payment works, and they will have a greater understanding of insurance. That of course, will translate to more streamlined patient collections.

Patients will also have a better understanding of their benefits, which means they will  understand when billing questions and complaints should be directed to insurers, rather than to your practice. With all of the insurance exchanges marketing to patients; and the print, electronic, and television ads touting “affordable plans” to your patient population, it is more imperative than ever to spend the time explaining patient benefits clearly.
Consider the time spent explaining payment and benefits to your patients as part of your customer service package. Train your front-office staff to step out from behind the desk, sit with the patient, answer any question, and build rapport. You won't be sorry.

Article  By P.j. Cloud-moulds of Physicians Practice
http://www.physicianspractice.com/blog/improve-patient-education-improve-medical-practice-collections?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=01112013

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Part A and Part B Endeavor Contact Information (Medicare/Noridian)

Medicare Updates

• Part A and Part B Endeavor Contact Information
User Security may assist providers with locked accounts, password resets, etc.:
o JE: 855-609-9960
o JF: 877-908-8431
For assistanct with specific claim or eligibility issues, contact Customer Service:
o JE: 855-609-9960
o JF: 877-908-8431

JE states include California, Hawaii, Nevada, American Samoa, Guam and the Northern Mariana Islands.
JF states include Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington and Wyoming.
Additional Endeavor Information
Information regarding Endeavor is available on the Noridian website:
o Part A:
 JE: med.noridianmedicare.com/web/jea
 JF: www.noridianmedicare.com/parta/
o Part B:
 JE: med.noridianmedicare.com/web/jeb
 JF: www.noridianmedicare.com/partb/

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