MyHealthEData Initiative Puts Patients at the Center of the US Health Care System
On March 6, CMS Administrator Seema Verma announced a new Trump Administration initiative – MyHealthEData – to empower patients by giving them control of their health care data and allowing it to follow them through their health care journey. MyHealthEData will help to break down the barriers that prevent patients from having electronic access and true control of their own health records. Patients will be able to choose the provider that best meets their needs and then give that provider secure access to their data, leading to greater competition and reducing costs.
In an address at the Healthcare Information and Management Systems Society (HIMSS) Annual Conference in Las Vegas, Administrator Verma also announced the launch of Medicare’s Blue Button 2.0 – a new and secure way for Medicare beneficiaries to access and share their personal health data in a universal digital format. This enables patients who participate in the traditional Medicare program to connect their claims data to the secure applications, providers, services, and research programs they trust.
Additionally, CMS intends to overhaul the Electronic Health Record Incentive Programs to refocus the programs on interoperability and reduce the time and cost required of providers to comply with the programs’ requirements.
The Administrator also highlighted other CMS plans to empower patients with data:
Resource: CMS News: March 6, 2018
In an address at the Healthcare Information and Management Systems Society (HIMSS) Annual Conference in Las Vegas, Administrator Verma also announced the launch of Medicare’s Blue Button 2.0 – a new and secure way for Medicare beneficiaries to access and share their personal health data in a universal digital format. This enables patients who participate in the traditional Medicare program to connect their claims data to the secure applications, providers, services, and research programs they trust.
Additionally, CMS intends to overhaul the Electronic Health Record Incentive Programs to refocus the programs on interoperability and reduce the time and cost required of providers to comply with the programs’ requirements.
The Administrator also highlighted other CMS plans to empower patients with data:
- Require providers to update their systems to ensure data sharing
- Require that a patient’s data follow them after they are discharged from the hospital
- Streamline documentation and billing requirements for providers to allow doctors to spend more time with their patients
- Reduce the incidence of unnecessary and duplicative testing which occurs as a result of providers not sharing data
- Fact Sheet: Trump Administration Announces MyHealthEData Initiative at HIMSS18
- Speech: Remarks by CMS Administrator Seema Verma at the HIMSS18 Conference
Resource: CMS News: March 6, 2018
Medicare Premiums & Deductibles will stay the same in 2018
Today, November 17, 2017, CMS announced the 2018 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs.
Medicare Part B Premiums/Deductibles
Medicare Part B covers physician services, outpatient hospital services, certain home health services, durable medical equipment, and other items.
The standard monthly premium for Medicare Part B enrollees will be $134 for 2018, the same amount as in 2017. Some beneficiaries who were held harmless against Part B premium increases in prior years will have a Part B premium increase in 2018, but the premium increase will be offset by the increase in their Social Security benefits next year.
"Medicare's top priority is to ensure that beneficiaries have choices for affordable, high-quality care that fit their needs," said CMS Administrator Seema Verma. "Next year, no beneficiary protected by the hold-harmless provision will see a Part B premium increase that is greater than the increase in their Social Security benefits. We encourage Medicare beneficiaries to explore their options to make an informed choice between Original Medicare and Medicare Advantage before Open Enrollment ends on December 7."
CMS recently released the benefit, premium, and Star Ratings information for Medicare health and drug plans which shows that there will be more health coverage choices, improved access to high-quality health choices, and decreased premiums in 2018. CMS estimates that the Medicare Advantage average monthly premium will decrease by $1.91 (about 6 percent) in 2018, from an average of $31.91 in 2017 to $30. More than three-fourths (77 percent) of Medicare Advantage enrollees remaining in their current plan will have the same or lower premium for 2018. The average basic premium for a Medicare prescription drug plan in 2018 is projected to decline to an estimated $33.50 per month. This represents a decrease of approximately $1.20 below the average basic premium of $34.70 in 2017. The Medicare prescription drug plan average basic premium is projected to decline for the first time since 2012.
CMS also announced that the annual deductible for all Medicare Part B beneficiaries will be $183 in 2018, the same annual deductible in 2017. Premiums and deductibles for Medicare Advantage and Medicare Prescription Drug plans are already finalized and are unaffected by this announcement.
Medicare Part A Premiums/Deductibles
Medicare Part A covers inpatient hospital, skilled nursing facility, and some home health care services. About 99 percent of Medicare beneficiaries do not have a Part A premium since they have at least 40 quarters of Medicare-covered employment.
The Medicare Part A annual inpatient hospital deductible that beneficiaries pay when admitted to the hospital will be $1,340 per benefit period in 2018, an increase of $24 from $1,316 in 2017.
For a fact sheet on the 2018 Medicare Parts A & B premiums and deductibles, please visit: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-11-17.html .
Resource: CMS News: November 17, 2017
Last Updated Nov 20, 2017
Today, November 17, 2017, CMS announced the 2018 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs.
Medicare Part B Premiums/Deductibles
Medicare Part B covers physician services, outpatient hospital services, certain home health services, durable medical equipment, and other items.
The standard monthly premium for Medicare Part B enrollees will be $134 for 2018, the same amount as in 2017. Some beneficiaries who were held harmless against Part B premium increases in prior years will have a Part B premium increase in 2018, but the premium increase will be offset by the increase in their Social Security benefits next year.
"Medicare's top priority is to ensure that beneficiaries have choices for affordable, high-quality care that fit their needs," said CMS Administrator Seema Verma. "Next year, no beneficiary protected by the hold-harmless provision will see a Part B premium increase that is greater than the increase in their Social Security benefits. We encourage Medicare beneficiaries to explore their options to make an informed choice between Original Medicare and Medicare Advantage before Open Enrollment ends on December 7."
CMS recently released the benefit, premium, and Star Ratings information for Medicare health and drug plans which shows that there will be more health coverage choices, improved access to high-quality health choices, and decreased premiums in 2018. CMS estimates that the Medicare Advantage average monthly premium will decrease by $1.91 (about 6 percent) in 2018, from an average of $31.91 in 2017 to $30. More than three-fourths (77 percent) of Medicare Advantage enrollees remaining in their current plan will have the same or lower premium for 2018. The average basic premium for a Medicare prescription drug plan in 2018 is projected to decline to an estimated $33.50 per month. This represents a decrease of approximately $1.20 below the average basic premium of $34.70 in 2017. The Medicare prescription drug plan average basic premium is projected to decline for the first time since 2012.
CMS also announced that the annual deductible for all Medicare Part B beneficiaries will be $183 in 2018, the same annual deductible in 2017. Premiums and deductibles for Medicare Advantage and Medicare Prescription Drug plans are already finalized and are unaffected by this announcement.
Medicare Part A Premiums/Deductibles
Medicare Part A covers inpatient hospital, skilled nursing facility, and some home health care services. About 99 percent of Medicare beneficiaries do not have a Part A premium since they have at least 40 quarters of Medicare-covered employment.
The Medicare Part A annual inpatient hospital deductible that beneficiaries pay when admitted to the hospital will be $1,340 per benefit period in 2018, an increase of $24 from $1,316 in 2017.
For a fact sheet on the 2018 Medicare Parts A & B premiums and deductibles, please visit: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-11-17.html .
Resource: CMS News: November 17, 2017
Last Updated Nov 20, 2017
Why Doctors Should Outsource Their Billing
By Dave Jakielo
Given the complexity of today's revenue cycle processes, it takes the specialized skill of medical billing professionals to ensure your practices' economic success and compliance with the many government regulations. Billing is no longer something someone does to fill in the time between scheduling and rooming patients.
When I first started in the medical billing field, things were much simpler. Payors would occasionally change a rule and give you ample notice to adjust your processes. Denials averaged less than 5 percent of total claims.
Fast forward to today, where if you don't have sophisticated claim scrubbing software, it's not unusual to have a 35 percent or higher claim rejection rate, which requires extensive and expensive follow-up.
The challenges that internal billing operations are faced with on a regular basis can lead to collection shortfalls and non-compliance issues. Here are some reasons why outsourcing billing to a professional practice management/billing company makes sense.
Regulation and Education
Regulations change constantly, which means that dedicated personnel must have the time to read bulletins, interact with payors, and attend industry seminars and webinars. Billing managers should be certified to ensure their competency. One such designation is the HBMA CHBME designation. Coding personnel who have the responsibility for ensuring that your documentation and coding are compliant with the new ICD-10 requirements should also be certified by one of the accredited coding organizations.
Cost Management
Implementing and maintaining a compliance plan can be expensive for an individual practice. A professional billing company can spread the cost of their compliance professionals across many clients. Technology is another major expense for an individual practice. Besides the initial cost of an EMR and practice management system, you also need to invest in additional software such as a claim scrubber, denial management tools, and a business intelligence reporting software, which is an expensive but necessary tool to proactively manage a practice.
Business Management
Lack of follow-up on unpaid claims or underpaid claims is one of the biggest problems I encounter when reviewing a practice's billing operation. Follow-up is time consuming and burdensome, and it seems to be the last thing people get around to – if ever. When follow-up isn't done on a regularly scheduled basis it can lead to lost revenue due to "timely filing" requirements. I also have seen contractual allowance adjustments applied to a patient's account even when the practice doesn't participate with the third-party payor.
Compliant and Competent Workforce
It is getting harder to attract and retain competent billing personnel. The Society for Human Resources Management states that the cost of recruiting, hiring, and training a new employee is at least $4,000. Utilizing a professional billing company eliminates this expense in its entirety. Given the complexity of the revenue cycle process, practices need full-time professionals to handle their billing operations – it can no longer be something someone will get around too. Professional billing companies offer economies of scale, which make their services less costly than doing billing in-house. The goal of any billing company is to maximize collections while ensuring compliance.
Today most physicians are working harder than ever and taking home less due to declining reimbursement and the high cost of collecting on a claim. The question every doctor should ask themselves is, "Why should I have the additional burden of running an internal billing operation?"
There are two things a practice should keep in mind. First, do what you do best (practice medicine) and outsource the rest. Second, never do anything that you can have someone else do more efficiently and at a lower cost.
By Dave Jakielo
Given the complexity of today's revenue cycle processes, it takes the specialized skill of medical billing professionals to ensure your practices' economic success and compliance with the many government regulations. Billing is no longer something someone does to fill in the time between scheduling and rooming patients.
When I first started in the medical billing field, things were much simpler. Payors would occasionally change a rule and give you ample notice to adjust your processes. Denials averaged less than 5 percent of total claims.
Fast forward to today, where if you don't have sophisticated claim scrubbing software, it's not unusual to have a 35 percent or higher claim rejection rate, which requires extensive and expensive follow-up.
The challenges that internal billing operations are faced with on a regular basis can lead to collection shortfalls and non-compliance issues. Here are some reasons why outsourcing billing to a professional practice management/billing company makes sense.
Regulation and Education
Regulations change constantly, which means that dedicated personnel must have the time to read bulletins, interact with payors, and attend industry seminars and webinars. Billing managers should be certified to ensure their competency. One such designation is the HBMA CHBME designation. Coding personnel who have the responsibility for ensuring that your documentation and coding are compliant with the new ICD-10 requirements should also be certified by one of the accredited coding organizations.
Cost Management
Implementing and maintaining a compliance plan can be expensive for an individual practice. A professional billing company can spread the cost of their compliance professionals across many clients. Technology is another major expense for an individual practice. Besides the initial cost of an EMR and practice management system, you also need to invest in additional software such as a claim scrubber, denial management tools, and a business intelligence reporting software, which is an expensive but necessary tool to proactively manage a practice.
Business Management
Lack of follow-up on unpaid claims or underpaid claims is one of the biggest problems I encounter when reviewing a practice's billing operation. Follow-up is time consuming and burdensome, and it seems to be the last thing people get around to – if ever. When follow-up isn't done on a regularly scheduled basis it can lead to lost revenue due to "timely filing" requirements. I also have seen contractual allowance adjustments applied to a patient's account even when the practice doesn't participate with the third-party payor.
Compliant and Competent Workforce
It is getting harder to attract and retain competent billing personnel. The Society for Human Resources Management states that the cost of recruiting, hiring, and training a new employee is at least $4,000. Utilizing a professional billing company eliminates this expense in its entirety. Given the complexity of the revenue cycle process, practices need full-time professionals to handle their billing operations – it can no longer be something someone will get around too. Professional billing companies offer economies of scale, which make their services less costly than doing billing in-house. The goal of any billing company is to maximize collections while ensuring compliance.
Today most physicians are working harder than ever and taking home less due to declining reimbursement and the high cost of collecting on a claim. The question every doctor should ask themselves is, "Why should I have the additional burden of running an internal billing operation?"
There are two things a practice should keep in mind. First, do what you do best (practice medicine) and outsource the rest. Second, never do anything that you can have someone else do more efficiently and at a lower cost.
New Quality Reporting Program to Reward Value-Based Care
Merit-Based Incentive Payment System (MIPS) reporting begins in January 2017, with payment adjustments starting in January 2019. How should you prepare?
This is the second in a continuing series of articles on value-based payment.
The American health care system is moving from paying physicians for the volume of services they perform to paying for the value of the care they provide. This movement toward “value-based payment” has greatly accelerated in recent years to address the high level of Medicare spending and is furthered by advances in technology—especially the proliferation of electronic health records (EHRs) and payer-incentive programs to encourage more EHR adoption. The goal of this evolution is summed up in the so-called Triple Aim: improved patient care, better population health, and lower per capita cost of health care.
In the second of a series of articles in “Changing Practice/Changing Payment,” Psychiatric News focuses on a new quality program, known as the Merit-Based Incentive Payment System (MIPS), which was established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). APA submitted detailed comments on the MACRA proposed rule that the Centers for Medicare and Medicaid Services (CMS) issued on April 27. The final MACRA rule is expected in November.
Q: What is MIPS?
A: MIPS consolidates current Medicare quality programs (Physician Quality Reporting System, EHR Meaningful Use, and Value-Based Payment Modifier) and adds a new category for “clinical practice improvement.” MIPS also offers the first substantial rewards for achieving high-quality care.
MIPS reporting begins in January 2017, with payment adjustments starting in January 2019. Each “eligible clinician” or group will receive a “composite performance score” for performance in four categories—quality, resource use, use of certified electronic health records under “Advancing Care Information,” and clinical practice improvement activities—compared against the average of all MIPS clinicians. Those scoring above average receive a bonus, while those scoring below average receive a penalty. Scoring is somewhat flexible, but here are some general guidelines:
Q: What else do I need to know before the MIPS adjustments take effect in 2019?
A: In 2017 and 2018, Medicare payments to all psychiatrists (regardless of practice size) will be subject to value-based payment modifier bonuses or penalties. These currently range up to 4 percent.
Starting in 2018, all Medicare claims will include special codes to identify the care episode, patient condition, and physician’s relationship to the patient. These codes will link patients to clinicians for measuring resource use. APA is working with member experts to recommend appropriate psychiatric episodes of care.
MACRA sets a goal of achieving interoperability of EHRs by the end of 2018.
Q: What are the key features of the >MIPS program for psychiatrists?
A: Psychiatrists are exempt from MIPS reporting and payment adjustments for a particular year if (1) this is their first year of Medicare enrollment; (2) they meet the “low volume threshold” of no more than $10,000 in Medicare billings and 100 Medicare patients; (3) they qualify for the MACRA bonus for “advanced” alternative payment models (APMs); or (4) they meet the definition of a partial qualifying APM participant and choose not to report under MIPS.
Psychiatrists will no longer be required to report nine quality measures across three National Quality Strategy “domains.” They will have to report only six quality measures, including one cross-cutting measure and one outcome measure. If no outcome measure is available, they must report one measure related to appropriate use, patient safety, efficiency, patient experience, or care coordination.
APA will post a list of MIPS quality measures relevant to psychiatry after the final rule is issued. The new ACI program offers partial credit for using electronic health records; however, some psychiatrists may find the limited outcome measures in high-priority areas a significant barrier to meeting the scoring criteria.
CPIA options include “Integrated Behavioral and Mental Health” activities such as providing integrated care consistent with the collaborative care model.
Starting in 2018, psychiatrists in small practices (of up to 10 clinicians) may form “virtual groups” for joint MIPS reporting and assessment. The infrastructure is still being developed, and APA will keep members informed as more details become available.
MIPS may apply to clinical psychologists and clinical social workers starting with reporting in 2019 and payments in 2021.
MACRA includes $100 million for technical assistance to small and rural practices, plus those in health professional shortage areas, for MIPS reporting and transitioning to new models of care.
MIPS does not apply to Medicare Advantage payments or programs.
Q: Are there advantages for registry reporting?
A: MACRA preserves current reporting methods but also encourages reporting via qualified clinical data registries (QCDRs) by individuals and group practices. In addition to being less burdensome, registry reporting counts toward the ACI and CPIA categories, potentially leading to higher MIPS scores and bonuses. QCDR measures can also be directly approved by CMS, avoiding longer review by the National Quality Forum—the only organization designated by Congress to endorse quality measures. APA is now beginning to develop a mental health clinical quality data registry for use by psychiatrists in quality reporting.
Q: What is new for quality measures?
A: MIPS will continue most valid PQRS quality measures and add measures used by private payers and for different settings. MACRA includes $75 million in development funding of new measures. CMS has issued a final Quality Measure Development Plan to address measure gaps. (Information on the plan is availablehere.) APA submitted comments on the draft plan in February.
Q: How can APA help you prepare for MIPS?
A: We welcome your questions!
This is the second in a continuing series of articles on value-based payment.
The American health care system is moving from paying physicians for the volume of services they perform to paying for the value of the care they provide. This movement toward “value-based payment” has greatly accelerated in recent years to address the high level of Medicare spending and is furthered by advances in technology—especially the proliferation of electronic health records (EHRs) and payer-incentive programs to encourage more EHR adoption. The goal of this evolution is summed up in the so-called Triple Aim: improved patient care, better population health, and lower per capita cost of health care.
In the second of a series of articles in “Changing Practice/Changing Payment,” Psychiatric News focuses on a new quality program, known as the Merit-Based Incentive Payment System (MIPS), which was established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). APA submitted detailed comments on the MACRA proposed rule that the Centers for Medicare and Medicaid Services (CMS) issued on April 27. The final MACRA rule is expected in November.
Q: What is MIPS?
A: MIPS consolidates current Medicare quality programs (Physician Quality Reporting System, EHR Meaningful Use, and Value-Based Payment Modifier) and adds a new category for “clinical practice improvement.” MIPS also offers the first substantial rewards for achieving high-quality care.
MIPS reporting begins in January 2017, with payment adjustments starting in January 2019. Each “eligible clinician” or group will receive a “composite performance score” for performance in four categories—quality, resource use, use of certified electronic health records under “Advancing Care Information,” and clinical practice improvement activities—compared against the average of all MIPS clinicians. Those scoring above average receive a bonus, while those scoring below average receive a penalty. Scoring is somewhat flexible, but here are some general guidelines:
- Quality counts 30 percent (50 percent in 2019 and 45 percent in 2020), based largely on the Physician Quality Reporting System (PQRS).
- Resource use counts 30 percent (10 percent in 2019 and 15 percent in 2020), replacing the Value-Based Payment Modifier (VM). CMS will calculate this, with no reporting required.
- Advancing care information (ACI), which assesses the use of EHRs and replaces the Meaningful Use program, counts 25 percent.
- Clinical practice improvement activity (CPIA), the new category, counts 15 percent.
Q: What else do I need to know before the MIPS adjustments take effect in 2019?
A: In 2017 and 2018, Medicare payments to all psychiatrists (regardless of practice size) will be subject to value-based payment modifier bonuses or penalties. These currently range up to 4 percent.
Starting in 2018, all Medicare claims will include special codes to identify the care episode, patient condition, and physician’s relationship to the patient. These codes will link patients to clinicians for measuring resource use. APA is working with member experts to recommend appropriate psychiatric episodes of care.
MACRA sets a goal of achieving interoperability of EHRs by the end of 2018.
Q: What are the key features of the >MIPS program for psychiatrists?
A: Psychiatrists are exempt from MIPS reporting and payment adjustments for a particular year if (1) this is their first year of Medicare enrollment; (2) they meet the “low volume threshold” of no more than $10,000 in Medicare billings and 100 Medicare patients; (3) they qualify for the MACRA bonus for “advanced” alternative payment models (APMs); or (4) they meet the definition of a partial qualifying APM participant and choose not to report under MIPS.
Psychiatrists will no longer be required to report nine quality measures across three National Quality Strategy “domains.” They will have to report only six quality measures, including one cross-cutting measure and one outcome measure. If no outcome measure is available, they must report one measure related to appropriate use, patient safety, efficiency, patient experience, or care coordination.
APA will post a list of MIPS quality measures relevant to psychiatry after the final rule is issued. The new ACI program offers partial credit for using electronic health records; however, some psychiatrists may find the limited outcome measures in high-priority areas a significant barrier to meeting the scoring criteria.
CPIA options include “Integrated Behavioral and Mental Health” activities such as providing integrated care consistent with the collaborative care model.
Starting in 2018, psychiatrists in small practices (of up to 10 clinicians) may form “virtual groups” for joint MIPS reporting and assessment. The infrastructure is still being developed, and APA will keep members informed as more details become available.
MIPS may apply to clinical psychologists and clinical social workers starting with reporting in 2019 and payments in 2021.
MACRA includes $100 million for technical assistance to small and rural practices, plus those in health professional shortage areas, for MIPS reporting and transitioning to new models of care.
MIPS does not apply to Medicare Advantage payments or programs.
Q: Are there advantages for registry reporting?
A: MACRA preserves current reporting methods but also encourages reporting via qualified clinical data registries (QCDRs) by individuals and group practices. In addition to being less burdensome, registry reporting counts toward the ACI and CPIA categories, potentially leading to higher MIPS scores and bonuses. QCDR measures can also be directly approved by CMS, avoiding longer review by the National Quality Forum—the only organization designated by Congress to endorse quality measures. APA is now beginning to develop a mental health clinical quality data registry for use by psychiatrists in quality reporting.
Q: What is new for quality measures?
A: MIPS will continue most valid PQRS quality measures and add measures used by private payers and for different settings. MACRA includes $75 million in development funding of new measures. CMS has issued a final Quality Measure Development Plan to address measure gaps. (Information on the plan is availablehere.) APA submitted comments on the draft plan in February.
Q: How can APA help you prepare for MIPS?
A: We welcome your questions!
- MIPS Quality and Resource Use: Samantha Shugarman, sshugarman@psych.org
- MIPS CPIA: Nevena Minor, nminor@psych.org
- MIPS ACI/EHRs: Nathan Tatro, ntatro@psych.org
- MACRA APMs: Eileen Carlson, ecarlson@psych.org
- Coding, reimbursement, and practice management questions: APA Practice Management Helpline, (800) 343-4671
Copyright © American Psychiatric Association Publishing
ALL RIGHTS RESERVEDCopyright © American Psychiatric Association
2016: The Year of the Regulation Physician Payment is Getting Trickier
By Bill Finerfrock - In Chinese culture, 2016 is the "Year of the Monkey." For those involved in healthcare, 2016 will be the year of the regulation!
The general rule of thumb in Washington, DC is that very little legislative action occurs in an election year, particularly a presidential election year. There is no reason to think that from a legislative standpoint, nothing will be different in 2016 than in years past.
It is important to keep in mind, though, that 2016 is also the last year of the Obama Administration. We anticipate that in 2016 the federal government will try to finalize a number of regulations proposed in previous years as well as propose and finalize a number of new regulations before the new administration is sworn in in January 2017. We anticipate that CMS will propose a number of regulatory changes that were mandated by the Medicare Access and CHIP Reauthorization Act (MACRA) that, if adopted, will significantly impact physician practices and, subsequently, HBMA members.
This article highlights some of the top issues that the HBMA Government Relations Committee will be monitoring and influencing over the next 10 months.
MACRA
On April 16, 2015, President Obama signed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) into law. This law will usher in a new era in physician payment and is considered by many to be the most significant change in Medicare-physician payment policy since the establishment of the resource-based relative value scale (RBRVS) system in the early 1990s. Because MACRA is being covered elsewhere in this issue of Billing (see page 12), this article won't go into detail on MACRA other than to note that the legislation sets in motion a series of changes in how physicians will be paid for services over the next few years.
Implementation of the New Physician Payment Systems
Since 1992, the value of physician services has been determined using the RBRVS methodology. Under this system, each service is assigned a point value that Medicare and other payors can then convert into an actual dollar value using a conversion factor. This methodology is considered by some to be inherently inflationary because it rewards physicians based on the volume of services provided rather than the value of those services.
MACRA mandates a change in that methodology by creating two options: merit-based incentive payments (MIPS) or alternative payment models (APMs).
MIPS would retain RBRVS as the foundational basis for determining physician payments, which would then be adjusted up or down based on the physician's ranking on a variety of quality-based measures. Physicians not wishing to have their payments based on this combination of RBRVS and MIPS could opt out either fully or partially into yet defined APMs.
During 2016, we anticipate that CMS will begin to formally identify the quality metrics it will use to determine the MIPS scoring and we will begin to see the emergence of newly developed APMs. Any APM put forward for consideration will have to be approved by CMS.
Although each of these new payment systems is not slated to begin until 2019, we expect that CMS will release a number of guidance documents and regulations this year that will set in motion the process for moving to the new models.
Site-Neutral Payments
For the past few years, data has emerged documenting the dramatic differences between what Medicare will pay for a service depending on the type of facility in which that service was provided. In many instances, Medicare payment for the same service can be significantly higher if the service is provided in a hospital-based facility versus in a physician's office.
This has led many physician organizations to question why Medicare values a service two to three times more when the service is provided in a hospital-based facility. And it has created a tremendous incentive for physicians to sell their practices to hospitals to obtain the higher facility-based payments. (The American Hospital Association fully supports these payment differentials.)
In late 2015 Congress and the president agreed on legislation, called the Bipartisan Budget Act of 2015, that will require that new off-campus hospital-based facilities be paid no more for a service than what Medicare would have paid for that same service had it been provided in a physician's office. Off-campus hospital-based facilities that existed at the time of enactment would continue to be paid the higher rates (i.e., grandfathered) and are not subject to the physician-office limit. This is referred to as a "site-neutral payment policy."
According to the Congressional Budget Office, these higher payments result in billions in additional revenue for hospitals all across America. It has been estimated that this limited application of site-neutral payments will reduce Medicare spending by more than $9 billion over the next 10 years.
Physician organizations, although pleased with the approval of this policy, remain concerned that existing facilities will continue to receive higher payments. Consequently, it is expected that the debate on site-neutral payments and on equalization of payments will continue in 2016.
While it is unlikely that Congress will make any additional statutory changes in the site-neutral payment policy in 2016, changes could roll out from the regulatory process that will be required to actually operationalize the policy. For example, the site-neutral payment policy is effective on the date of enactment of the legislation (November 2, 2015). Although the legislation stipulates that the site-neutral payment policy applies to new off-campus hospital-based facilities, it is possible that CMS will use its regulatory authority to further clarify what constitutes a "new" off-campus facility.
If, for example, an off-campus hospital-based facility had completed all of the necessary regulatory paperwork required for designation by November 2, 2015, but had not officially opened its doors, could it be grandfathered or subject to the new payment limitations? If an off-campus facility were still under construction at the time of enactment but – again – not open, would it fall under the grandfather clause or be subject to the site-neutral payment limits?
Administrative Simplification
Although HIPAA was enacted 20 years ago, physician practices and medical billing companies have not realized many of the administrative simplification benefits promised by it.
During 2016, the National Committee on Vital and Health Statistics (NCVHS), a government advisory committee charged with advising the Department of Health and Human Services (HHS) on administrative simplification policies, will be making recommendations to HHS on new standards and mandates that will get us closer to the administrative simplification goals of HIPAA.
In mid-February, HBMA testified before the NCVHS Standards Subcommittee on possible new standards for electronic submission of prior authorization requests and health plan response standards, as well as possible new policies setting standards for the electronic submission of claims attachments. HBMA's witness identified numerous ways in which adoption of enforceable standards could help achieve the claims processing efficiencies promised by the authors of HIPAA.
NCVHS is expected to make its recommendations to the HHS secretary in late summer 2016.
Copyright 2016 HBMA. All Rights Reserved.
The general rule of thumb in Washington, DC is that very little legislative action occurs in an election year, particularly a presidential election year. There is no reason to think that from a legislative standpoint, nothing will be different in 2016 than in years past.
It is important to keep in mind, though, that 2016 is also the last year of the Obama Administration. We anticipate that in 2016 the federal government will try to finalize a number of regulations proposed in previous years as well as propose and finalize a number of new regulations before the new administration is sworn in in January 2017. We anticipate that CMS will propose a number of regulatory changes that were mandated by the Medicare Access and CHIP Reauthorization Act (MACRA) that, if adopted, will significantly impact physician practices and, subsequently, HBMA members.
This article highlights some of the top issues that the HBMA Government Relations Committee will be monitoring and influencing over the next 10 months.
MACRA
On April 16, 2015, President Obama signed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) into law. This law will usher in a new era in physician payment and is considered by many to be the most significant change in Medicare-physician payment policy since the establishment of the resource-based relative value scale (RBRVS) system in the early 1990s. Because MACRA is being covered elsewhere in this issue of Billing (see page 12), this article won't go into detail on MACRA other than to note that the legislation sets in motion a series of changes in how physicians will be paid for services over the next few years.
Implementation of the New Physician Payment Systems
Since 1992, the value of physician services has been determined using the RBRVS methodology. Under this system, each service is assigned a point value that Medicare and other payors can then convert into an actual dollar value using a conversion factor. This methodology is considered by some to be inherently inflationary because it rewards physicians based on the volume of services provided rather than the value of those services.
MACRA mandates a change in that methodology by creating two options: merit-based incentive payments (MIPS) or alternative payment models (APMs).
MIPS would retain RBRVS as the foundational basis for determining physician payments, which would then be adjusted up or down based on the physician's ranking on a variety of quality-based measures. Physicians not wishing to have their payments based on this combination of RBRVS and MIPS could opt out either fully or partially into yet defined APMs.
During 2016, we anticipate that CMS will begin to formally identify the quality metrics it will use to determine the MIPS scoring and we will begin to see the emergence of newly developed APMs. Any APM put forward for consideration will have to be approved by CMS.
Although each of these new payment systems is not slated to begin until 2019, we expect that CMS will release a number of guidance documents and regulations this year that will set in motion the process for moving to the new models.
Site-Neutral Payments
For the past few years, data has emerged documenting the dramatic differences between what Medicare will pay for a service depending on the type of facility in which that service was provided. In many instances, Medicare payment for the same service can be significantly higher if the service is provided in a hospital-based facility versus in a physician's office.
This has led many physician organizations to question why Medicare values a service two to three times more when the service is provided in a hospital-based facility. And it has created a tremendous incentive for physicians to sell their practices to hospitals to obtain the higher facility-based payments. (The American Hospital Association fully supports these payment differentials.)
In late 2015 Congress and the president agreed on legislation, called the Bipartisan Budget Act of 2015, that will require that new off-campus hospital-based facilities be paid no more for a service than what Medicare would have paid for that same service had it been provided in a physician's office. Off-campus hospital-based facilities that existed at the time of enactment would continue to be paid the higher rates (i.e., grandfathered) and are not subject to the physician-office limit. This is referred to as a "site-neutral payment policy."
According to the Congressional Budget Office, these higher payments result in billions in additional revenue for hospitals all across America. It has been estimated that this limited application of site-neutral payments will reduce Medicare spending by more than $9 billion over the next 10 years.
Physician organizations, although pleased with the approval of this policy, remain concerned that existing facilities will continue to receive higher payments. Consequently, it is expected that the debate on site-neutral payments and on equalization of payments will continue in 2016.
While it is unlikely that Congress will make any additional statutory changes in the site-neutral payment policy in 2016, changes could roll out from the regulatory process that will be required to actually operationalize the policy. For example, the site-neutral payment policy is effective on the date of enactment of the legislation (November 2, 2015). Although the legislation stipulates that the site-neutral payment policy applies to new off-campus hospital-based facilities, it is possible that CMS will use its regulatory authority to further clarify what constitutes a "new" off-campus facility.
If, for example, an off-campus hospital-based facility had completed all of the necessary regulatory paperwork required for designation by November 2, 2015, but had not officially opened its doors, could it be grandfathered or subject to the new payment limitations? If an off-campus facility were still under construction at the time of enactment but – again – not open, would it fall under the grandfather clause or be subject to the site-neutral payment limits?
Administrative Simplification
Although HIPAA was enacted 20 years ago, physician practices and medical billing companies have not realized many of the administrative simplification benefits promised by it.
During 2016, the National Committee on Vital and Health Statistics (NCVHS), a government advisory committee charged with advising the Department of Health and Human Services (HHS) on administrative simplification policies, will be making recommendations to HHS on new standards and mandates that will get us closer to the administrative simplification goals of HIPAA.
In mid-February, HBMA testified before the NCVHS Standards Subcommittee on possible new standards for electronic submission of prior authorization requests and health plan response standards, as well as possible new policies setting standards for the electronic submission of claims attachments. HBMA's witness identified numerous ways in which adoption of enforceable standards could help achieve the claims processing efficiencies promised by the authors of HIPAA.
NCVHS is expected to make its recommendations to the HHS secretary in late summer 2016.
Copyright 2016 HBMA. All Rights Reserved.
Medicare's Chronic Care Management Program is Good News for Patients and Providers
This innovative program from CMS aims to improve care of patients with chronic diseases and increase practice revenue.
The Centers for Medicare and Medicaid Services (CMS) chronic care management (CCM) incentive program, which launched January 1, 2015, is good news for primary care practitioners and other providers who offer chronic care management. Through this new incentive program, Medicare pays providers for non-face-to-face chronic care management. This is care which they have likely already been providing.
The CMS final rule updates payment policies and payment rates for services furnished under the Medicare Physician Fee Schedule. By offering these incentives to manage chronic care patients, CMS is taking steps to improve the quality of healthcare and cut costs. The new incentive is part of a broader multiyear strategy which supports the value of primary care and care management services.
For billing companies, this is information you'll want to share with your medical practice clients. The opportunity to increase revenue for you and your practice is significant.
Why is there a need for the CCM incentive program?
The program was developed to help manage the growing challenges of managing chronic diseases such as cancer, diabetes, hypertension, heart disease, and mental illness.
In a recent study, the CDC found that chronic diseases are responsible for 7 of 10 deaths annually, and treating people with chronic diseases accounts for 86% of the country's healthcare costs. 133 million Americans experience at least one chronic disease, and more than two-thirds of Medicare spending goes to patients with five or more chronic diseases.
Prior to the introduction of the CCM incentive program, payment for non-face-to-face care management services was rolled into payment for face-to-face evaluation and management. This, however, did not cover the significant resources and investment that went into ongoing management of chronic patients. Often, because of the lack of incentive, providers did not provide these services, and patients were left to manage themselves between visits to the provider. Infrequent care management has typically resulted in higher rates of complications, readmission, and higher costs.
Key facts about the CCM incentive program
There are certain requirements physicians and providers must adhere to in order to participate and receive reimbursement. Also, they must explain the program to their patients and have them sign an agreement that outlines what they will provide.
Facts:
In a recent industry webinar hosted by PracticeAdmin about CCM, Matt Ethington, CEO & founder of Discharge IQ, discussed the incentive program's significance and the positive impact it will have for patients and physicians.
"The big term now is patient engagement,'" says Ethington. "Chronic care patients don't want to be engaged.' They want to be divorced from chronic care. And their physicians want a way to manage their chronic patients more effectively. Managing a chronic condition is with you every moment of your life. I know because I was diagnosed with diabetes type 1 fifteen years ago. This experience prompted me to develop DischargeIQ which helps to monitor and manage chronic care patients."
According to Ethington, Medicare could spend up to $17 billion on the program, an indication of how seriously they are invested in its success. As the program is adopted and practices begin to realize its value, more products and solutions will enter the market that will target managing the program and helping physicians get their reimbursement.
He urges providers to review such products and services carefully. Some may say they monitor chronic care, but actually they focus on monitoring fitness and wellness. The key is to look for a solution which was developed based on clinical protocols specifically to manage and monitor chronic patients' care and their data.
How can physicians and providers participate in the program?
Identify patients in your practice that qualify. This includes fee for service Medicare patients that will likely have multiple chronic conditions for at least 12 months, or until death of the patient, the patient is at significant risk of death, acute exacerbation/decompensation, or functional decline. Contact and inform the identified patient that they qualify. Have them sign a consent form to participate in the program and include this as part of their medical record.
Physicians can only bill in months when there is activity. Specialists can also bill if they are providing CCM. If the patient's primary care physician is a key referral source, you can expect that they will bill for CCM. Defer to the primary provider for this service.
Create a care plan and patient consent form. Providers must provide the patient with a written or electronic copy of their care plan and include it in their medical record. They must also have patients sign a patient consent form. The patient consent form must include an agreement to electronic communication of patient information with other providers for care coordination. This includes details about what chronic care management services are and how they are accessed, details about how the patient information will be shared with providers on the care team, and information on cost sharing, which applies to these services even when they are not provided face-to-face in the practice. CMS has not provided a consent form, but sample forms are available in industry white papers.
Provide 20 minutes or more of non-face-to-face chronic care management per month per patient. CMS has set a payment rate of $42.60 for CCM that can be billed once a month per qualified patient for 20 minutes of non-face-to-face care to qualified Medicare beneficiaries who have two or more chronic conditions. Chronic care management services include regular development and revision of a plan of care, communication with other treating health professionals, and medication management. Patients must also have 24/7 access to their healthcare providers. Providers offering CCM services and coordination of care must be available to discuss chronic care needs and ensure continuity of care with their patients.
File claims using the CCM-specific CPT codes. Until the launch of the CCM incentive program, there were not specific CPT codes for CCM services. Providers can now bill for the services using CPT codes 99490, 99487, and 99489. According to the rule, CMS plans to make a bundled payment for 99487 and 99489. Note that the codes apply only to Medicare patients with two or more significant, chronic conditions.
For more information on the CCM program
As part of an industry webinar series, PracticeAdmin hosted a webinar about CCM. Visit www.practiceadmin.com to view the recorded webinar and to download a white paper on CCM, which includes a sample patient consent form.
For a list of frequently asked questions about billing for CCM services, visit the www.CMS.gov website and review the FAQ sheet http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/Payment_for_CCM_Services_FAQ.pdf
For a copy of the CCM Final Rule, see http://www.gpo.gov/fdsys/pkg/FR-2014-11-13/pdf/2014-26183.pdf
The Centers for Medicare and Medicaid Services (CMS) chronic care management (CCM) incentive program, which launched January 1, 2015, is good news for primary care practitioners and other providers who offer chronic care management. Through this new incentive program, Medicare pays providers for non-face-to-face chronic care management. This is care which they have likely already been providing.
The CMS final rule updates payment policies and payment rates for services furnished under the Medicare Physician Fee Schedule. By offering these incentives to manage chronic care patients, CMS is taking steps to improve the quality of healthcare and cut costs. The new incentive is part of a broader multiyear strategy which supports the value of primary care and care management services.
For billing companies, this is information you'll want to share with your medical practice clients. The opportunity to increase revenue for you and your practice is significant.
Why is there a need for the CCM incentive program?
The program was developed to help manage the growing challenges of managing chronic diseases such as cancer, diabetes, hypertension, heart disease, and mental illness.
In a recent study, the CDC found that chronic diseases are responsible for 7 of 10 deaths annually, and treating people with chronic diseases accounts for 86% of the country's healthcare costs. 133 million Americans experience at least one chronic disease, and more than two-thirds of Medicare spending goes to patients with five or more chronic diseases.
Prior to the introduction of the CCM incentive program, payment for non-face-to-face care management services was rolled into payment for face-to-face evaluation and management. This, however, did not cover the significant resources and investment that went into ongoing management of chronic patients. Often, because of the lack of incentive, providers did not provide these services, and patients were left to manage themselves between visits to the provider. Infrequent care management has typically resulted in higher rates of complications, readmission, and higher costs.
Key facts about the CCM incentive program
There are certain requirements physicians and providers must adhere to in order to participate and receive reimbursement. Also, they must explain the program to their patients and have them sign an agreement that outlines what they will provide.
Facts:
- Physician practices can charge approximately $42 per month for 20 minutes of non-faceto-face chronic care per patient for patients with two or more chronic conditions.
- There may be some patient payment responsibility such as a co-pay.
- Medicare Advantage plans must cover CCM.
- Physicians, advanced NPs, PAs, clinical nurse specialists, and certified midwives can bill Medicare for CCM.
- Transitional care management, home healthcare supervision, hospice care supervision, and certain end stage renal disease services in the month billed are not covered.
- CCM is not recognized as an RHC (Rural Health Center) service.
- Providers can contract with a third party to provide nonfaceto-face care management services.
In a recent industry webinar hosted by PracticeAdmin about CCM, Matt Ethington, CEO & founder of Discharge IQ, discussed the incentive program's significance and the positive impact it will have for patients and physicians.
"The big term now is patient engagement,'" says Ethington. "Chronic care patients don't want to be engaged.' They want to be divorced from chronic care. And their physicians want a way to manage their chronic patients more effectively. Managing a chronic condition is with you every moment of your life. I know because I was diagnosed with diabetes type 1 fifteen years ago. This experience prompted me to develop DischargeIQ which helps to monitor and manage chronic care patients."
According to Ethington, Medicare could spend up to $17 billion on the program, an indication of how seriously they are invested in its success. As the program is adopted and practices begin to realize its value, more products and solutions will enter the market that will target managing the program and helping physicians get their reimbursement.
He urges providers to review such products and services carefully. Some may say they monitor chronic care, but actually they focus on monitoring fitness and wellness. The key is to look for a solution which was developed based on clinical protocols specifically to manage and monitor chronic patients' care and their data.
How can physicians and providers participate in the program?
Identify patients in your practice that qualify. This includes fee for service Medicare patients that will likely have multiple chronic conditions for at least 12 months, or until death of the patient, the patient is at significant risk of death, acute exacerbation/decompensation, or functional decline. Contact and inform the identified patient that they qualify. Have them sign a consent form to participate in the program and include this as part of their medical record.
Physicians can only bill in months when there is activity. Specialists can also bill if they are providing CCM. If the patient's primary care physician is a key referral source, you can expect that they will bill for CCM. Defer to the primary provider for this service.
Create a care plan and patient consent form. Providers must provide the patient with a written or electronic copy of their care plan and include it in their medical record. They must also have patients sign a patient consent form. The patient consent form must include an agreement to electronic communication of patient information with other providers for care coordination. This includes details about what chronic care management services are and how they are accessed, details about how the patient information will be shared with providers on the care team, and information on cost sharing, which applies to these services even when they are not provided face-to-face in the practice. CMS has not provided a consent form, but sample forms are available in industry white papers.
Provide 20 minutes or more of non-face-to-face chronic care management per month per patient. CMS has set a payment rate of $42.60 for CCM that can be billed once a month per qualified patient for 20 minutes of non-face-to-face care to qualified Medicare beneficiaries who have two or more chronic conditions. Chronic care management services include regular development and revision of a plan of care, communication with other treating health professionals, and medication management. Patients must also have 24/7 access to their healthcare providers. Providers offering CCM services and coordination of care must be available to discuss chronic care needs and ensure continuity of care with their patients.
File claims using the CCM-specific CPT codes. Until the launch of the CCM incentive program, there were not specific CPT codes for CCM services. Providers can now bill for the services using CPT codes 99490, 99487, and 99489. According to the rule, CMS plans to make a bundled payment for 99487 and 99489. Note that the codes apply only to Medicare patients with two or more significant, chronic conditions.
For more information on the CCM program
As part of an industry webinar series, PracticeAdmin hosted a webinar about CCM. Visit www.practiceadmin.com to view the recorded webinar and to download a white paper on CCM, which includes a sample patient consent form.
For a list of frequently asked questions about billing for CCM services, visit the www.CMS.gov website and review the FAQ sheet http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/Payment_for_CCM_Services_FAQ.pdf
For a copy of the CCM Final Rule, see http://www.gpo.gov/fdsys/pkg/FR-2014-11-13/pdf/2014-26183.pdf
ICD-10: Feds OK Waiver for CA to Use 'Crosswalk' for Transition
Under the crosswalk system, claims that are submitted using ICD-10 codes will be cross-referenced to identify the appropriate ICD-9 codes that will be used to process the claims.This article originally appeared in California HealthFax.
California is one of four states that received a federal waiver to use a "crosswalk" coding translation system for Medi-Cal claims for the Oct. 1 transition to ICD-10 coding.
The state Department of Health Care Services (DHCS) said it was granted a waiver from the Centers for Medicare & Medicaid Services (CMS) to use the crosswalk for ICD-9 codes until it replaces an antiquated health information technology system. Other states that received similar waivers are Louisiana, Maryland, and Montana.
DHCS officials said the department requested the waiver as a temporary fix while it works with Xerox Health Systems to create a new health information system for Medi-Cal. "California is working on a computer system replacement that, when implemented, will process claims using ICD-10," said Adam Weintraub, assistant deputy director for DHCS. "Medi-Cal requested and received approval from CMS to implement ICD-10 on our legacy system using a crosswalk. This is designed to reduce the cost and avoid changes to an aging system that is already being replaced."
Under the crosswalk system, claims that are submitted using the new ICD- 10 codes will be cross-referenced to identify the appropriate ICD-9 codes that will be used to process the claim. DHCS said the crosswalk will be used until the project to replace the state's existing computer system is completed in 2017. DHCS said its new system "has mapped all ICD-10 codes to corresponding ICD-9 codes starting with General Equivalency Mapping and Reimbursement Mappings provided by CMS."
And though DHCS is using the crosswalk for Medi-Cal, Weintraub said that "DHCS is fully prepared to implement ICD-10" and will "accept provider claims with ICD-10 codes, correctly adjudicate those claims, and return ICD-10 codes to providers."
Weintraub said the state "has thoroughly tested the crosswalk system in order to minimize gaps or variances in payments and to reduce any potential of disruption or impact to quality of care as a result of the ICD-10 implementation." He added that the crosswalk "is solely used internally within the California Medicaid Management Information System" and that "CMS staff has joined our state staff to train providers on their own readiness for ICD-10."
The California Hospital Association (CHA) said it has some concerns about the crosswalk system being implemented during an ICD-10 transition period that already carries the potential for billing issues and other problems.
"As is the case with any new system, the introduction of ICD-10 will create a greater margin for error in billing and payments," said Amber Ott, vice president of finance for the CHA. "Our concern with the crosswalk program is that it will add to that margin for error." Ott also said that hospitals in California lose billions of dollars each year with Medi-Cal because of low reimbursement rates and that "any additional problems with ICD-10 will just add to those losses."
The California Medical Association (CMA) did not offer an opinion on the crosswalk program but CMA associate vice president of public affairs Molly Weedn said the organization will "watch the situation closely and make sure our members are aware of what's going on." Weedn said the CMA has been assisting members with the ICD-10 transition through online toolkits, webinars, and other educational programs and materials.
Doug Desjardins , September 22, 2015
California is one of four states that received a federal waiver to use a "crosswalk" coding translation system for Medi-Cal claims for the Oct. 1 transition to ICD-10 coding.
The state Department of Health Care Services (DHCS) said it was granted a waiver from the Centers for Medicare & Medicaid Services (CMS) to use the crosswalk for ICD-9 codes until it replaces an antiquated health information technology system. Other states that received similar waivers are Louisiana, Maryland, and Montana.
DHCS officials said the department requested the waiver as a temporary fix while it works with Xerox Health Systems to create a new health information system for Medi-Cal. "California is working on a computer system replacement that, when implemented, will process claims using ICD-10," said Adam Weintraub, assistant deputy director for DHCS. "Medi-Cal requested and received approval from CMS to implement ICD-10 on our legacy system using a crosswalk. This is designed to reduce the cost and avoid changes to an aging system that is already being replaced."
Under the crosswalk system, claims that are submitted using the new ICD- 10 codes will be cross-referenced to identify the appropriate ICD-9 codes that will be used to process the claim. DHCS said the crosswalk will be used until the project to replace the state's existing computer system is completed in 2017. DHCS said its new system "has mapped all ICD-10 codes to corresponding ICD-9 codes starting with General Equivalency Mapping and Reimbursement Mappings provided by CMS."
And though DHCS is using the crosswalk for Medi-Cal, Weintraub said that "DHCS is fully prepared to implement ICD-10" and will "accept provider claims with ICD-10 codes, correctly adjudicate those claims, and return ICD-10 codes to providers."
Weintraub said the state "has thoroughly tested the crosswalk system in order to minimize gaps or variances in payments and to reduce any potential of disruption or impact to quality of care as a result of the ICD-10 implementation." He added that the crosswalk "is solely used internally within the California Medicaid Management Information System" and that "CMS staff has joined our state staff to train providers on their own readiness for ICD-10."
The California Hospital Association (CHA) said it has some concerns about the crosswalk system being implemented during an ICD-10 transition period that already carries the potential for billing issues and other problems.
"As is the case with any new system, the introduction of ICD-10 will create a greater margin for error in billing and payments," said Amber Ott, vice president of finance for the CHA. "Our concern with the crosswalk program is that it will add to that margin for error." Ott also said that hospitals in California lose billions of dollars each year with Medi-Cal because of low reimbursement rates and that "any additional problems with ICD-10 will just add to those losses."
The California Medical Association (CMA) did not offer an opinion on the crosswalk program but CMA associate vice president of public affairs Molly Weedn said the organization will "watch the situation closely and make sure our members are aware of what's going on." Weedn said the CMA has been assisting members with the ICD-10 transition through online toolkits, webinars, and other educational programs and materials.
Doug Desjardins , September 22, 2015
Clarifying the CMS/AMA Joint Announcement and Guidance Regarding ICD-10
The Centers for Medicare & Medicaid Services (CMS) published a set of questions and answers to clarify the July 6, 2015, joint announcement made by CMS and the American Medical Association (AMA). Providers can read Clarifying the CMS/AMA Joint Announcement and Guidance FAQs on the CMS website.
State Medicaids are not directly impacted by this agreement. Medi-Cal requirements specify that providers submit claims with valid ICD-10-CM/PCS diagnosis codes with dates of service/dates of discharge on or after October 1, 2015.
Providers can find the Draft ICD-10 Code Release manual sections on the Medi-Cal ICD-10 webpage. The final provider manuals containing ICD-10 updates will be posted to the Medi-Cal website in the September Medi-Cal, Family PACT and CHDP Update bulletins with an effective date of October 1, 2015.
Copyright © 2007 State of California
CMS Letter to Providers about ICD-10 Readiness
CMS began issuing letters to Medicare Fee-for-Service providers emphasizing the importance of readiness for ICD-10 and reminding them of the resources available from CMS and other organizations to get ready. View the CMS Letter to Providers about ICD-10 Readiness.
Internal Medicine Subsequent Hospital Care, 99233 - Southern CA Widespread Service Specific Targeted Review Notification
CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. To meet this requirement, Noridian's Part B Medical Review (MR) analyzes national and local data in conjunction with the findings from the Office of Inspector General (OIG) and other CMS contractors such as Comprehensive Error Rate Testing (CERT) and Recovery Auditor (RA) to identify atypical billing. After data analysis, MR must verify if billing problems exist through claim reviews to validate provider compliance with Medicare coverage as well as coding and billing guidelines. If issues are identified, MR then determines the severity of problems and develops interventions to correct the problem.
This article is to notify providers of the initiation of a Service Specific Targeted Review for Internal Medicine on:
Review CriteriaThe Southern California service specific targeted review of claims will be initiated for claims billed on or after July 6, 2015 with the following criteria:
Submit all applicable documentation requested for each claim with a copy of the ADS as a coversheet. Records should be mailed (hardcopy or CD) or faxed to Noridian within 45 days of receipt or a claim denial will occur. Denials may result in future provider specific complex reviews and may be appealed through the normal appeal process. Additional information for this review including a listing of references, required documentation and detailed instructions on ADS submissions, see the Automated Development System (ADS) Requests for Medical Record Submissions web page.
Noridian MR DeterminationMR will review the claim documentation within 30 days of its receipt and will determine whether or not the services billed are reasonable and necessary per Medicare coverage requirements. Along with the claim determination, MR will make a determination of liability for services and whether you are without fault for overpayments. Overall results of the service specific review will be posted to the Noridian website at the end of each quarter and at the end of the review. Noridian will not post provider specific results on the website. Noridian is only required to give a high-level notice of determination of the claims reviewed. You will not receive an individual notice detailing why your claim(s) was denied and/or paid at a different level of service. Individual claim determinations can be found on your Remittance Advice (RA). If you have any questions, contact the Provider Contact Center.
For questions related to Service Specific Reviews, the Noridian provider community is able to contact Part B Medical Review staff directly via email at medicalreviewpartb@noridian.com.
Last Updated Jun 22, 2015
© 2015 Noridian Healthcare Solutions, LLC.
This article is to notify providers of the initiation of a Service Specific Targeted Review for Internal Medicine on:
- CPT ® 99233: Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a detailed interval history; a detailed examination; medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit.
Review CriteriaThe Southern California service specific targeted review of claims will be initiated for claims billed on or after July 6, 2015 with the following criteria:
- CPT ® 99233: Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a detailed interval history; a detailed examination; medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit.
- Data analysis has identified a potentially high use of Subsequent Hospital Care CPT ® 99233 provided by Internal Medicine.
Submit all applicable documentation requested for each claim with a copy of the ADS as a coversheet. Records should be mailed (hardcopy or CD) or faxed to Noridian within 45 days of receipt or a claim denial will occur. Denials may result in future provider specific complex reviews and may be appealed through the normal appeal process. Additional information for this review including a listing of references, required documentation and detailed instructions on ADS submissions, see the Automated Development System (ADS) Requests for Medical Record Submissions web page.
Noridian MR DeterminationMR will review the claim documentation within 30 days of its receipt and will determine whether or not the services billed are reasonable and necessary per Medicare coverage requirements. Along with the claim determination, MR will make a determination of liability for services and whether you are without fault for overpayments. Overall results of the service specific review will be posted to the Noridian website at the end of each quarter and at the end of the review. Noridian will not post provider specific results on the website. Noridian is only required to give a high-level notice of determination of the claims reviewed. You will not receive an individual notice detailing why your claim(s) was denied and/or paid at a different level of service. Individual claim determinations can be found on your Remittance Advice (RA). If you have any questions, contact the Provider Contact Center.
For questions related to Service Specific Reviews, the Noridian provider community is able to contact Part B Medical Review staff directly via email at medicalreviewpartb@noridian.com.
Last Updated Jun 22, 2015
© 2015 Noridian Healthcare Solutions, LLC.
HBMA Washington Report
Here are some highlights from the most recent Washington Update from the HBMA
SGR is gone.............but read on for some more changes coming.
Copyright 2015 HBMA. All Rights Reserved.
SGR is gone.............but read on for some more changes coming.
- That piece of the SGR repeal/replace effort fell into place earlier this year on April 16 th when President Obama signed into law the Medicare Access and CHIP Reauthorization Act of 2015. This legislation not only immediately repealed the SGR – retroactive to April 1, 2015, it set in place a transition from traditional fee-for-service payments by Medicare to a new ―value based‖ or ―quality based‖ payment model that would be fully in place by 2019.This bill will transition Medicare FFS payments towards a value-based payment system and incentivize the development of new, value-based payment models.
- Before fully transitioning to the new payment models, there will be a period of relative stability and predictability to Medicare payments. Later this year (July 1, 2015) Medicare Physician Fee Schedule Conversion Factor (CF) will be automatically adjusted upward by .5%. Then, each January 1st, for the next four years, the CF will be automatically adjusted upward by .5%.
- Between now and 2019, CMS has been directed to work with physicians specialty organizations and other stakeholders to develop Alternative Payment Models (APMs). Broadly, these will be payment models built on the fee-for-service payment architecture but that incorporate the concepts of value and quality into the final payment received by the provider. CMS and their stakeholder partners will also use this time period to develop more bundled payment opportunities where providers will be paid a pre-determined amount of money based upon the primary diagnosis of the patient and the expected level of patient involvement. The goal here is to pay providers for treating and managing the patient rather than paying the provider for the accumulated value of the services rendered. Beginning in 2019, the Conversion Factor will be frozen for five years. There will be no automatic updates. Instead, provides will have to ―earn‖ their annual updates either through participation in one of a number of ―to-be-developed‖ Alternative Payment Models or, through participation in a new program called MIPS – Merit-based Incentive Payment System.
- MIPS will essentially be combining the existing PQRS, EHR Meaningful Use and Value Based Payment programs into a single new update initiative that will allow providers to obtain increases (or be subject to decreases) depending upon how well a provider scores on these initiatives compared to his/her peers. Some providers may not want to participate in either MIPS or APM and the law gives the Secretary of Health and Human Services the authority to exempt providers. How easy or extensive that process will be remains to be seen. The operating assumption is, however, that remaining in traditional fee-for-service will be very unattractive financially due to the freeze and so the expectation is that the vast majority of providers will ―voluntarily‖ move to either an APM or MIPS. The theory behind this shift in payment models is that by incentivizing the providers to better manage the patient, particularly patients with chronic diseases (diabetes, COPD, asthma, etc.), the rate of hospitalization and ER utilization for these patients can be dramatically reduced and Medicare will save money. Of course in 1997, in theory, SGR was supposed to incentivize physicians to modify their practice styles to fit the ―new‖ updating process and we know how that turned out… While the repeal of the SGR brings to a close a rather tumultuous period in the Medicare program’s history, it also represents the beginning of a new phase for the Medicare program.
Copyright 2015 HBMA. All Rights Reserved.
Good news about Medicare reimbursement!
Re: SGR Repeal/Replace Update – 9:45pm EASTERN
A short while ago, by a vote of 92 - 8 the Senate passed H.R. 2, legislation that would permanently repeal and replace the Medicare Sustainable Growth Rate formula (SGR). There were six amendments offered during floor consideration and all were defeated. Therefore, the Senate has passed the bill in the identical form as the House passed version. This means that the bill can immediately go to the President for his signature. The President has previously agreed to sign this bill into law.
Once signed into law by the President, this bill immediately repeals the SGR, retroactive to April 1st therefore averting a 21% reduction in Medicare fee-for-service (FFS) payments to providers. It replaces the SGR with a new payment system that includes automatic payment updates for physician fee schedule payments for five years, transitions Medicare FFS payments towards a value-based payment system and incentivizes the development and participation in new, alternative payment models, among other notable provisions.
It is not clear how quickly CMS will be able to reprogram the claims processing computers to prevent claims schedule to be paid tomorrow from being subject to the SGR cut. We expect CMS to make a quick announcement soon on their plans now that the SGR will be repealed. Although it is possible for CMS to continue to hold any claims submitted with a date of service on or after April 1st, at this time we do not know whether CMS will exercise this discretionary authority.
Home Health Care Face-to-Face Visits
Recent update on the requirements for Home Health Services
https://med.noridianmedicare.com/web/jeb/cert-reviews/cert/home-health-care-face-to-face-visits
https://med.noridianmedicare.com/web/jeb/cert-reviews/cert/home-health-care-face-to-face-visits
Specific Modifiers for Distinct Procedural Services
Effective Date: January 1, 2015
The Medicare National Correct Coding Initiative (NCCI) has Procedure to Procedure (PTP) edits to prevent unbundling of services, and the consequent overpayment to physicians and outpatient facilities. The underlying principle is that the second code defines a subset of the work of the first code. Reporting the codes separately is inappropriate. Separate reporting would trigger a separate payment and would constitute double billing. CR8863discusses changes to HCPCS modifier -59, a modifier which is used to define a “Distinct Procedural Service.” Modifier -59 indicates that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled. The -59 modifier is the most widely used HCPCS modifier. Modifier -59 can be broadly applied. Some providers incorrectly consider it to be the “modifier to use to bypass (NCCI).” This modifier is associated with considerable abuse and high levels of manual audit activity; leading to reviews, appeals and even civil fraud and abuse cases.
The primary issue associated with the -59 modifier is that it is defined for use in a wide variety of circumstances, such as to identify:
Different encounters;
Different anatomic sites; and
Distinct services.
The -59 modifier is
Infrequently (and usually correctly) used to identify a separate encounter;
Less commonly (and less correctly) used to define a separate anatomic site; and
More commonly (and frequently incorrectly) used to define a distinct service.
The -59 modifier often overrides the edit in the exact circumstance for which CMS created it in the first place. CMS believes that more precise coding options coupled with increased education and selective editing is needed to reduce the errors associated with this overpayment.
CR8863 provides that CMS is establishing the following four new HCPCS modifiers (referred to collectively as -X{EPSU} modifiers) to define specific subsets of the -59 modifier:
XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter
XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure,
XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner, and
XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service.
CMS will continue to recognize the -59 modifier, but notes that Current Procedural Terminology (CPT) instructions state that the -59 modifier should not be used when a more descriptive modifier is available. While CMS will continue to recognize the -59 modifier in many instances, it may selectively require a more specific - X{EPSU} modifier for billing certain codes at high risk for incorrect billing. For example, a particular NCCI PTP code pair may be identified as payable only with the -XE separate encounter modifier but not the -59 or other -X{EPSU} modifiers. The -X{EPSU} modifiers are more selective versions of the -59 modifier so it would be incorrect to include both modifiers on the same line.
The combination of alternative specific modifiers with a general less specific modifier creates additional discrimination in both reporting and editing. As a default, at this time CMS will initially accept either a -59 modifier or a more selective - X{EPSU} modifier as correct coding, although the rapid migration of providers to the more selective modifiers is encouraged.
However, please note that these modifiers are valid even before national edits are in place. MACs are not prohibited from requiring the use of selective modifiers in lieu of the general -59 modifier, when necessitated by local program integrity and compliance needs.
Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2013 American Medical Association.
The Medicare National Correct Coding Initiative (NCCI) has Procedure to Procedure (PTP) edits to prevent unbundling of services, and the consequent overpayment to physicians and outpatient facilities. The underlying principle is that the second code defines a subset of the work of the first code. Reporting the codes separately is inappropriate. Separate reporting would trigger a separate payment and would constitute double billing. CR8863discusses changes to HCPCS modifier -59, a modifier which is used to define a “Distinct Procedural Service.” Modifier -59 indicates that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled. The -59 modifier is the most widely used HCPCS modifier. Modifier -59 can be broadly applied. Some providers incorrectly consider it to be the “modifier to use to bypass (NCCI).” This modifier is associated with considerable abuse and high levels of manual audit activity; leading to reviews, appeals and even civil fraud and abuse cases.
The primary issue associated with the -59 modifier is that it is defined for use in a wide variety of circumstances, such as to identify:
Different encounters;
Different anatomic sites; and
Distinct services.
The -59 modifier is
Infrequently (and usually correctly) used to identify a separate encounter;
Less commonly (and less correctly) used to define a separate anatomic site; and
More commonly (and frequently incorrectly) used to define a distinct service.
The -59 modifier often overrides the edit in the exact circumstance for which CMS created it in the first place. CMS believes that more precise coding options coupled with increased education and selective editing is needed to reduce the errors associated with this overpayment.
CR8863 provides that CMS is establishing the following four new HCPCS modifiers (referred to collectively as -X{EPSU} modifiers) to define specific subsets of the -59 modifier:
XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter
XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure,
XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner, and
XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service.
CMS will continue to recognize the -59 modifier, but notes that Current Procedural Terminology (CPT) instructions state that the -59 modifier should not be used when a more descriptive modifier is available. While CMS will continue to recognize the -59 modifier in many instances, it may selectively require a more specific - X{EPSU} modifier for billing certain codes at high risk for incorrect billing. For example, a particular NCCI PTP code pair may be identified as payable only with the -XE separate encounter modifier but not the -59 or other -X{EPSU} modifiers. The -X{EPSU} modifiers are more selective versions of the -59 modifier so it would be incorrect to include both modifiers on the same line.
The combination of alternative specific modifiers with a general less specific modifier creates additional discrimination in both reporting and editing. As a default, at this time CMS will initially accept either a -59 modifier or a more selective - X{EPSU} modifier as correct coding, although the rapid migration of providers to the more selective modifiers is encouraged.
However, please note that these modifiers are valid even before national edits are in place. MACs are not prohibited from requiring the use of selective modifiers in lieu of the general -59 modifier, when necessitated by local program integrity and compliance needs.
Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2013 American Medical Association.
What sort of policy do I need to email with patients?
Question:
Hi Jennifer, My practice sends out appointment reminders, bills and answers quick questions from our patients using email. What sort of policy should I have in place for my staff and patients? Thanks! Dr. K.
Answer:
(provided by Erica Youngerman, Esq.)
More and more practices are utilizing email to reach out to their patients and offer instant access. First of all, you should ensure that you have an updated HIPAA compliant Privacy Policy and consent form in place that includes the patient’s consent to email communication.
Second, I recommend having a policy in place that you could send to patients who email you, post on your website and provide to patients in the office that deals exclusively with email usage as there are several conditions, guidelines and risks that should be addressed. For example, when told that they may contact you by email, some patients may be under the mistaken impression that you, like many people, are carrying your smart phone at all times and checking and responding to your emails immediately. As a result, a patient may email you in an emergency and delay necessary care. It is vital that your patients be informed that email is not the appropriate communication tool for emergencies and that they should be calling 911. Additionally, your policy should educate your patients on reasonable expectations for response time, appropriate topics for email communication, proper email format, who may be responding or viewing their emails, the fact that the emails will be included in the medical record and many other conditions and guidelines for email usage.
An email policy is also recommended in order to advise your patients of some of the risks of email communication. For example, if a patient is emailing you from their office computer, their office may have a policy that allows that patient’s employer access to email communication, thereby compromising the confidential nature of their communication. Additional risks include interception, unintended recipients, viruses and many other substantial risks.
For assistance developing an email policy that is right for your office, give us a call. Erica Youngerman may be reached at (516) 747-6700 x. 308 or
at EYoungerman@Kirschenbaumesq.com and Jennifer may be reached at x. 302 orJennifer@kirschenbaumesq.com.
Copyright © 2014 by Kirschenbaum & Kirschenbaum PC.
Hi Jennifer, My practice sends out appointment reminders, bills and answers quick questions from our patients using email. What sort of policy should I have in place for my staff and patients? Thanks! Dr. K.
Answer:
(provided by Erica Youngerman, Esq.)
More and more practices are utilizing email to reach out to their patients and offer instant access. First of all, you should ensure that you have an updated HIPAA compliant Privacy Policy and consent form in place that includes the patient’s consent to email communication.
Second, I recommend having a policy in place that you could send to patients who email you, post on your website and provide to patients in the office that deals exclusively with email usage as there are several conditions, guidelines and risks that should be addressed. For example, when told that they may contact you by email, some patients may be under the mistaken impression that you, like many people, are carrying your smart phone at all times and checking and responding to your emails immediately. As a result, a patient may email you in an emergency and delay necessary care. It is vital that your patients be informed that email is not the appropriate communication tool for emergencies and that they should be calling 911. Additionally, your policy should educate your patients on reasonable expectations for response time, appropriate topics for email communication, proper email format, who may be responding or viewing their emails, the fact that the emails will be included in the medical record and many other conditions and guidelines for email usage.
An email policy is also recommended in order to advise your patients of some of the risks of email communication. For example, if a patient is emailing you from their office computer, their office may have a policy that allows that patient’s employer access to email communication, thereby compromising the confidential nature of their communication. Additional risks include interception, unintended recipients, viruses and many other substantial risks.
For assistance developing an email policy that is right for your office, give us a call. Erica Youngerman may be reached at (516) 747-6700 x. 308 or
at EYoungerman@Kirschenbaumesq.com and Jennifer may be reached at x. 302 orJennifer@kirschenbaumesq.com.
Copyright © 2014 by Kirschenbaum & Kirschenbaum PC.
ICD-10 Deadline for Compliance
Earlier this year, Congress adopted legislation that postponed the ICD-10 effective date from October 1, 2014 to a date – no sooner than October 1, 2015. Because of the way the legislation was written, it left it up to the Secretary of HHS to set a new effective date.
For many months, CMS officials have stated publicly that it was their intent to set the new effective date for October 1, 2015. However, until this date was published in the Federal Register, it was not official. A short while ago, the Department of Health and Human Services issued a Final Rule officially setting the ICD-10 effective date as October 1, 2015. In addition, HHS is also mandating continued use of ICD-9 through September 30, 2015. By mandating use of ICD-9 through the end of September, 2015, individual payers cannot voluntarily seek to adopt ICD-10 prior to October 1 as some had suggested.
In announcing the new effective date, CMS, the agency responsible for overseeing and enforcing ICD-10 compliance, acknowledged that much of the industry has already invested significant resources toward the implementation of ICD-10. It is hoped that the additional time afforded the industry will be sufficient to ensure wide-spread industry readiness for adoption of ICD-10 by the new effective date.
For many months, CMS officials have stated publicly that it was their intent to set the new effective date for October 1, 2015. However, until this date was published in the Federal Register, it was not official. A short while ago, the Department of Health and Human Services issued a Final Rule officially setting the ICD-10 effective date as October 1, 2015. In addition, HHS is also mandating continued use of ICD-9 through September 30, 2015. By mandating use of ICD-9 through the end of September, 2015, individual payers cannot voluntarily seek to adopt ICD-10 prior to October 1 as some had suggested.
In announcing the new effective date, CMS, the agency responsible for overseeing and enforcing ICD-10 compliance, acknowledged that much of the industry has already invested significant resources toward the implementation of ICD-10. It is hoped that the additional time afforded the industry will be sufficient to ensure wide-spread industry readiness for adoption of ICD-10 by the new effective date.
Notice Regarding Cal MediConnect
Below is a nice reference sheet from Cal MediConnect regarding the Dual Program and Continuing Care. Take a moment to read through it and notice the clause about only covering out of the network if you already have a relationship with the patient.
Continuing Your Care After You Join a Health Plan
Coordinated Care Initiative Fact sheet - February 2014
Your new Cal MediConnect or Medi-Cal health plan is required to make sure your care continues and is not disrupted. Your health plan will work with you and your doctors to make sure you get all the care you need. You have the right to continue to receive needed services, even if you may no longer be able to receive them from the same provider. Eventually, you must get all your covered services from providers who work with your plan. These are “in-network” providers. If you have a scheduled treatment and just joined a new health plan, call your new health plan right away. Tell the plan about your treatment so they can work with you to arrange it.
Continuing Care: Your Doctors
If your doctor is not in your plan, you may be able to continue to see them for:
• Medicare services: 6 months
• Medi-Cal services: 12 months
This applies to primary care doctors and specialists, like heart doctors, called cardiologists, or eye doctors, called ophthalmologists.
You must show a relationship with the provider in the 12 months prior to enrolling in the plan:
• Primary Care: one visit over 12 months
• Specialists: two visits over 12 months
In addition, your provider must:
• Be willing to work with the plan;
• Accept payment from the plan; and
• Not be excluded from the plan’s network for quality or other concerns.
Eventually, you must get all your covered services from providers who work with your health plan. These are “in-network” providers.
You may be able to see an out-of-network doctor after you join the plan.
1. Call your health plan and tell them about your scheduled care. Ask if your doctor is in their network.
2. Tell your doctor that you joined a health plan. If the doctor is not “in-network,” you can ask them about joining the plan network.
3. If your doctor is “out-of-network,” tell the plan you want to keep seeing your doctor.
4. If you have seen the doctor twice in the last 12 months, the plan must contact your doctor and allow you to keep seeing them. The doctor must
agree to work with the health plan.
5. If you are not happy with your plan’s response, you can call: Cal MediConnect Ombudsman: (855) 501-3077 [starts April 1, 2014].
Continuing Your Care After You Join a Health Plan
Continuing Care: Other Providers
You will have to get other non-doctor services through the health plan’s network, such as suppliers of medical equipment, medical supplies, and transportation. You will also have to switch to home health or physical therapy providers who are in your plan’s network.
Continuing Care: Long-Term Supports and Services (LTSS) Providers
If you’re in a nursing home, you have a right to stay in your current nursing home under Cal MediConnect, unless it is excluded from the plan’s network for quality or other concerns. Also, you can ask your health plan about getting help to return to the community. If you’re already receiving long-term supports and services (LTSS), you also won’t have to change your In-Home Supportive Services (IHSS), Community-Based Adult Services
(CBAS) and Multipurpose Senior Services Program (MSSP) providers.
Continuing Care: Prescription Drugs
Every health plan has a list of drugs that they will pay for, a list that is called a formulary. Before you enroll in a plan, you should call the plan and see if the drugs you need are
included on their formulary. Otherwise you may have to switch drugs. For example, you may need to switch between brand name and generic.
Your Rights as a Health Plan Member:
As a health plan member, you have a right to:
• Be treated with respect and dignity
• Get timely access to services for a health problem or disability
• Be told where, when, and how to get needed services
• Take part in decisions about your care, including the right to refuse treatment
• Be treated by providers who have experience/expertise in your condition
• Have your medical records and treatment kept private
• Get a copy of your medical records
• Continue to have the right to hire, fire, and manage your IHSS provider
You can always change health plans, or switch from Cal MediConnect to original
Medicare and a Medi-Cal managed care plan. To make a change, call Health Care
Options at 1-800-580-7272 (TTY: 1-800-430-7077.
Copyright www.calduals.org
Continuing Your Care After You Join a Health Plan
Coordinated Care Initiative Fact sheet - February 2014
Your new Cal MediConnect or Medi-Cal health plan is required to make sure your care continues and is not disrupted. Your health plan will work with you and your doctors to make sure you get all the care you need. You have the right to continue to receive needed services, even if you may no longer be able to receive them from the same provider. Eventually, you must get all your covered services from providers who work with your plan. These are “in-network” providers. If you have a scheduled treatment and just joined a new health plan, call your new health plan right away. Tell the plan about your treatment so they can work with you to arrange it.
Continuing Care: Your Doctors
If your doctor is not in your plan, you may be able to continue to see them for:
• Medicare services: 6 months
• Medi-Cal services: 12 months
This applies to primary care doctors and specialists, like heart doctors, called cardiologists, or eye doctors, called ophthalmologists.
You must show a relationship with the provider in the 12 months prior to enrolling in the plan:
• Primary Care: one visit over 12 months
• Specialists: two visits over 12 months
In addition, your provider must:
• Be willing to work with the plan;
• Accept payment from the plan; and
• Not be excluded from the plan’s network for quality or other concerns.
Eventually, you must get all your covered services from providers who work with your health plan. These are “in-network” providers.
You may be able to see an out-of-network doctor after you join the plan.
1. Call your health plan and tell them about your scheduled care. Ask if your doctor is in their network.
2. Tell your doctor that you joined a health plan. If the doctor is not “in-network,” you can ask them about joining the plan network.
3. If your doctor is “out-of-network,” tell the plan you want to keep seeing your doctor.
4. If you have seen the doctor twice in the last 12 months, the plan must contact your doctor and allow you to keep seeing them. The doctor must
agree to work with the health plan.
5. If you are not happy with your plan’s response, you can call: Cal MediConnect Ombudsman: (855) 501-3077 [starts April 1, 2014].
Continuing Your Care After You Join a Health Plan
Continuing Care: Other Providers
You will have to get other non-doctor services through the health plan’s network, such as suppliers of medical equipment, medical supplies, and transportation. You will also have to switch to home health or physical therapy providers who are in your plan’s network.
Continuing Care: Long-Term Supports and Services (LTSS) Providers
If you’re in a nursing home, you have a right to stay in your current nursing home under Cal MediConnect, unless it is excluded from the plan’s network for quality or other concerns. Also, you can ask your health plan about getting help to return to the community. If you’re already receiving long-term supports and services (LTSS), you also won’t have to change your In-Home Supportive Services (IHSS), Community-Based Adult Services
(CBAS) and Multipurpose Senior Services Program (MSSP) providers.
Continuing Care: Prescription Drugs
Every health plan has a list of drugs that they will pay for, a list that is called a formulary. Before you enroll in a plan, you should call the plan and see if the drugs you need are
included on their formulary. Otherwise you may have to switch drugs. For example, you may need to switch between brand name and generic.
Your Rights as a Health Plan Member:
As a health plan member, you have a right to:
• Be treated with respect and dignity
• Get timely access to services for a health problem or disability
• Be told where, when, and how to get needed services
• Take part in decisions about your care, including the right to refuse treatment
• Be treated by providers who have experience/expertise in your condition
• Have your medical records and treatment kept private
• Get a copy of your medical records
• Continue to have the right to hire, fire, and manage your IHSS provider
You can always change health plans, or switch from Cal MediConnect to original
Medicare and a Medi-Cal managed care plan. To make a change, call Health Care
Options at 1-800-580-7272 (TTY: 1-800-430-7077.
Copyright www.calduals.org
Verifying Patient Coverage in a Health Insurance Marketplace Plan - January 2014
Beginning January 1, 2014, providers will be verifying their patient’s insurance status when they show up for their appointments. Many of these patients may be newly insured individuals who will be getting their health insurance through the Health Insurance Marketplace, also known as Health Insurance Exchange. Due to the on-going problems with the federal Exchange, many of these individuals may have only signed up for insurance within the last few days of 2013. HHS is reporting that there was a surge of enrollments in the last week. Insurers are also reporting inaccurate enrollment information so there may be considerable confusion during the first few weeks of 2014 in terms of the insured status of some newly enrolled individuals.
Because of these late enrollments, HHS is warning that many of these individuals “may not have received their card yet or they may be unaware of the need to carry their insurance information.” For all of these reasons, providers are strongly encouraged to verify the patient’s coverage status.
The Department of Health and Human Services offers the following advice:
How do you verify their coverage? - If the marketplace in the state where the patient purchased insurance is run by the federal government, it is best to call the plan’s customer service line. A list of all plans and their customer service numbers can be found in the database. There’s a fact sheet for using the data base. If you can’t find the number, call the Marketplace Call Center (1-800-318- 2596). If the marketplace in the state where the patient purchased insurance is run by the state, contact that state. To find the website for the state-run exchanges, select the name of the state in the box at the left hand side of the healthcare.gov website.
Providers should remember that many of the people who will be newly insured are not familiar with certain terms and or terminology common in health insurance. For example, many newly insured patients may not understand the difference between the deductible, co-insurance and co-pay. Therefore, providers are encouraged to remind their patients to keep all of their paperwork and receipts from all of their doctor’s appointments and from the pharmacy as well. Newly insured patients (and some previously insured) may not understand how deductibles are calculated, for example. Finally, your providers may want to remind their patients to always carry their health insurance card at all times. If the patients do not have an insurance card, they should be encouraged to contact their plan to get a card.
Finally, if you have patients who are still uninsured after January 1, 2014, you may want to remind them that they have until March 31st to sign up for non-employer based coverage. They can go to HealthCare.gov to sign up for a plan and apply for financial assistance.
A federal government website managed by the U.S. Centers for Medicare & Medicaid Services. 7500 Security Boulevard, Baltimore, MD 21244
Because of these late enrollments, HHS is warning that many of these individuals “may not have received their card yet or they may be unaware of the need to carry their insurance information.” For all of these reasons, providers are strongly encouraged to verify the patient’s coverage status.
The Department of Health and Human Services offers the following advice:
How do you verify their coverage? - If the marketplace in the state where the patient purchased insurance is run by the federal government, it is best to call the plan’s customer service line. A list of all plans and their customer service numbers can be found in the database. There’s a fact sheet for using the data base. If you can’t find the number, call the Marketplace Call Center (1-800-318- 2596). If the marketplace in the state where the patient purchased insurance is run by the state, contact that state. To find the website for the state-run exchanges, select the name of the state in the box at the left hand side of the healthcare.gov website.
Providers should remember that many of the people who will be newly insured are not familiar with certain terms and or terminology common in health insurance. For example, many newly insured patients may not understand the difference between the deductible, co-insurance and co-pay. Therefore, providers are encouraged to remind their patients to keep all of their paperwork and receipts from all of their doctor’s appointments and from the pharmacy as well. Newly insured patients (and some previously insured) may not understand how deductibles are calculated, for example. Finally, your providers may want to remind their patients to always carry their health insurance card at all times. If the patients do not have an insurance card, they should be encouraged to contact their plan to get a card.
Finally, if you have patients who are still uninsured after January 1, 2014, you may want to remind them that they have until March 31st to sign up for non-employer based coverage. They can go to HealthCare.gov to sign up for a plan and apply for financial assistance.
A federal government website managed by the U.S. Centers for Medicare & Medicaid Services. 7500 Security Boulevard, Baltimore, MD 21244
CMS Finalizes Physician Payment Rates for 2014 - Nov 27, 2013
In a rule issued today, the Centers for Medicare & Medicaid Services (CMS) finalized payment rates and policies for 2014, including a major proposal to support care management outside the routine office interaction as well as other policies to promote high quality care and efficiency in Medicare. CMS’ care coordination policy is a milestone, and demonstrates Medicare’s recognition of the importance of care that occurs outside of a face-to-face visit for a wide range of beneficiaries beginning in 2015. The final rule sets payment rates for physicians and non-physician practitioners paid under the Medicare Physician Fee Schedule for 2014 and addresses the policies included in the proposed rule issued in July. CMS projects that total payments under the fee schedule in 2014 will be approximately $87 billion.
As part of CMS’ continuing effort to recognize the critical role primary care plays in providing care to beneficiaries with multiple chronic conditions, beginning in 2015, the agency is establishing separate payments for managing a patient’s care outside of a face-to-face visit for practices equipped to provide these services.
“Health care is changing, and part of delivery system reform is recognizing this and making sure payment systems account for these changes,” said CMS Principal Deputy Administrator Jonathan Blum. “We believe that successful efforts to improve chronic care management for these patients could improve the quality of care while simultaneously decreasing costs, through reductions in hospitalizations, use of post-acute care services, and emergency department visits.”
The 2014 payment rates increase payments for many medical specialties with some of the greatest increases going to providers of mental health services including psychiatry, clinical psychologists and clinical social workers.
CMS is finalizing a process to adjust payment rates for test codes on the Clinical Laboratory Fee Schedule (CLFS) based on technological changes. Currently, the payment rates for test codes on the CLFS do not change once they have been set (except for changes due to inflation and other statutory adjustments). This review process will enable CMS to pay more accurately for laboratory tests on the CLFS.
The final rule also includes several provisions regarding physician quality programs and the Physician Value-Based Payment Modifier (Value Modifier). As CMS continues to phase-in the Physician Value-Based Payment Modifier, for 2016 CMS is finalizing its proposals to apply the Physician Value Modifier to groups of physicians with 10 or more eligible professionals, and to apply upward and downward payment adjustments based on performance to groups of physicians with 100 or more eligible professionals. However, only upward adjustments based on performance (not downward adjustments) will be applied to groups of physicians with between 10 and 99 eligible professionals.
CMS also is finalizing several related proposals to the Physician Quality Reporting System (PQRS) for 2014, including a new option for individual eligible professionals to report quality measures through qualified clinical data registries. In 2014, quality measures will be aligned across quality reporting programs so that physicians and other eligible professionals may report a measure once to receive credit in all quality reporting programs in which that measure is used. Additionally, CMS is better aligning PQRS measures with the National Quality Strategy and meaningful use requirements, and transitioning away from process measures in favor of performance and outcome measures. Finally, certain data collected in 2012 for groups reporting certain PQRS measures under the Group Practice Reporting Option (GPRO) will be publicly reported on the CMS Physician Compare website in 2014.
“Aligning measures across quality programs focuses providers on the most important measures and makes it easier to participate in programs like PQRS, which are designed to emphasize quality for Medicare beneficiaries,” said Dr. Patrick Conway, CMS Deputy Administrator for Innovation and Quality and CMS Chief Medical Officer. “PQRS and value-based purchasing, along with demonstration projects taking place through the Innovation Center, are transforming our health system to achieve better outcomes for patients and spend dollars more wisely.”
The final rule is on display at the Federal Register and will be published on December 10, 2013.
For more information about the final rule, please visit: http://www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1
For more information about the Physician Fee Schedule, please visit: http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html
For more information regarding the Physician Value-Based Payment Modifier and PQRS, please visit:
http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/index.html
http://cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html
As part of CMS’ continuing effort to recognize the critical role primary care plays in providing care to beneficiaries with multiple chronic conditions, beginning in 2015, the agency is establishing separate payments for managing a patient’s care outside of a face-to-face visit for practices equipped to provide these services.
“Health care is changing, and part of delivery system reform is recognizing this and making sure payment systems account for these changes,” said CMS Principal Deputy Administrator Jonathan Blum. “We believe that successful efforts to improve chronic care management for these patients could improve the quality of care while simultaneously decreasing costs, through reductions in hospitalizations, use of post-acute care services, and emergency department visits.”
The 2014 payment rates increase payments for many medical specialties with some of the greatest increases going to providers of mental health services including psychiatry, clinical psychologists and clinical social workers.
CMS is finalizing a process to adjust payment rates for test codes on the Clinical Laboratory Fee Schedule (CLFS) based on technological changes. Currently, the payment rates for test codes on the CLFS do not change once they have been set (except for changes due to inflation and other statutory adjustments). This review process will enable CMS to pay more accurately for laboratory tests on the CLFS.
The final rule also includes several provisions regarding physician quality programs and the Physician Value-Based Payment Modifier (Value Modifier). As CMS continues to phase-in the Physician Value-Based Payment Modifier, for 2016 CMS is finalizing its proposals to apply the Physician Value Modifier to groups of physicians with 10 or more eligible professionals, and to apply upward and downward payment adjustments based on performance to groups of physicians with 100 or more eligible professionals. However, only upward adjustments based on performance (not downward adjustments) will be applied to groups of physicians with between 10 and 99 eligible professionals.
CMS also is finalizing several related proposals to the Physician Quality Reporting System (PQRS) for 2014, including a new option for individual eligible professionals to report quality measures through qualified clinical data registries. In 2014, quality measures will be aligned across quality reporting programs so that physicians and other eligible professionals may report a measure once to receive credit in all quality reporting programs in which that measure is used. Additionally, CMS is better aligning PQRS measures with the National Quality Strategy and meaningful use requirements, and transitioning away from process measures in favor of performance and outcome measures. Finally, certain data collected in 2012 for groups reporting certain PQRS measures under the Group Practice Reporting Option (GPRO) will be publicly reported on the CMS Physician Compare website in 2014.
“Aligning measures across quality programs focuses providers on the most important measures and makes it easier to participate in programs like PQRS, which are designed to emphasize quality for Medicare beneficiaries,” said Dr. Patrick Conway, CMS Deputy Administrator for Innovation and Quality and CMS Chief Medical Officer. “PQRS and value-based purchasing, along with demonstration projects taking place through the Innovation Center, are transforming our health system to achieve better outcomes for patients and spend dollars more wisely.”
The final rule is on display at the Federal Register and will be published on December 10, 2013.
For more information about the final rule, please visit: http://www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1
For more information about the Physician Fee Schedule, please visit: http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html
For more information regarding the Physician Value-Based Payment Modifier and PQRS, please visit:
http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/index.html
http://cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html
Coordinated Care Initiative to begin no earlier than April 2014 - August 16, 2013
San Diego County
Enrollment in Cal MediConnect will begin no sooner than April 2014. Notification of these changes will be mailed to eligible participants starting in January 2014. Enrollment will be phased in over 12 months in all counties, except Los Angeles and San Mateo. The Los Angeles enrollment strategy is currently in development and in San Mateo enrollment will occur the first month of the program.
Understanding Enrollment for Different Populations
Note: Opting out applies only to Medicare benefits. Beneficiaries must still get their Medi-Cal benefits through a health plan, as described below.
Enrollment in Cal MediConnect will begin no sooner than April 2014. Notification of these changes will be mailed to eligible participants starting in January 2014. Enrollment will be phased in over 12 months in all counties, except Los Angeles and San Mateo. The Los Angeles enrollment strategy is currently in development and in San Mateo enrollment will occur the first month of the program.
Understanding Enrollment for Different Populations
- For people with both Medicare and Medi-Cal eligible for Cal MediConnect: The state will use a passive enrollment process. This means that the state will enroll eligible individuals into a health plan that combines their Medicare and Medi-Cal benefits unless the individual actively chooses not to join and notifies the state of this choice. The state will send eligible individuals multiple notices describing their choices, including the option to “opt out” of joining a Cal MediConnect health plan.
Note: Opting out applies only to Medicare benefits. Beneficiaries must still get their Medi-Cal benefits through a health plan, as described below.
- For nearly all people with Medi-Cal: The state will require mandatory enrollment into a Medi-Cal health plan. This means that nearly all people with Medi-Cal in the eight CCI counties MUST get all their Medi-Cal benefits, including long-term services and supports, through a Medi-Cal health plan. Most people with only Medi-Cal already are enrolled in a Medi-Cal health plan; now they will also get their long-term supports and services through their health plan.
- For people with both Medicare and Medi-Cal who do not enroll in a Cal MediConnect Health Plan: The state will require enrollment in a Medi-Cal plan for all Medi-Cal long-term services and supports and any Medicare deductibles or costs. For dual eligible beneficiaries, enrolling in a Medi-Cal health plan does not change their Medicare benefits. They can still go to their Medicare doctors, hospitals, and providers.
- Care 1st Health Plan
- Community Health Group CommuniCare Advantage
- Health Net
- Molina Dual Options
- Copyright www.calduals.org
Medi-Cal cuts to begin in January 2014 - July 2013
Implementation of Assembly Bill 97 Reductions
The Department of Health Care Services (DHCS) is announcing the implementation plan for the provider payment reductions required pursuant to Assembly Bill 97 (Chapter 3, Statutes of 2011). AB 97 requires DHCS to implement 10 percent provider payment reductions to most categories of services in Medi-Cal fee-for-service (FFS) as well as actuarially equivalent reductions in Medi-Cal managed care.
DHCS received federal approval for the reductions, effective June 1, 2011, but has been prevented from implementing many of these reductions due to a court injunction in the Managed Pharmacy Care, et al v. Kathleen Sebelius, et al case. On June 14, 2013, the United States Court of Appeals for the Ninth Circuit denied the plaintiffs’ motion for a stay of mandate in this case, allowing the implementation of all of the AB 97 Medi-Cal provider 10 percent payment reductions.
Providers affected by the earlier court injunction that blocked the payment reductions will soon have a 10 percent prospective payment reduction applied to all claims they submit for services. The chart below shows the date on which providers will begin to see the reductions.
Provider Categories Date
Medical Transportation 9/5/2013
Dental 9/5/2013
Durable Medical Equipment/Medical Supplies 10/24/2013
Pharmacy 1/9/2014
Physician/Clinic 1/9/2014
Distinct Part Nursing Facility Level B (PT 17 & AC 1,2,3) 1/9/2014
Copyright © 2007 State of California
The Department of Health Care Services (DHCS) is announcing the implementation plan for the provider payment reductions required pursuant to Assembly Bill 97 (Chapter 3, Statutes of 2011). AB 97 requires DHCS to implement 10 percent provider payment reductions to most categories of services in Medi-Cal fee-for-service (FFS) as well as actuarially equivalent reductions in Medi-Cal managed care.
DHCS received federal approval for the reductions, effective June 1, 2011, but has been prevented from implementing many of these reductions due to a court injunction in the Managed Pharmacy Care, et al v. Kathleen Sebelius, et al case. On June 14, 2013, the United States Court of Appeals for the Ninth Circuit denied the plaintiffs’ motion for a stay of mandate in this case, allowing the implementation of all of the AB 97 Medi-Cal provider 10 percent payment reductions.
Providers affected by the earlier court injunction that blocked the payment reductions will soon have a 10 percent prospective payment reduction applied to all claims they submit for services. The chart below shows the date on which providers will begin to see the reductions.
Provider Categories Date
Medical Transportation 9/5/2013
Dental 9/5/2013
Durable Medical Equipment/Medical Supplies 10/24/2013
Pharmacy 1/9/2014
Physician/Clinic 1/9/2014
Distinct Part Nursing Facility Level B (PT 17 & AC 1,2,3) 1/9/2014
Copyright © 2007 State of California
Medi-Cal Audits to start in - June 2013
Payment Error Rate Measurement Program Review - The California Department of Health Care Services (DHCS) wishes to notify all California Medi-Cal providers of the Payment Error Rate Measurement (PERM) review that is being conducted in California by the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS). The purpose of PERM is to identify erroneous payments made in Medicaid and the Children's Health Insurance Program (CHIP) in all 50 states and report improper payment estimates to Congress.
Approximately 167 Medi-Cal claims will be selected per quarter, between October 1, 2012, and September 30, 2013. Beginning in June 2013 and ending in July 2014, providers whose medical records have been selected for review will begin receiving requests from A+ Government Solutions, the review contractor (RC), for copies of medical records. The RC will collect the medical records for sampled claims from providers via secure fax and mail to perform medical and data processing reviews to determine if the claims were paid correctly.
Providers will also be required to send a duplicate copy of the medical records requested by the RC to DHCS. DHCS is taking this proactive step in order to review the submitted documentation and determine if further information is needed to support the claim. In cases where DHCS determines that the medical records have not been submitted or further information is needed, providers will be contacted by a DHCS representative, either by telephone or in person, to help facilitate obtaining copies of this important documentation.
DHCS is urging all providers to comply with requests for medical records from the RC and DHCS. Failure to comply with the request from the RC will result in an error being counted against California, and DHCS will be required to recover the claim payment amount from providers. Your cooperation will help ensure that the payment measurement rate is accurate and that California retains its much needed federal match monies for the Medi-Cal Program.
Copyright © 2007 State of California
Approximately 167 Medi-Cal claims will be selected per quarter, between October 1, 2012, and September 30, 2013. Beginning in June 2013 and ending in July 2014, providers whose medical records have been selected for review will begin receiving requests from A+ Government Solutions, the review contractor (RC), for copies of medical records. The RC will collect the medical records for sampled claims from providers via secure fax and mail to perform medical and data processing reviews to determine if the claims were paid correctly.
Providers will also be required to send a duplicate copy of the medical records requested by the RC to DHCS. DHCS is taking this proactive step in order to review the submitted documentation and determine if further information is needed to support the claim. In cases where DHCS determines that the medical records have not been submitted or further information is needed, providers will be contacted by a DHCS representative, either by telephone or in person, to help facilitate obtaining copies of this important documentation.
DHCS is urging all providers to comply with requests for medical records from the RC and DHCS. Failure to comply with the request from the RC will result in an error being counted against California, and DHCS will be required to recover the claim payment amount from providers. Your cooperation will help ensure that the payment measurement rate is accurate and that California retains its much needed federal match monies for the Medi-Cal Program.
Copyright © 2007 State of California
UnitedHealth, Aetna and Cigna opt out of California insurance exchange - May 22, 2103
Kaiser Permanente, Anthem Blue Cross and Blue Shield of California are all expected to participate in the state-run market for individual health coverage.
May 22, 2013|By Chad Terhune, Los Angeles Times
Some prominent health insurers, including industry giant UnitedHealth Group Inc., are not participating in California's new state-run health insurance market, possibly limiting the number of choices for millions of consumers.
UnitedHealth, the nation's largest private insurer, Aetna Inc. and Cigna Corp. are sitting out the first year of Covered California, the state's insurance exchange and a key testing ground nationally for a massive coverage expansion under the federal healthcare law.
Copyright © 2011 Tribune Company.
May 22, 2013|By Chad Terhune, Los Angeles Times
Some prominent health insurers, including industry giant UnitedHealth Group Inc., are not participating in California's new state-run health insurance market, possibly limiting the number of choices for millions of consumers.
UnitedHealth, the nation's largest private insurer, Aetna Inc. and Cigna Corp. are sitting out the first year of Covered California, the state's insurance exchange and a key testing ground nationally for a massive coverage expansion under the federal healthcare law.
Copyright © 2011 Tribune Company.
Cal Duals Program not to start until January 2014 or later - May 6, 2013
The Department of Health Care Services (DHCS) announced on Monday that Cal MediConnect will begin no earlier than January 2014.
Cal MediConnect represents a historic effort to integrate the medical, social, and mental health services provided to some of the most vulnerable members of society. Already, there has been an impressive amount of work completed moving California toward this goal, including stakeholder support and participation, which moves this effort forward.
Cal MediConnect is an opportunity to support people who have both Medicare and Medicaid with more coordinated care. Doing so requires work on multiple levels between governments, health plans, and communities. This kind of systematic change takes time, and therefore the new timeline provides the opportunity to give every issue the full consideration it deserves.
The state places a high premium on beneficiary protections and is working deliberately to ensure a successful implementation. DHCS will continue assessing readiness for implementation and the final start date.
Copyright www.calduals.org
Cal MediConnect represents a historic effort to integrate the medical, social, and mental health services provided to some of the most vulnerable members of society. Already, there has been an impressive amount of work completed moving California toward this goal, including stakeholder support and participation, which moves this effort forward.
Cal MediConnect is an opportunity to support people who have both Medicare and Medicaid with more coordinated care. Doing so requires work on multiple levels between governments, health plans, and communities. This kind of systematic change takes time, and therefore the new timeline provides the opportunity to give every issue the full consideration it deserves.
The state places a high premium on beneficiary protections and is working deliberately to ensure a successful implementation. DHCS will continue assessing readiness for implementation and the final start date.
Copyright www.calduals.org
Covered California announces Plans and Rates for 2014 - May 25, 2013
SACRAMENTO, CA – Covered California™ today announced 13 diverse health insurance plans that will offer in 2014, affordable, quality health care coverage to millions of Californians. The plans reflect a mix of large non- profit and commercial plan leaders, along with well-known Medi-Cal and regional plans.
The tentative selection of health plans is subject to a rate review by state regulators. It is difficult to make a direct comparison of these rates to existing premiums in the commercial individual market because in 2014, there will be new standard benefit designs under the Affordable Care Act, and the actual change in an individual’s premium will depend on the person’s current insurance coverage. However, Covered California believes that a valuable frame of reference for its premiums, is comparing them to the small employer market in California. Both the small employer market and Covered California are competitive markets, and offer guaranteed issue – you cannot be denied for pre-existing condition.
The rates submitted to Covered California for the 2014 individual market ranged from two percent above to 29 percent below the 2013 average premium for small employer plans in California’s most populous regions. This is impressive since the 2014 products include doctor visits, prescriptions, hospital stays and more essential benefits; protecting consumers from the "gimmicks and gotchas" of many insurance policies.
“This is a home run for consumers in every region of California,” said Peter V. Lee, Executive Director of Covered California. “Our active negotiating will not only benefit potential enrollees to Covered California, but will benefit all Californians by making health care affordable.”
Additionally, there is financial protection like a maximum out-of-pocket cost of $6,350 which will dramatically reduce the chance of someone going bankrupt because of medical bills not covered by insurance.
“Californians should be proud of how not only health plans in this state, but doctors, medical groups and hospitals have stepped up – and creating a market that will allow millions of consumers to enroll in affordably priced products. Because of that, we will be able to deliver exceptional value, low rates, access to health care in every region of the state, and a solid platform to achieve the dream of providing quality health care for all Californians,” Lee said.
Covered California’s rigorous review and selection process resulted in a portfolio of plans that achieve three objectives: a robust choice of offerings throughout the state, affordable prices, and access to doctors and hospitals. The terms of Covered California’s relationship with its partnering health plans means they will collaboratively work to promote care improvements, foster prevention, and seek to reduce costs by promoting better care.
Once plan rates are approved by state regulators, Covered California looks forward to signing final contracts and beginning the work of enrolling millions of Californians in the following health plans:
• Alameda Alliance for Health
• Anthem Blue Cross of California
• Blue Shield of California
• Chinese Community Health Plan
• Contra Costa Health Plan
• Health Net
• Kaiser Permanente
• L.A. Care Health Plan
• Molina Healthcare
• Sharp Health Plan
• Valley Health Plan
• Ventura County Health Care Plan
• Western Health Advantage
"Covered California plans include the largest current health insurers in the individual market, as well as new entrants, regional plans and local Medi-Cal plans that want to be part of making history," Lee said. On average, there will be five plans from which to choose.
Even in rural areas where choice has been historically sparse, there will be two or three health plans. Throughout the state consumers will have a choice of Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs) and Exclusive Provider Organizations (EPOs).
To get prices at such competitive points, winning health plans built their bids around the expectation of high enrollment, not high profit. Plans reduced profit margins down to two and three percent; embraced Affordable Care Act programs such as Accountable Care Organizations and Patient-Centered Medical Homes, that seek to improve care while lowering costs; found common ground with doctors, medical groups and hospitals on lower reimbursement rates to make care affordable.
Virtually every health plan designed a custom network for Covered California. Negotiations included a detailed review of each plan’s rates, their mix of hospitals, physicians and other providers, and their contingency plans for expanding networks in the event more consumers sign up than expected.
The current list of insurers is for individual policies only. Covered California will announce its options for small businesses to buy health insurance in June.
About Covered CaliforniaCalifornia was the first state to create a health benefit exchange following the passage of the federal health care law. Covered California is charged with creating a new insurance marketplace in which individuals and small businesses can get access to health insurance. With coverage starting in 2014, Covered California will help individuals compare and choose a health plan that works best for their health needs and budget. Financial help will be available from the federal government to help lower costs for people who qualify on a sliding scale. Small businesses will be able to purchase competitively priced health plans and offer their employees the ability to choose from an array of plans and may qualify for federal tax credits. Covered California is an independent part of state government whose job is to make the new market work for California’s consumers. It is overseen by a five-member board appointed by the Governor and Legislature. For more information on Covered California, please visit www.CoveredCA.com. - Silver Plan rates - http://www.coveredca.com/news/PDFs/SilverPlanRatesChart.pdf
Copyright © 2013 - All Rights Reserved - Covered California News
The tentative selection of health plans is subject to a rate review by state regulators. It is difficult to make a direct comparison of these rates to existing premiums in the commercial individual market because in 2014, there will be new standard benefit designs under the Affordable Care Act, and the actual change in an individual’s premium will depend on the person’s current insurance coverage. However, Covered California believes that a valuable frame of reference for its premiums, is comparing them to the small employer market in California. Both the small employer market and Covered California are competitive markets, and offer guaranteed issue – you cannot be denied for pre-existing condition.
The rates submitted to Covered California for the 2014 individual market ranged from two percent above to 29 percent below the 2013 average premium for small employer plans in California’s most populous regions. This is impressive since the 2014 products include doctor visits, prescriptions, hospital stays and more essential benefits; protecting consumers from the "gimmicks and gotchas" of many insurance policies.
“This is a home run for consumers in every region of California,” said Peter V. Lee, Executive Director of Covered California. “Our active negotiating will not only benefit potential enrollees to Covered California, but will benefit all Californians by making health care affordable.”
Additionally, there is financial protection like a maximum out-of-pocket cost of $6,350 which will dramatically reduce the chance of someone going bankrupt because of medical bills not covered by insurance.
“Californians should be proud of how not only health plans in this state, but doctors, medical groups and hospitals have stepped up – and creating a market that will allow millions of consumers to enroll in affordably priced products. Because of that, we will be able to deliver exceptional value, low rates, access to health care in every region of the state, and a solid platform to achieve the dream of providing quality health care for all Californians,” Lee said.
Covered California’s rigorous review and selection process resulted in a portfolio of plans that achieve three objectives: a robust choice of offerings throughout the state, affordable prices, and access to doctors and hospitals. The terms of Covered California’s relationship with its partnering health plans means they will collaboratively work to promote care improvements, foster prevention, and seek to reduce costs by promoting better care.
Once plan rates are approved by state regulators, Covered California looks forward to signing final contracts and beginning the work of enrolling millions of Californians in the following health plans:
• Alameda Alliance for Health
• Anthem Blue Cross of California
• Blue Shield of California
• Chinese Community Health Plan
• Contra Costa Health Plan
• Health Net
• Kaiser Permanente
• L.A. Care Health Plan
• Molina Healthcare
• Sharp Health Plan
• Valley Health Plan
• Ventura County Health Care Plan
• Western Health Advantage
"Covered California plans include the largest current health insurers in the individual market, as well as new entrants, regional plans and local Medi-Cal plans that want to be part of making history," Lee said. On average, there will be five plans from which to choose.
Even in rural areas where choice has been historically sparse, there will be two or three health plans. Throughout the state consumers will have a choice of Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs) and Exclusive Provider Organizations (EPOs).
To get prices at such competitive points, winning health plans built their bids around the expectation of high enrollment, not high profit. Plans reduced profit margins down to two and three percent; embraced Affordable Care Act programs such as Accountable Care Organizations and Patient-Centered Medical Homes, that seek to improve care while lowering costs; found common ground with doctors, medical groups and hospitals on lower reimbursement rates to make care affordable.
Virtually every health plan designed a custom network for Covered California. Negotiations included a detailed review of each plan’s rates, their mix of hospitals, physicians and other providers, and their contingency plans for expanding networks in the event more consumers sign up than expected.
The current list of insurers is for individual policies only. Covered California will announce its options for small businesses to buy health insurance in June.
About Covered CaliforniaCalifornia was the first state to create a health benefit exchange following the passage of the federal health care law. Covered California is charged with creating a new insurance marketplace in which individuals and small businesses can get access to health insurance. With coverage starting in 2014, Covered California will help individuals compare and choose a health plan that works best for their health needs and budget. Financial help will be available from the federal government to help lower costs for people who qualify on a sliding scale. Small businesses will be able to purchase competitively priced health plans and offer their employees the ability to choose from an array of plans and may qualify for federal tax credits. Covered California is an independent part of state government whose job is to make the new market work for California’s consumers. It is overseen by a five-member board appointed by the Governor and Legislature. For more information on Covered California, please visit www.CoveredCA.com. - Silver Plan rates - http://www.coveredca.com/news/PDFs/SilverPlanRatesChart.pdf
Copyright © 2013 - All Rights Reserved - Covered California News
Implementation of the Award for Jurisdiction E Part A/Part B Medicare Contractor - April 26, 2013
The Centers for Medicare & Medicaid Services (CMS) has awarded the JE A/B MAC contract for the administration of the Part A and Part B Medicare fee-for-service claims in the states and territories of California, Hawaii, Nevada, American Somoa, Guam and the Northern Marianas to Noridian Administrative Services, LLC (NAS). Please share with appropriate staff.
Part B Southern California JE A/B MAC Workload Number - 01182; Effective Date - 09/16/2013;
Current Workload Number - 01192; OGC- PGBA.
Part B Southern California JE A/B MAC Workload Number - 01182; Effective Date - 09/16/2013;
Current Workload Number - 01192; OGC- PGBA.
CMS approves California dual eligible demonstration - April 1, 2013
By Anthony Brino
California's three-year demonstration program for Medicare-Medicaid dual eligibles has been approved by the federal government.
Managed by the California Health and Human Services Agency and called the Cal MediConnect, the program will provide an integrated health plan to an estimated 456,000 Californians in eight counties, mostly in Southern California and the Bay Area.
Dual eligible patients account for an estimated 25 percent of California Medicaid spending, at least in part because of what Centers for Medicare & Medicaid (CMS) officials have called a financial misalignment between Medicare and Medicaid.
The health plans participating in the program will receive a blended capitation payment monthly from Medi-Cal and Medicare, with beneficiaries having a single membership card and access to a care coordination team. The MOU signed between CMS and the state calls for Cal MediConnect implementation to begin no earlier than October 2013, with phased-in enrollment for different counties.
The 456,000 Californians who will be transitioned to the program represent a little less than half of 1.2 million dual eligible patients in California (out of about 9 million nationally). California Gov. Jerry Brown had initially proposed transitioning 800,000 of those 1.2 million into the demonstration program. In another change from the original proposal, the number of enrollees in Los Angeles County — home to an estimated 271,000 dual eligible patients — will be capped at 200,000.
“We are confident that the managed care plans we selected will make a positive impact on enrollees’ lives by coordinating care across the full continuum of services, including medical care, behavioral health services and home- and community-based care, such as the In-Home Supportive Services program,” Toby Douglas, director of the Department of Health Care Services, said in a media release. “Additionally, we have taken extensive measures to plan for and enforce strict quality and readiness standards.”
The state is contracting with 12 health plans, including Health Net, Molina and Anthem Blue Cross. For Health Net, Medicare-Medicaid dual plans have been a specialty and a potentially strong revenue source (amid earning struggles in other areas).
“That’s an area where we think that there is real opportunity to really fundamentally change service for people” and improve care quality and efficiency, Health Net president and CEO Jay Gellert said on a conference call in January.
Healthcare Payer News is a publication of MedTech Media.
For more information about MedTech Media and its publications, please visit medtechmedia.com.
©2013 MedTech Media
California's three-year demonstration program for Medicare-Medicaid dual eligibles has been approved by the federal government.
Managed by the California Health and Human Services Agency and called the Cal MediConnect, the program will provide an integrated health plan to an estimated 456,000 Californians in eight counties, mostly in Southern California and the Bay Area.
Dual eligible patients account for an estimated 25 percent of California Medicaid spending, at least in part because of what Centers for Medicare & Medicaid (CMS) officials have called a financial misalignment between Medicare and Medicaid.
The health plans participating in the program will receive a blended capitation payment monthly from Medi-Cal and Medicare, with beneficiaries having a single membership card and access to a care coordination team. The MOU signed between CMS and the state calls for Cal MediConnect implementation to begin no earlier than October 2013, with phased-in enrollment for different counties.
The 456,000 Californians who will be transitioned to the program represent a little less than half of 1.2 million dual eligible patients in California (out of about 9 million nationally). California Gov. Jerry Brown had initially proposed transitioning 800,000 of those 1.2 million into the demonstration program. In another change from the original proposal, the number of enrollees in Los Angeles County — home to an estimated 271,000 dual eligible patients — will be capped at 200,000.
“We are confident that the managed care plans we selected will make a positive impact on enrollees’ lives by coordinating care across the full continuum of services, including medical care, behavioral health services and home- and community-based care, such as the In-Home Supportive Services program,” Toby Douglas, director of the Department of Health Care Services, said in a media release. “Additionally, we have taken extensive measures to plan for and enforce strict quality and readiness standards.”
The state is contracting with 12 health plans, including Health Net, Molina and Anthem Blue Cross. For Health Net, Medicare-Medicaid dual plans have been a specialty and a potentially strong revenue source (amid earning struggles in other areas).
“That’s an area where we think that there is real opportunity to really fundamentally change service for people” and improve care quality and efficiency, Health Net president and CEO Jay Gellert said on a conference call in January.
Healthcare Payer News is a publication of MedTech Media.
For more information about MedTech Media and its publications, please visit medtechmedia.com.
©2013 MedTech Media
Mandatory Payment Reductions in the Medicare Fee-for-service Program - Sequestration - March 8, 2013
The Budget Control Act of 2011 requires, among other things, mandatory across-the-board reductions in Federal spending, also known as sequestration. The American Taxpayer Relief Act of 2012 postponed sequestration for 2 months. As required by law, President Obama issued a sequestration order on March 1, 2013. The Administration continues to urge Congress to take prompt action to address the current budget uncertainty and the economic hardships imposed by sequestration.
This listserv message is directed at the Medicare FFS program (i.e., Part A and Part B). In general, Medicare FFS claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will incur a two percent reduction in Medicare payment. Claims for durable medical equipment (DME), prosthetics, orthotics, and supplies, including claims under the DME Competitive Bidding Program, will be reduced by two percent based upon whether the date-of-service, or the start date for rental equipment or multi-day supplies, is on or after April 1, 2013. The claims payment adjustment shall be applied to all claims after determining coinsurance, any applicable deductible, and any applicable Medicare Secondary Payment adjustments.
Though beneficiary payments for deductibles and coinsurance are not subject to the two percent payment reduction, Medicare’s payment to beneficiaries for unassigned claims is subject to the two percent reduction. The Centers for Medicare & Medicaid Services encourages Medicare physicians, practitioners, and suppliers who bill claims on an unassigned basis to discuss with beneficiaries the impact of sequestration on Medicare’s reimbursement.
Questions about reimbursement should be directed to your Medicare claims administration contractor. As indicated above, we are hopeful that Congress will take action to eliminate the mandatory payment reductions.
last updated on 03/08/2013
Status of MAC Contract Awards as of - Feb 26, 2013
Protest Updates: On January 18, 2013, the Government Accountability Office (GAO) denied the two protests that had been pending against the Jurisdiction E A/B MAC contract award to Noridian Administrative Services since October 2012. As permitted by law, both protestors filed complaints challenging the Jurisdiction E MAC contract award with the U.S. Court of Federal Claims on February 1, 2013. The Department of Justice is representing CMS before the Court.
For at least the next several months, Medicare providers in California, Hawaii, Nevada, and the Pacific territories will continue to file their Medicare claims with the incumbent A/B MAC (Palmetto GBA). CMS will notify affected Medicare providers about the situation, including any implementation dates, following the Court of Federal Claims review.
For at least the next several months, Medicare providers in California, Hawaii, Nevada, and the Pacific territories will continue to file their Medicare claims with the incumbent A/B MAC (Palmetto GBA). CMS will notify affected Medicare providers about the situation, including any implementation dates, following the Court of Federal Claims review.
Primary Care Physician Rate Increase - January 31, 2013
Effective for dates of service from January 1, 2013, through December 31, 2014, Medi-Cal reimbursement to qualifying providers for specified primary care services will be at the same level as Medicare reimbursement for the same services. However, because of questions that remain regarding the final rule released in November 2012, the timing of State Plan approval and changes to the claims processing system, the increased reimbursements will not be immediately available.
The Department of Health Care Services (DHCS) expects implementation to occur during the summer of 2013. The increases will be retroactive and will apply to all services provided from January 1, 2013 through December 31, 2014. It is not necessary for providers to identify eligibility on their claims for the Medicare rate.
DHCS expects that additional guidance will be provided next month regarding implementation in managed care. Managed care plans will not receive additional funding for this increase until the managed care methodology is approved and contracts are amended. Managed care plans are not required to make higher payments to their primary care providers until they receive additional funding from the state.
The rate increase applies to eligible physicians for specified primary care services. Per the final rule released by the Centers for Medicare & Medicaid Services, the applicable primary care services include Evaluation and Management codes 99201 through 99499 and vaccine administration codes 90460, 90461, 90471, 90472 and 90473, or their successor codes. In order to be eligible, physicians must self-attest they are board certified in family medicine, general internal medicine, pediatric medicine, or a related subspecialty. Physicians are also eligible if 60 percent of the services they bill Medi-Cal fall within the designated Evaluation and Management and vaccine administration codes. The increased reimbursement will also be provided to non-physician practitioners who work under the supervision of an eligible physician.
DHCS is developing an online tool for physicians to self-attest their eligibility for the payment increase. DHCS will provide additional bulletins and conduct additional outreach as more information becomes available regarding the increase and the self-attestation process.
Copyright © 2007 State of California
The Department of Health Care Services (DHCS) expects implementation to occur during the summer of 2013. The increases will be retroactive and will apply to all services provided from January 1, 2013 through December 31, 2014. It is not necessary for providers to identify eligibility on their claims for the Medicare rate.
DHCS expects that additional guidance will be provided next month regarding implementation in managed care. Managed care plans will not receive additional funding for this increase until the managed care methodology is approved and contracts are amended. Managed care plans are not required to make higher payments to their primary care providers until they receive additional funding from the state.
The rate increase applies to eligible physicians for specified primary care services. Per the final rule released by the Centers for Medicare & Medicaid Services, the applicable primary care services include Evaluation and Management codes 99201 through 99499 and vaccine administration codes 90460, 90461, 90471, 90472 and 90473, or their successor codes. In order to be eligible, physicians must self-attest they are board certified in family medicine, general internal medicine, pediatric medicine, or a related subspecialty. Physicians are also eligible if 60 percent of the services they bill Medi-Cal fall within the designated Evaluation and Management and vaccine administration codes. The increased reimbursement will also be provided to non-physician practitioners who work under the supervision of an eligible physician.
DHCS is developing an online tool for physicians to self-attest their eligibility for the payment increase. DHCS will provide additional bulletins and conduct additional outreach as more information becomes available regarding the increase and the self-attestation process.
Copyright © 2007 State of California
California’s Duals Demonstration - December 20, 2012
The state Medi-Cal program and the federal Medicare program are partnering to launch a three-year demonstration starting in 2013 that would promote coordinated health care delivery to seniors and people with disabilities who are dually eligible for both of the public health insurance programs, “dual eligible beneficiaries.”
The demonstration aims to improve care coordination for dual eligible beneficiaries to drive high quality care that helps people stay health and in their homes for as long as possible. Additionally, shifting services out of institutional settings and into the home and community will help create a person-centered health care system that is also sustainable.
The demonstration is part of California’s larger Coordinated Care Initiative (CCI). Building on many years of stakeholder discussions, the CCI was enacted in July 2012 through SB 1008 (Chapter 33, Statutes of 2012) and SB 1036 (Chapter 45, Statutes of 2012). Pending federal approval, the CCI will be implemented in 2013 in eight counties: Alameda, San Mateo, Santa Clara, Los Angeles, Orange, San Diego, Riverside and San Bernardino.
Major Parts of the Coordinated Care Initiative
Where would the demonstration take place?Under the state’s proposal , dual eligible beneficiaries who reside in the following eight counties would be able to enroll in new integrated plans: Los Angeles, Orange, San Diego, San Mateo, Alameda, Riverside, San Bernardino, and Santa Clara.
About 530,000 dual eligible beneficiaries in these eight counties would be eligible for the duals demonstration.
When is it proposed to begin?Pending federal approval, the new integrated care models would begin no sooner than June of 2013.
How would services be integrated under the demonstration?In the counties selected for the proposed demonstration, a single integrated health plan will be responsible for delivering all Medicare and Medi-Cal benefits and services, including medical care, long-term care, behavioral health care and social supports that help people live at home. Beneficiaries, their family members and other caregivers will be able to participate in care coordination teams that help ensure delivery of the right services at the right time and place. Strong consumer protections grounded in personal choice and continuity of care will be core to the demonstration’s success. State and federal officials will monitor the demonstration closely to ensure provision of all beneficiary protections. Additionally, the In-Home Supportive Services program would become a managed care benefit, but it would remain an entitlement program and current consumers’ rights would not change.
Will dual eligible beneficiaries living in those counties have to sign up for the demonstration program? No. Beneficiaries can choose to opt out of the demonstration and stay in traditional Medicare or a different Medicare Advantage health plan. Medicare covers most medical services, including doctors and hospitals.
Opting out of the demonstration does not mean people will lose any benefits. Starting in 2013, dual eligible beneficiaries in these eight counties must enroll in a managed care health plan for their Medi-Cal benefits, which include long-term care services and the cost-sharing for Medicare. Enrolling in the same managed care health plan for all Medicare and Medi-Cal benefits will lead to better coordinated care, but beneficiaries may choose to stay in traditional Medicare and enroll in managed care for ONLY their Medi-Cal benefits.
Why is the government proposing changes?Today dual eligible beneficiaries must access services through a complex system of disconnected programs funded by different government offices. This fragmentation often leads to beneficiary confusion, delayed care, inappropriate utilization and unnecessary costs. Integrating all services and financing for dual eligible beneficiaries will promote care coordination and result in improved beneficiary health and lower costs.
San Diego County - County Population: 3 million
Demonstration Eligible Population: 50,952
Demonstration Health Plans: Care 1st, Community Health Group, Health Net and Molina
Under the proposed demonstration, these health plans would be responsible for delivering all Medicare and Medi-Cal benefits and services, including medical care, long-term care, and social supports that help dual eligible beneficiaries maintain their health and live at home as long as possible.
Copyright www.calduals.org
The demonstration aims to improve care coordination for dual eligible beneficiaries to drive high quality care that helps people stay health and in their homes for as long as possible. Additionally, shifting services out of institutional settings and into the home and community will help create a person-centered health care system that is also sustainable.
The demonstration is part of California’s larger Coordinated Care Initiative (CCI). Building on many years of stakeholder discussions, the CCI was enacted in July 2012 through SB 1008 (Chapter 33, Statutes of 2012) and SB 1036 (Chapter 45, Statutes of 2012). Pending federal approval, the CCI will be implemented in 2013 in eight counties: Alameda, San Mateo, Santa Clara, Los Angeles, Orange, San Diego, Riverside and San Bernardino.
Major Parts of the Coordinated Care Initiative
- Duals Demonstration: A voluntary three-year demonstration for dual eligible beneficiaries to receive coordinated medical, behavioral health, long-term institutional, and home-and community-based services through a single organized delivery system. About 530,000 beneficiaries would be eligible for the duals demonstration in the eight counties.
- Managed Medi-Cal Long-Term Supports and Services (LTSS): All Medi-Cal beneficiaries, including dual eligible beneficiaries, required to join a Medi-Cal managed care health plan to receive their Medi-Cal benefits, including LTSS and Medicare wrap-around benefits.
Where would the demonstration take place?Under the state’s proposal , dual eligible beneficiaries who reside in the following eight counties would be able to enroll in new integrated plans: Los Angeles, Orange, San Diego, San Mateo, Alameda, Riverside, San Bernardino, and Santa Clara.
About 530,000 dual eligible beneficiaries in these eight counties would be eligible for the duals demonstration.
When is it proposed to begin?Pending federal approval, the new integrated care models would begin no sooner than June of 2013.
How would services be integrated under the demonstration?In the counties selected for the proposed demonstration, a single integrated health plan will be responsible for delivering all Medicare and Medi-Cal benefits and services, including medical care, long-term care, behavioral health care and social supports that help people live at home. Beneficiaries, their family members and other caregivers will be able to participate in care coordination teams that help ensure delivery of the right services at the right time and place. Strong consumer protections grounded in personal choice and continuity of care will be core to the demonstration’s success. State and federal officials will monitor the demonstration closely to ensure provision of all beneficiary protections. Additionally, the In-Home Supportive Services program would become a managed care benefit, but it would remain an entitlement program and current consumers’ rights would not change.
Will dual eligible beneficiaries living in those counties have to sign up for the demonstration program? No. Beneficiaries can choose to opt out of the demonstration and stay in traditional Medicare or a different Medicare Advantage health plan. Medicare covers most medical services, including doctors and hospitals.
Opting out of the demonstration does not mean people will lose any benefits. Starting in 2013, dual eligible beneficiaries in these eight counties must enroll in a managed care health plan for their Medi-Cal benefits, which include long-term care services and the cost-sharing for Medicare. Enrolling in the same managed care health plan for all Medicare and Medi-Cal benefits will lead to better coordinated care, but beneficiaries may choose to stay in traditional Medicare and enroll in managed care for ONLY their Medi-Cal benefits.
Why is the government proposing changes?Today dual eligible beneficiaries must access services through a complex system of disconnected programs funded by different government offices. This fragmentation often leads to beneficiary confusion, delayed care, inappropriate utilization and unnecessary costs. Integrating all services and financing for dual eligible beneficiaries will promote care coordination and result in improved beneficiary health and lower costs.
San Diego County - County Population: 3 million
Demonstration Eligible Population: 50,952
Demonstration Health Plans: Care 1st, Community Health Group, Health Net and Molina
Under the proposed demonstration, these health plans would be responsible for delivering all Medicare and Medi-Cal benefits and services, including medical care, long-term care, and social supports that help dual eligible beneficiaries maintain their health and live at home as long as possible.
Copyright www.calduals.org
Covered California Health Insurance Exchange - Nov 30, 2012
By: Anthony Brino
Covered California, the state-based health insurance exchange, plans to be financially self-sufficient by 2017 -- a goal all the more pressing in a state with some $617 billion in government debt.
In its financing proposal to the Center for Consumer Information and Insurance Oversight (CCIIO), the Centers for Medicare and Medicaid Services agency in charge of HIXs, Covered California laid out plans for generating revenue through premium fees and participation fees, based on various enrollment estimates. To date, Covered California has received about $230 million in federal funding and is requesting about $700 million more through 2014.
"We can never go to the state general fund," Peter Lee, Covered California’s executive director and a former CMS official, said at a November meeting, as California Healthline reported. "That's in our charter. No state general fund dollars. And the federal money runs out at some point."
The plan includes a mix of premium fees on qualified health plans sold in the exchange, premium fees assessed on the qualified plans sold in the private market, fixed participation fees for insurers, fees for customers, fees for supplemental coverage like dental and vision plans and a participation fee on companies selling other insurance products in the exchange, like life and disability plans.Using market simulation software developed by researchers at University of California Los Angeles and Berkeley, Covered California officials are estimating several scenarios for enrollment, the base estimate, the “enhanced” scenario and a worst case scenario where only a few hundred thousand of California’s 20 million residents buy insurance through the state HIX.In the base estimate, subsidized and unsubsidized enrollment in the exchange is expected to grow from 500,000 to 1.6 million by 2017. Under the enhanced estimate, which the board has set as its target goal, about 2.3 million Californians could buy coverage through the exchange by 2017.
Targeting for the enhanced scenario, Covered California has a $900,000 PR contract with Ogilvy Public Relations Worldwide, and is crafting a robust outreach and marketing campaign aimed at young people, first-time insurance buyers and California's many multicultural communities, including people who speak English as a second language.
If the exchange meets its enhanced enrollment goals, the premium fee would start at 3 percent and drop to 2.5 percent in 2016 and then later to 2 percent. Exchange officials say this would generate about $138 million in revenue in 2014, and would steadily increase each year along with enrollment. Costs during 2014 are estimated at $390 million, covered by both federal grants and premium-generated revenue. In 2015 the costs are estimated to level out at around $315 million. As federal funding ends in 2015, Covered California expects revenue to increase with enrollment to fill the gap. The exchange, under its founding legislation, also must establish a three month cash reserve.
Under the base scenario, the premium fee would start at 3 percent and reach 4 percent in 2015, to compensate for lower enrollment. Under a third “worst case” scenario with enrollment 20 percent lower than the base estimate, the assessment fee would reach 5 percent in 2015. That estimate is extreme and not very likely, exchange officials say. It assumes about 326,000 enrollees in the 2014, compared to the target of 1 million.
Covered California currently has around 70 people on staff, which by 2014 is planned to grow to 293, not including the customer support center, which is estimated to require a staff of about 850.
Covered California, the state-based health insurance exchange, plans to be financially self-sufficient by 2017 -- a goal all the more pressing in a state with some $617 billion in government debt.
In its financing proposal to the Center for Consumer Information and Insurance Oversight (CCIIO), the Centers for Medicare and Medicaid Services agency in charge of HIXs, Covered California laid out plans for generating revenue through premium fees and participation fees, based on various enrollment estimates. To date, Covered California has received about $230 million in federal funding and is requesting about $700 million more through 2014.
"We can never go to the state general fund," Peter Lee, Covered California’s executive director and a former CMS official, said at a November meeting, as California Healthline reported. "That's in our charter. No state general fund dollars. And the federal money runs out at some point."
The plan includes a mix of premium fees on qualified health plans sold in the exchange, premium fees assessed on the qualified plans sold in the private market, fixed participation fees for insurers, fees for customers, fees for supplemental coverage like dental and vision plans and a participation fee on companies selling other insurance products in the exchange, like life and disability plans.Using market simulation software developed by researchers at University of California Los Angeles and Berkeley, Covered California officials are estimating several scenarios for enrollment, the base estimate, the “enhanced” scenario and a worst case scenario where only a few hundred thousand of California’s 20 million residents buy insurance through the state HIX.In the base estimate, subsidized and unsubsidized enrollment in the exchange is expected to grow from 500,000 to 1.6 million by 2017. Under the enhanced estimate, which the board has set as its target goal, about 2.3 million Californians could buy coverage through the exchange by 2017.
Targeting for the enhanced scenario, Covered California has a $900,000 PR contract with Ogilvy Public Relations Worldwide, and is crafting a robust outreach and marketing campaign aimed at young people, first-time insurance buyers and California's many multicultural communities, including people who speak English as a second language.
If the exchange meets its enhanced enrollment goals, the premium fee would start at 3 percent and drop to 2.5 percent in 2016 and then later to 2 percent. Exchange officials say this would generate about $138 million in revenue in 2014, and would steadily increase each year along with enrollment. Costs during 2014 are estimated at $390 million, covered by both federal grants and premium-generated revenue. In 2015 the costs are estimated to level out at around $315 million. As federal funding ends in 2015, Covered California expects revenue to increase with enrollment to fill the gap. The exchange, under its founding legislation, also must establish a three month cash reserve.
Under the base scenario, the premium fee would start at 3 percent and reach 4 percent in 2015, to compensate for lower enrollment. Under a third “worst case” scenario with enrollment 20 percent lower than the base estimate, the assessment fee would reach 5 percent in 2015. That estimate is extreme and not very likely, exchange officials say. It assumes about 326,000 enrollees in the 2014, compared to the target of 1 million.
Covered California currently has around 70 people on staff, which by 2014 is planned to grow to 293, not including the customer support center, which is estimated to require a staff of about 850.
California state exchange beckons 33 insurers - Nov 5, 2012
HIX Digest for the week of November 5, 2012
Covered California, the newly branded state exchange, is taking applications from insurers to sell plans next fall, and so far, 33 have said they’re interested in bidding to sell plans in the HIX's 19 regional markets.
California health officials, as the LA Times put it, are “eager to flex their purchasing power under the federal healthcare law by selecting only certain individual and small business health plans” in certain markets.
Cover California executive director Peter Lee, a former director of delivery system reform at HHS, told the LA Times that competition for the slots “will enable the exchange to be an active purchaser in every region and pick the best five or six plans."
Kaiser Permanente, Anthem Blue Cross, Blue Shield of California and Health Net Inc, California's four largest insurers in the individual market, have expressed interest in bidding, and the winning health plans are expected to be announced by June.
Patrick Johnston, from the California Association of Health Plans, told the LA Times that the trade group is emphasizing “that affordability matters most" in talks with state exchange regulators.
Covered California, the newly branded state exchange, is taking applications from insurers to sell plans next fall, and so far, 33 have said they’re interested in bidding to sell plans in the HIX's 19 regional markets.
California health officials, as the LA Times put it, are “eager to flex their purchasing power under the federal healthcare law by selecting only certain individual and small business health plans” in certain markets.
Cover California executive director Peter Lee, a former director of delivery system reform at HHS, told the LA Times that competition for the slots “will enable the exchange to be an active purchaser in every region and pick the best five or six plans."
Kaiser Permanente, Anthem Blue Cross, Blue Shield of California and Health Net Inc, California's four largest insurers in the individual market, have expressed interest in bidding, and the winning health plans are expected to be announced by June.
Patrick Johnston, from the California Association of Health Plans, told the LA Times that the trade group is emphasizing “that affordability matters most" in talks with state exchange regulators.
Final rule equalizes Medicaid payment rates for primary care physicians - Nov 1, 2012
On November 1, CMS announced the final rule for the Medicaid Payment Equalization policy enacted as part of the Patient Protection and Affordable Care Act (PPACA). As mandated by the PPACA, Medicaid payments to primary care providers for primary care services, will, for both 2013 and 2014 be “equalized” to the Medicare payment level. The rule announced on
November 1 will provide the necessary direction to the states on how they are to implement this new policy.
Beginning January 1, 2013, all states are mandated to increase their Medicaid payment rates for primary care services so that they are at least equal to the Medicare payment rates for similar services. The federal government will fully cover the cost of these higher payments for both 2013 and 2014. This means that for the differential between what the state would have paid and what it would take to raise those payments to the Medicare level, the FMAP will be 100%.
How Medicaid pay parity will work
Eligible physicians who provide certain primary care services under Medicaid will be paid at Medicare rates for two years for those services.
November 1 will provide the necessary direction to the states on how they are to implement this new policy.
Beginning January 1, 2013, all states are mandated to increase their Medicaid payment rates for primary care services so that they are at least equal to the Medicare payment rates for similar services. The federal government will fully cover the cost of these higher payments for both 2013 and 2014. This means that for the differential between what the state would have paid and what it would take to raise those payments to the Medicare level, the FMAP will be 100%.
How Medicaid pay parity will work
Eligible physicians who provide certain primary care services under Medicaid will be paid at Medicare rates for two years for those services.
- Eligible physicians must have a specialty designation of family medicine, general internal medicine, pediatrics or a related subspecialty.
- At least 60% of codes eligible physicians submit to Medicaid in 2012 must be for primary care services, or the physicians must be board certified in their specialties.
- Midlevel practitioners, such as physician assistants, may be eligible for the enhanced payments, provided they are supervised by physicians who also qualify for the increase.
- States will receive 100% federal funding for the difference between the Medicaid state plan payment amount for selected evaluation and management services as of July 1, 2009, and the Medicare rates in effect for calendar years 2013 and 2014.
- The Medicaid payment ceiling for children’s vaccine administration will be raised.
- The increases will not apply to federally qualified health centers and rural health clinics.
- The estimated federal cost of the pay boosts is $5.5 billion a year for each of the two years.
Outpatient Mental Health Treatment Limitation - Oct 23, 2012
The Centers for Medicare & Medicaid Services (CMS) is phasing out the outpatient mental health treatment limitation (the limitation) over a 5-year period, from 2010-2014. Effective January 1, 2014, Medicare will pay outpatient mental health services at the same rate as other Part B services, that is, at 80 percent of the physician fee schedule.
Section 102 of MIPPA requires that the current 62.5 percent outpatient mental health treatment limitation (effective since the inception of the Medicare program until December 31, 2009) will be reduced as follows:
Section 102 of MIPPA requires that the current 62.5 percent outpatient mental health treatment limitation (effective since the inception of the Medicare program until December 31, 2009) will be reduced as follows:
- January 1, 2010 – December 31, 2011, the limitation percentage is 68.75 percent (of which Medicare pays 55 percent and the patient pays 45 percent);
- January 1, 2012 – December 31, 2012, the limitation percentage is 75 percent (of which Medicare pays 60 percent and the patient pays 40 percent);
- January 1, 2013 – December 31, 2013, the limitation percentage is 81.25 percent (of which Medicare pays 65 percent and the patient pays 35 percent);
- January 1, 2014 – onward, the limitation percentage is 100 percent, at which time Medicare pays 80 percent and the patient pays 20 percent
From the APA - Oct 16, 2012
The American Psychiatric Association is aware that some psychiatrists have contracts with payers that limit the codes they will be reimbursed for to those in the Psychiatry section of CPT. We will be doing outreach to major payers to ensure that they are aware the codes are changing and will be making the necessary accommodations so there will not be a hold-up with reimbursement when the new codes go into effect.
Practical Steps -The one specific we are able to provide about the changes is that code 90862, pharmacologic management, will no longer exist in 2013. Even now, it is appropriate to use a medical evaluation and management (E/M) code (i.e., 99212 or 99213) in place of 90862.)
Start familiarizing yourself with E/M codes for medication management and other patient encounters that are not primarily for psychotherapy. Unlike the psychotherapy codes, which are almost all timed codes, E/M codes are generally chosen based on the complexity of the presenting problem, the intensity of the examination required, and the difficulty of the medical decision making involved (as well as the setting where the service takes place and whether the patient is new or established). There are, however, typical times attached to the codes, and coding can be based on time if more than half of the patient encounter was spent in counseling the patient and providing coordination of care.
The Centers for Medicare and Medicaid Services (CMS) has a well written guide to E/M coding available on its website along with two sets of documentation guidelines for E/M coding – one from 1995 and the other from 1997. These guidelines are used by most payers when auditing E/M coding. The 1997 guidelines are the most appropriate ones for psychiatrists to use since they include a single-system psychiatric exam. We have posted an abridged version of the 1997 documentation guidelines (scroll to CMS Resources) on the APA website that just contains the information relevant to psychiatrists. The APA also has an online CME course that provides an introduction to E/M coding atwww.apaeducation.org.
Contracts - You should review any contracts you have with insurers to see if they limit you to the current codes in the Psychiatry section of CPT (most of which will no longer exist in 2013). The APA will be contacting the major payers to alert them to the code changes, but it would also make sense for you to contact them to inquire about what will be done to revise the contract to accommodate the coding changes. Under HIPAA (the Health Insurance Portability and Accountability Act) all insurers are required to use the current CPT codes, which means they will be required to use the new coding schema and will need to update any contracts to take into account the new codes that psychiatrists will be using and also to ensure that psychiatrists will be reimbursed for providing evaluation and management services as the Parity Act requires.
Conclusion - Since there may only be three months between when the new psychiatry CPT codes are made public and when they will go into effect, it’s good to be doing everything you can to prepare for the changes now. Keep watching the APA website for new information and contact the Practice Management HelpLine—800.343.4671, hsf@psych.org —if you have any questions.
© 2012 American Psychiatric Association. All Rights Reserved.
Practical Steps -The one specific we are able to provide about the changes is that code 90862, pharmacologic management, will no longer exist in 2013. Even now, it is appropriate to use a medical evaluation and management (E/M) code (i.e., 99212 or 99213) in place of 90862.)
Start familiarizing yourself with E/M codes for medication management and other patient encounters that are not primarily for psychotherapy. Unlike the psychotherapy codes, which are almost all timed codes, E/M codes are generally chosen based on the complexity of the presenting problem, the intensity of the examination required, and the difficulty of the medical decision making involved (as well as the setting where the service takes place and whether the patient is new or established). There are, however, typical times attached to the codes, and coding can be based on time if more than half of the patient encounter was spent in counseling the patient and providing coordination of care.
The Centers for Medicare and Medicaid Services (CMS) has a well written guide to E/M coding available on its website along with two sets of documentation guidelines for E/M coding – one from 1995 and the other from 1997. These guidelines are used by most payers when auditing E/M coding. The 1997 guidelines are the most appropriate ones for psychiatrists to use since they include a single-system psychiatric exam. We have posted an abridged version of the 1997 documentation guidelines (scroll to CMS Resources) on the APA website that just contains the information relevant to psychiatrists. The APA also has an online CME course that provides an introduction to E/M coding atwww.apaeducation.org.
Contracts - You should review any contracts you have with insurers to see if they limit you to the current codes in the Psychiatry section of CPT (most of which will no longer exist in 2013). The APA will be contacting the major payers to alert them to the code changes, but it would also make sense for you to contact them to inquire about what will be done to revise the contract to accommodate the coding changes. Under HIPAA (the Health Insurance Portability and Accountability Act) all insurers are required to use the current CPT codes, which means they will be required to use the new coding schema and will need to update any contracts to take into account the new codes that psychiatrists will be using and also to ensure that psychiatrists will be reimbursed for providing evaluation and management services as the Parity Act requires.
Conclusion - Since there may only be three months between when the new psychiatry CPT codes are made public and when they will go into effect, it’s good to be doing everything you can to prepare for the changes now. Keep watching the APA website for new information and contact the Practice Management HelpLine—800.343.4671, hsf@psych.org —if you have any questions.
© 2012 American Psychiatric Association. All Rights Reserved.
New Psych Codes - Oct 8, 2012
The new CPT Books for 2013 are here!! And with them are some significant changes for Psych......see below a brief overview of the old and new codes we will be using.......We will be doing a lot of tweaking over the next 3 months to get ready for the new codes..hang in there, breathe and remember, change is good!
Answers to your questions about the 2013 psychotherapy codes from Practice Central:
What are the new psychotherapy code numbers for 2013?
The codes most critical to psychologists who provide mental health services involve diagnostic and psychotherapeutic procedures. For individual psychotherapy, there will no longer be separate codes for outpatient and inpatient settings.
All individual psychotherapy will be captured through one of three new codes. The three new codes for 2013 are:
What if a session is shorter or longer than the time specified in the code? According to the 2013 CPT manual, psychotherapy times are for face-to-face services with the patient and/or family member, with the patient present for some or all of the service. Although the time for each code is specific, the manual allows for some flexibility. When reporting a psychotherapy service, the provider may choose the code closest to the actual time of the session. The examples provided in the manual are 16-37 minutes for code 90832, 38-52 minutes for 90834 and 53 minutes or more for 90837.
I now provide services for 75 to 80 minutes under code 90808. What happens in 2013? Mental health providers who now use code 90808 will be unable to do so effective Jan. 1, 2013, when 90808 is eliminated. Medicare’s utilization data guiding the psychotherapy codes revision process indicated that the 75 to 80 minute codes were rarely used. Psychologists who conduct sessions that require 75 minutes or longer may continue to do so using the new 90837 code but will not see an increase in payment for the additional time beyond 60 minutes. Reimbursement will be limited to whatever payment amount is applied by Medicare or a private insurance carrier to code 90837.
What are the payment rates for the new codes? The Medicare payment rates associated with the new codes are expected to be released in November when the Centers for Medicare and Medicaid Services (CMS) publishes the final Medicare fee schedule for 2013. We will inform members as soon as we have this payment information from CMS.
Commercial insurance carriers typically follow Medicare’s lead in determining payment amounts in the private insurance market. You may want to check with any such carriers with which you are involved about their psychotherapy payment rates for 2013.
What was psychology’s role in the psychotherapy codes review process? Revisions to the family of psychotherapy codes for 2013 resulted from the Five Year Review process required of the Centers for Medicare and Medicaid Services (CMS). The national associations representing psychology, psychiatry, social work and nursing participated in a confidential and proprietary process overseen by the American Medical Association (AMA) as part of the Five Year Review process.
Current Procedural Terminology® (CPT) copyright 2011 American Medical Association. All rights reserved.
Copyright © 1992-2012 Psych Central. All rights reserved.
Answers to your questions about the 2013 psychotherapy codes from Practice Central:
What are the new psychotherapy code numbers for 2013?
The codes most critical to psychologists who provide mental health services involve diagnostic and psychotherapeutic procedures. For individual psychotherapy, there will no longer be separate codes for outpatient and inpatient settings.
All individual psychotherapy will be captured through one of three new codes. The three new codes for 2013 are:
- 90832 Psychotherapy, 30 minutes with patient and/or family member
- 90834 Psychotherapy, 45 minutes with patient and/or family member
- 90837 Psychotherapy, 60 minutes with patient and/or family member
What if a session is shorter or longer than the time specified in the code? According to the 2013 CPT manual, psychotherapy times are for face-to-face services with the patient and/or family member, with the patient present for some or all of the service. Although the time for each code is specific, the manual allows for some flexibility. When reporting a psychotherapy service, the provider may choose the code closest to the actual time of the session. The examples provided in the manual are 16-37 minutes for code 90832, 38-52 minutes for 90834 and 53 minutes or more for 90837.
I now provide services for 75 to 80 minutes under code 90808. What happens in 2013? Mental health providers who now use code 90808 will be unable to do so effective Jan. 1, 2013, when 90808 is eliminated. Medicare’s utilization data guiding the psychotherapy codes revision process indicated that the 75 to 80 minute codes were rarely used. Psychologists who conduct sessions that require 75 minutes or longer may continue to do so using the new 90837 code but will not see an increase in payment for the additional time beyond 60 minutes. Reimbursement will be limited to whatever payment amount is applied by Medicare or a private insurance carrier to code 90837.
What are the payment rates for the new codes? The Medicare payment rates associated with the new codes are expected to be released in November when the Centers for Medicare and Medicaid Services (CMS) publishes the final Medicare fee schedule for 2013. We will inform members as soon as we have this payment information from CMS.
Commercial insurance carriers typically follow Medicare’s lead in determining payment amounts in the private insurance market. You may want to check with any such carriers with which you are involved about their psychotherapy payment rates for 2013.
What was psychology’s role in the psychotherapy codes review process? Revisions to the family of psychotherapy codes for 2013 resulted from the Five Year Review process required of the Centers for Medicare and Medicaid Services (CMS). The national associations representing psychology, psychiatry, social work and nursing participated in a confidential and proprietary process overseen by the American Medical Association (AMA) as part of the Five Year Review process.
Current Procedural Terminology® (CPT) copyright 2011 American Medical Association. All rights reserved.
Copyright © 1992-2012 Psych Central. All rights reserved.
Medi-Caid Parity-Sept 24, 2012
Good news below about Medicaid parity beginning January 1, 2013......We will have to wait and see if the rule takes effect and how the Medicare rates change?? Stay Tuned...................How Medicaid pay parity will workEligible physicians who provide certain primary care services under Medicaid will be paid at Medicare rates for two years for those services.
Physician organizations and other health care experts hailed the provision as a breakthrough in the effort to recognize the importance of primary care medicine in improving the health system. Assuming that the law is not invalidated by the U.S. Supreme Court, the federal government is expected to finalize the rule later this year.
This proposed rule would implement new requirements in sections 1902(a)(13), 1902(jj), 1932(f), and 1905(dd) of the Social Security Act, as amended by the Patient Protection and Affordable Care Act of 2010 (theAffordable Care Act). It implements Medicaid payment for primary care services furnished by certain physicians in calendar years (CYs) 2013 and 2014 at rates not less than the Medicare rates in effect in those CYs or, if greater, the payment rates that would be applicable in those CYs using the CY 2009 Medicare physician fee schedule conversion factor (CF). This minimum payment level applies to specified primary care services furnished by a physician with a specialty designation of family medicine, general internal medicine, or pediatric medicine, and also applies to services paid through Medicaid managed care plans. It would also provide for a 100 percent Federal matching rate for any increase in payment above the amounts that would be due for these services under the provisions of the State plan as of July 1, 2009. In this proposed rule, we specify which services and types of physicians qualify for the minimum payment level in CYs 2013 and 2014, and the method for calculating the payment amount and any increase for which increased Federal funding is due.
- Eligible physicians must have a specialty designation of family medicine, general internal medicine, pediatrics or a related subspecialty.
- At least 60% of codes eligible physicians submit to Medicaid in 2012 must be for primary care services, or the physicians must be board-certified in their specialties.
- States will receive 100% federal funding for the difference between the Medicaid state plan payment amount for selected evaluation and management services as of July 1, 2009, and the Medicare rates in effect for calendar years 2013 and 2014.
- The Medicaid payment ceiling for children’s vaccine administration will be raised.
- The increases will not apply to federally qualified health centers and rural health clinics.
- The estimated federal cost of the pay boosts is approximately $5.5 billion a year for each of the two years.
Physician organizations and other health care experts hailed the provision as a breakthrough in the effort to recognize the importance of primary care medicine in improving the health system. Assuming that the law is not invalidated by the U.S. Supreme Court, the federal government is expected to finalize the rule later this year.
This proposed rule would implement new requirements in sections 1902(a)(13), 1902(jj), 1932(f), and 1905(dd) of the Social Security Act, as amended by the Patient Protection and Affordable Care Act of 2010 (theAffordable Care Act). It implements Medicaid payment for primary care services furnished by certain physicians in calendar years (CYs) 2013 and 2014 at rates not less than the Medicare rates in effect in those CYs or, if greater, the payment rates that would be applicable in those CYs using the CY 2009 Medicare physician fee schedule conversion factor (CF). This minimum payment level applies to specified primary care services furnished by a physician with a specialty designation of family medicine, general internal medicine, or pediatric medicine, and also applies to services paid through Medicaid managed care plans. It would also provide for a 100 percent Federal matching rate for any increase in payment above the amounts that would be due for these services under the provisions of the State plan as of July 1, 2009. In this proposed rule, we specify which services and types of physicians qualify for the minimum payment level in CYs 2013 and 2014, and the method for calculating the payment amount and any increase for which increased Federal funding is due.
Southern CA Audits - Sept 21, 2012
There was an audit done recently in Southern California on the use of code 99214 and the results are surprising...........please take a look at the reasons for the denials? Those would be true for any audit that they may do and what your records need to have in them to get paid and approved. Good reminders..............
http://www.palmettogba.com/palmetto/providers.nsf/ls/J1B~8XPN9T2480?opendocument&utm_source=J1BL&utm_campaign=J1BLs&utm_medium=email#ps11
http://www.palmettogba.com/palmetto/providers.nsf/ls/J1B~8XPN9T2480?opendocument&utm_source=J1BL&utm_campaign=J1BLs&utm_medium=email#ps11
Palmetto Loses Medicare Contract - Sept 20, 2012
On September 20, 2012, CMS made a contract award for the Jurisdiction E A/B MAC contract to Noridian Administrative Services. The Jurisdiction E A/B MAC administers Medicare Part A and Part B claims for covered services in the California, Hawaii, and Nevada, as well as the U.S. territories of American Samoa, Guam, and the Northern Mariana Islands. The current A/B MAC for this geographic area, Palmetto GBA, will continue to administer provider claims for up to six months as CMS oversees the transfer of these Medicare contract responsibilities to Noridian Administrative Services. It is not yet clear whether Palmetto GBA plans to appeal the decision. If there is an appeal, the earliest the handover could take place would be mid-to-late 2014. For more information about the Jurisdiction E award, use the following hyperlink: Jurisdiction E Award Fact Sheet
Acronyms of Audits - August 6, 2012
August 6, 2012
To: HBMA Membership
From: HBMA GR Committee
Re: CMS Announces Provider Compliance Interactive Map
On August 1, CMS released the Provider Compliance Interactive Map, a new tool for providers, billing companies and others. The purpose of the map and new webpage is to give information on the following Contractors:
Payment Error Rate Measurement (PERM)
Comprehensive Error Rate Testing (CERT)
Medicare Recovery Audit Operations (RACs), and
Medicare Administrative Contractor (MACs)
In addition, the map and website contains contact information for various state organizations; emails and websites for the different organizations within the state; as well as information on other U.S. territories.
The Interactive Map webpage applies to all 50 states as well as U.S. territories Puerto Rico, Virgin Islands, Guam, Northern Mariana Island, and American Samoa. The webpage features benefits that allow not only physicians and billing companies to gather information about CMS but beneficiaries as well. The Interactive Map should assist you in identifying who to contact with questions or concerns about Medicare and Medicaid services. The Interactive Map includes telephone numbers and email addresses to several key organizations.
If you have any questions about the Interactive Map, you can submit questions to CMS.
Copyright 2012 HBMA. All Rights Reserved.
Medicaid Managed Care Plans - June 27, 2012
Interesting article on the Medi-Cal Managed Care plans...............
http://www.ama-assn.org/amednews/2012/06/25/bisb0625.htm
http://www.ama-assn.org/amednews/2012/06/25/bisb0625.htm
What's new with Healthcare Reform? - June 1, 2012
What's Next with Healthcare Reform? By Mike Farmer
The Patient Protection and Affordable Care Act (PPACA) is just over two years old now. Its future may or may not be in jeopardy, but for now it is the law. So far we have seen expanded eligibility for children on the parents' policies, a health insurance credit for employers, and a few other changes. We have also seen some parts of the bill – like the changes to 1099 reporting, W-2 reporting, and long-term care insurance – thrown out. The changes for 2012 to 2014 are where the biggest impacts will be felt. Below are some of the upcoming items that may affect you and your business.
2012
2014
The Patient Protection and Affordable Care Act (PPACA) is just over two years old now. Its future may or may not be in jeopardy, but for now it is the law. So far we have seen expanded eligibility for children on the parents' policies, a health insurance credit for employers, and a few other changes. We have also seen some parts of the bill – like the changes to 1099 reporting, W-2 reporting, and long-term care insurance – thrown out. The changes for 2012 to 2014 are where the biggest impacts will be felt. Below are some of the upcoming items that may affect you and your business.
2012
- Financial incentives will be paid to hospitals that improve quality of care.
- Fraud and Abuse Prevention – a new procedure for the screening and oversight of providers and suppliers participating in Medicare, Medicaid, and the Children's Health Insurance Program (CHIP). This will be subsidized by a $505 fee for providers updating their information with Medicare.
- The Medicare bundled payment pilot program will begin. This program will change the reimbursement method to payment on an episodic basis. Payments for acute, inpatient hospital services; physician services; outpatient hospital services; and post-acute services will be bundled together and paid to the hospital. The hospital will be responsible for splitting up the payments.
- Medicaid reimbursements will be increased. Medicaid payments for primary care services will increase to 100% of the Medicare payment rate for 2013 and 2014. The states will be reimbursed for 100% of the difference.
- The threshold for claiming itemized deductions of medical expenses on federal taxes will increase from 7.5% to 10%. Most people do not qualify for this deduction as it stands, so this will not affect many people.
- Limits on the medical portion of flexible spending accounts will increase to $2,500 per year.
2014
- U.S. citizens and legal residents will be required to have health insurance. This is one of the issues the Supreme Court will rule on this summer.
- Businesses with more than 50 employees will be charged a $2,000 penalty per employee if they do not offer affordable health insurance. Employers with fewer than 50 employees will be exempt from the penalty.
- State-based health insurance exchanges will be developed. This will give individuals and small employers (up to 100 employees) a place to apply for and purchase health insurance.
- Health insurance premium subsidies will be established for families with incomes between 133% and 400% of the federal poverty level in order to facilitate the purchase of insurance through the exchanges. There will also be a cost sharing subsidy for those with incomes of up to 250% of the poverty level.
- Availability of insurance will be guaranteed. Insurance companies will no longer be able to deny coverage based on health status. This part of the bill is essential for people with pre-existing conditions who are currently denied insurance coverage. Insurance companies rate a pool of people against possible loss, and actuaries have become quite accurate at estimating the costs involved. As a result, a group of people who will most likely utilize more healthcare resources will enter the insurance market, increasing some costs to insurance companies. The insurance companies have been preparing for this increase in cost by raising their premiums over the last several years.
- There will be no annual limits on benefits paid. This will benefit people who are undergoing expensive treatments relative to the general population. For the rest of us, it will increase our costs.
- Medicaid coverage will be expanded. Medicaid will be expanded to all individuals not eligible for Medicare under age 65 with incomes of up to 133% of the federal poverty level. This is the other area the Supreme Court will rule on this summer.
- Businesses with fewer than 25 full-time employees with annual average salaries below $50,000 will be eligible for a credit of up to 35% of the premiums paid. In 2014 the credit will increase to 50%.
PECOS Update - April 10, 2012
Last week, Timna, our credentialing specialist, attended a Medicare Webinar on the PECOS System (Provider Enrollment Chain and Ownership System). This is what we will use for provider enrollment going forward as it can cut the time in half! Below are her notes:
Finally Medicare is listening to the Provider Community. They realized that the Medicare enrollment process has left many providers feeling overwhelmed and frustrated! Here are a few highlights that should help to ease this burden using PECOS to enroll:
1) PECOS is now 100% electronic. Once you complete an application online thru PECOS, you no longer have to mail your signature page to Medicare. You can e-sign and upload any supporting documents required. Medicare is hoping this will encourage providers to manage their Medicare enrollments online instead of submitting paper.
2) PECOS should shorten the enrollment wating time. This is a huge concern for providers. By making the enrollment completely electronic this can shorten the enrollment time by 15-20 days.
3) PECOS has become more user friendly. If you need to revalidate your information with Medicare you can use the Fast Track feature. This allows you to see all your enrollment data on one screen and revalidate your information in just a few clicks.
4) Providers will be able to sign up for EFT's online.
5) In the fall of 2012, Providers will be able to assign someone else to have access to the PECOS account and complete applications on their behalf.
Hopefully, PECOS will evolve into all that Medicare promises!
Finally Medicare is listening to the Provider Community. They realized that the Medicare enrollment process has left many providers feeling overwhelmed and frustrated! Here are a few highlights that should help to ease this burden using PECOS to enroll:
1) PECOS is now 100% electronic. Once you complete an application online thru PECOS, you no longer have to mail your signature page to Medicare. You can e-sign and upload any supporting documents required. Medicare is hoping this will encourage providers to manage their Medicare enrollments online instead of submitting paper.
2) PECOS should shorten the enrollment wating time. This is a huge concern for providers. By making the enrollment completely electronic this can shorten the enrollment time by 15-20 days.
3) PECOS has become more user friendly. If you need to revalidate your information with Medicare you can use the Fast Track feature. This allows you to see all your enrollment data on one screen and revalidate your information in just a few clicks.
4) Providers will be able to sign up for EFT's online.
5) In the fall of 2012, Providers will be able to assign someone else to have access to the PECOS account and complete applications on their behalf.
Hopefully, PECOS will evolve into all that Medicare promises!
E-Prescribing Reporting - March 29, 2012
It is that time again to either report E-Rx codes with your patient visits or to file an exemption to avoid the penalty next year. If you are going to report, do it early, their deadline is very strict. In order to receive incentive payments for ePrescribing in 2012, eligible physicians must report the ePrescribing G-code, G8553, at least 25 times for Medicare office visits, as well as the other listed services for the calendar year for applicable CPT codes included in the CMS ePrescribing measure specifications, on Medicare Part B claim forms. The reporting period for the 2012 ePrescribing incentive program will be for the entire 2012 calendar year (January 1, 2012, through December 31, 2012).
To avoid penalties in 2013, an eligible physician needs to report the ePrescribing G-code, G8553, at least 10 times for Medicare office visits or services for the January 1, 2012 through June 30, 2012 reporting period on your Medicare Part B claim forms. For eligible physicians and group practices using the claims-based reporting mechanism, all claims for services furnished between January 1, 2012, and June 30, 2012 needed to be received and processed by CMS no later than one month after the reporting period.
Calendar year of ePrescribing Incentive amount Penalty amount
2012 Incentive 1.0% Penalty-1.0%
2013 Incentive 0.5% Penalty-1.5%
2014 Incentive — Penalty-2.0%
To avoid penalties in 2013, an eligible physician needs to report the ePrescribing G-code, G8553, at least 10 times for Medicare office visits or services for the January 1, 2012 through June 30, 2012 reporting period on your Medicare Part B claim forms. For eligible physicians and group practices using the claims-based reporting mechanism, all claims for services furnished between January 1, 2012, and June 30, 2012 needed to be received and processed by CMS no later than one month after the reporting period.
Calendar year of ePrescribing Incentive amount Penalty amount
2012 Incentive 1.0% Penalty-1.0%
2013 Incentive 0.5% Penalty-1.5%
2014 Incentive — Penalty-2.0%
Tricare contract going to United Health - March 16, 2012
March 16, 2012 - TriWest has just been informed by the Department of Defense that we have not been selected to provide access to health care to America's heroes in the TRICARE West region, and that their intention is to instead have United Health perform the work. This news is extremely disappointing to all of us at TriWest, who for the past 16 years have worked tirelessly and with the highest levels of respect to meet the healthcare needs of West Region military families who have very much become our family.
Despite this news, we have a commitment to West Region families to continue serving them through March 31, 2013, as April 1, 2013 is the date on which the work will transition, with the same fervor and dedication as we have since we opened our doors to TRICARE-a job we couldn't have done as well as we have without the tremendous work by to deliver the best care for West Region families.
The procurement for this contract has been a long and arduous process, running nearly four years. We are extremely disappointed by the Department of Defense's announcement. Consistent with federal regulations, TriWest expects to learn more about the government's decision in an upcoming debriefing in an effort to determine the substance of their decision to award this work to United Healthcare. From this information, we will be deciding our future course of action.
Since winning the first TRICARE contract to manage the 16-state Central Region in 1996, and again successfully securing the expanded West Region contract eight years later, as the only incumbent to initially win a T-3 contract, we believe our performance has been exemplary. We have provided exemplary customer service, innovation and value to the taxpayer in delivering on the promise of TRICARE for the 2.9 million beneficiaries we have been privileged to serve throughout the geographically challenging 21-state service area. And, you as a provider have been a big part of making that possible. For that, we thank you for the healthcare services you have provided to those whom we have been honored and privileged to count as our customers.
In the meantime, rest assured that we will continue to provide the high standard of service that we've always delivered for the TRICARE beneficiaries of the West Region.
Copyright 2012 © - TriWest Healthcare Alliance
Despite this news, we have a commitment to West Region families to continue serving them through March 31, 2013, as April 1, 2013 is the date on which the work will transition, with the same fervor and dedication as we have since we opened our doors to TRICARE-a job we couldn't have done as well as we have without the tremendous work by to deliver the best care for West Region families.
The procurement for this contract has been a long and arduous process, running nearly four years. We are extremely disappointed by the Department of Defense's announcement. Consistent with federal regulations, TriWest expects to learn more about the government's decision in an upcoming debriefing in an effort to determine the substance of their decision to award this work to United Healthcare. From this information, we will be deciding our future course of action.
Since winning the first TRICARE contract to manage the 16-state Central Region in 1996, and again successfully securing the expanded West Region contract eight years later, as the only incumbent to initially win a T-3 contract, we believe our performance has been exemplary. We have provided exemplary customer service, innovation and value to the taxpayer in delivering on the promise of TRICARE for the 2.9 million beneficiaries we have been privileged to serve throughout the geographically challenging 21-state service area. And, you as a provider have been a big part of making that possible. For that, we thank you for the healthcare services you have provided to those whom we have been honored and privileged to count as our customers.
In the meantime, rest assured that we will continue to provide the high standard of service that we've always delivered for the TRICARE beneficiaries of the West Region.
Copyright 2012 © - TriWest Healthcare Alliance
Advanced Pacific Medical, LLC
Toll Free (866) 284-2771
Fax (800) 334-1041
Toll Free (866) 284-2771
Fax (800) 334-1041