BILLING UPDATES – JANUARY 2017

By Tammy Bartlett, Billing Manager

IRS INSURANCE COMPANY PAYMENT SUMMARY

PF will aggregate your IRS Form 1099’s through February 17th.  These forms (1099-Misc) represent all of the payments made to you during calendar year 2016.  The IRS matches the aggregate of all 1099’s to the appropriate line of your entity’s tax return, to make sure recipients properly report their income.  In addition, any interest paid on claims is separately reportable on IRS Form 1099-Int.  This information is also matched and it is critical to properly report this income on the correct line of your tax return to avoid IRS scrutiny for under reporting income.

By law, insurance carriers are required to mail them by January 31st.  However, our past experience indicates that they do not comply with the due date and therefore they are not all generally received until the third week in February.  At that time, we will send them to you by mail or through our courier service. If you have any questions, please feel free to contact us.

UNIVERA – IMPORTANT UPDATE REGARDING PRODUCTS

Univera Healthcare will offer Medicaid Managed Care, Child Health Plus and Health and Recovery Plan (HARP) to Erie County residents beginning in the summer of 2017, pending approval by the New York State Department of Health.

Per Univera, you will have an opportunity to provide services for these product lines under your existing Participating Provider Agreement. The reimbursement schedule will be available on the secure portion of their website on or around February 1, 2017 at: UniveraHealthcare.com/Provider

Univera will provide further administrative details and other important information prior to the date when these products will be offered in Erie County. Please direct questions to your Provider Relations representative directly, or call the Provider Relations department at 716-857-4647.

For Billing questions, please contact Tammy Bartlett at 716-348-3923 or tammyb@pracfirst.com

 

BILLING UPDATES – NOVEMBER 2016

By Tammy Bartlett, Billing Manager

CENTERS FOR MEDICARE AND MEDICAID (CMS)

PQRS PAYMENT ADJUSTMENTS

We have received numerous letters from CMS for our clients that indicate PQRS criteria has not been met and  payment adjustments will occur, reducing Medicare payments by 2% for 2017 dates of service. The payment adjustments are based on services rendered in 2015. We will forward the letters to the applicable clients, as we receive them.

If you received a letter from CMS regarding reduction in payments and believe you have been incorrectly assessed, please review the payment adjustment resources located on the PQRS webpage at:

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Payment-Adjustment-Information.html

As mentioned in previous communications with our providers, Practicefirst recommended to report via a PQRS Qualified Registry.  By utilizing a registry, providers become eligible for measures group reporting, thus decreasing the required number of patients to report on.

As a reminder, due to the increasing requirements of PQRS reporting, Practicefirst no longer provides PQRS reporting services to providers at a reasonable cost.

MVP

MVP issued FASTFAX #50W on October 20, 2016 to the provider community regarding Preventive Visits and Modifier 25. Preventive visits (codes 99381-99397) are payable on the same date of service as a separately identifiable E&M service (i.e. 99213). The E&M would be submitted with modifier 25. The additional services for the E&M must be documented in the medical record and the claim should include both the preventive visit diagnosis code(s) and the relevant condition diagnosis code(s).

If the preventive code is not billed, the visit will not count for the preventive service quality measures (well child, adolescent and adult measures).

For additional information, please visit MVP’s website at http://www.mvphealthcare.com/provider/provider-resource-manual.html, select Section 15 for Payment Policies and then select the Modifier Policy from their bookmarks.

For Billing questions, please contact Tammy Bartlett at 716-348-3923 or tammyb@pracfirst.com

BILLING UPDATES – OCTOBER 2016

BLUE CROSS

Last month, our client memo indicated the new partnership between Blue Cross and Amerigroup for Medicaid Managed Care (MMC) and Child Health Plus (CHP) members. Blue Cross has indicated that the effective date has been delayed until November 1, 2016.

MEDICAID NEWS

On September 29th, the NYS Dept. of Health notified the provider community that NYS has redesigned the Common Benefit Identification Card for Medicaid beneficiaries. Cards with the new design will begin statewide in late September. An image of the new card is reflected below.

There will be no mass replacement of existing cards as a result of the new card design. Existing cards will remain active throughout the transition period.

Additional information on the new card design is located at:  www.otda.ny.gov/workingfamilies/ebt.asp

mEDICAID

HEALTH REPUBLIC UPDATE

As a first step in the claims adjudication process, a third party will conduct an independent audit of the existing inventory of policy claims. Based on the audit results, Explanation of Benefits (EOB’s) will be issued for each policy claim to providers.

The EOB’s will advise providers of the amounts of their respective claims against the estate and their rights. It is anticipated that EOB’s will begin to be mailed to providers in the first quarter of 2017.

If a provider accepts the EOB, they are not required to take any further action. If a Provider disagrees with the EOB, they will have the opportunity to appeal the determination through Health Republic’s website or by paper to the address indicated in the Claims Adjudication Procedure.

The written appeal and supporting documentation must be submitted within 60 days of the date of mailing of the EOB. The Liquidator will review each appeal and, within 60 days, either grant the appeal and issue a revised EOB or deny the appeal and provide the reasons for the denial.

It is anticipated that the total amount of allowed claims will not be known until at least mid-2017.

For additional information, please access Health Republic’s website at: www.healthrepublicny.org

For Billing questions, please contact Tammy Bartlett at 716-348-3923 or tammyb@pracfirst.com

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BILLING UPDATES – SEPTEMBER 2016

Blue Cross News

Blue Cross has entered into a partnership with Amerigroup Partnership Plan, LLC to administer services to Medicaid Managed Care (MMC) and Child Health Plus (CHP) members. They are targeting an October 1, 2016 effective date and will notify the provider community of any changes to this effective date.

Changes to anticipate:

  • New member identification cards, ID numbers and prefixes
    • The prefix for Medicaid Managed Care will be WNH
    • The prefix for Child Health Plus will be WNB
  • Claims submission process
  • Online provider website/portal
  • Preauthorization information and look-up tool
  • EFT and ERA capability
  • Provider service contact info
  • Medicaid and CHP-specific provider manual
  • HealtheNet will no longer be used to verify eligibility and benefits after 10/1/16 for MMC and CHP members only

Additional information is forthcoming from Blue Cross with detailed information about this transition.

For Billing questions, please contact Becky Amann at 716-348-3902 or beckya@pracfirst.co

BILLING UPDATES – AUGUST 2016

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BILLING UPDATES JUNE 2016

By Becky Amann

UNIVERA /EXCELLUS

ELECTRONIC PAYMENTS AND REMITTANCES THROUGH INSTAMED

Univera and Excellus have partnered with InstaMed to provide electronic funds transfers (EFT’s), beginning May 1, 2016. This service is offered free of charge to practitioners and is available for all lines of business.

Transition to InstaMed from PaySpan will not be automatic. Providers must register with InstaMed by September 30, 2016 or your Univera and Excellus remittances will convert to paper. Practitioners began to receive letters from InstaMed in mid-May regarding this process.

Practicefirst is in the process of transitioning EFT’s and remittances to InstaMed for the majority of our clients whom we have enrolled in Payspan previously. If you are unsure if we previously handled that enrollment, please contact our Jr. Credentialing Coordinator, Elisa Mize at (716) 566-4511.

UNIVERA

CLEAR COVERAGE PREAUTH REQUIREMENTS

Effective September 1, 2016, all pre-authorizations for T.E.N.S units must be requested through Univera and Excellus’s Clear Coverage. This applies to all lines of business that require preauthorization and impacts the following specialties: Pain Management, Internal Medicine, Family Practice, Neurology Physicians, Neurosurgeons and Orthopedic Surgeons.

If you have any questions related to Clear Coverage, please contact their Customer Care Medical Intake Unit at 1-800-363-4658.

MEDICAID

ePACES TO ADD NEW FEATURE EFFECTIVE JUNE 1, 2016

As we mentioned in our May Client Memo, in an effort to make user data more secure and to improve system performance, eMedNY will be installing a new feature that will impact ePACES users when signing on to the ePACES application. This new feature, commonly called CAPTCHA, is a program that can distinguish whether the user attempting to sign on is a human or a computer.

EFFECTIVE June 1, 2016: When users attempt to sign on to ePACES from the eMedNY website, the user will be asked to verify that he/she is a person and not a computer by selecting specific images. Once the user has successfully verified the correct images, he/she will be allowed to sign into the ePACES account. If the incorrect images are selected, the user will be asked to verify another set of images before being allowed access to ePACES.

This new feature is widely utilized by other secure websites. Many people are familiar with it and have probably had to use it to gain access to those secure websites. The NYS Department of Health is adding this feature to help secure your data, and to prevent unauthorized computer-automated access to ePACES that could adversely impact ePACES performance.

IMPORTANT NOTE: All users will need to have installed Internet Explorer (IE) version 10 or greater or any alternative browsers including Google Chrome, Mozilla Firefox, or Apple Safari. IE versions 9 and below will NOT be supported. Please be sure to coordinate with your IT department to upgrade your internet browser, if necessary, before the effective date shown above.

Questions about ePACES can be directed to the eMedNY Call Center at 800-343-9000.

HEALTH REPUBLIC – LIQUIDATION PROCEEDING AND CLAIMS PROCESS

Providers began to receive notices from the New York State Dept. of Financial Services (DFS) in early May, regarding the liquidation of Health Republic (HR). The superintendent of DFS, Maria Vullo, has been appointed as the liquidator of HR and has been directed to take possession and control of HR’s property and assets.

Practicefirst has previously submitted all claims to HR and not required to resubmit them based on the liquidation process. We have a record of all claims submitted to HR.

Per HR’s website regarding claims payment: Based on information available to date, any funds available will be applied first to administrative expenses incurred from the liquidation process and then to a portion of the claims submitted by providers and members. Under the NYS Insurance Law, administrative expenses and policy claims must be paid in full before any other claimants may receive distributions.

Information regarding the liquidation of HR can be found under the provider section of their website at: http://www.healthrepublicny.org/

For Billing questions, please contact Becky Amann at 716-348-3902 or beckya@pracfir

BILLING UPDATES – APRIL 2016

By Jacqueline Lucas, Billing Manager

MANDATORY ELECTRONIC PRESCRIBING BECAME EFFECTIVE March 27, 2016

As you know, effective March 27, 2016, electronic prescribing for both controlled and non-controlled substances is now required in New York State. In order to process Electronic Prescriptions for Controlled Substances (EPCS), a prescriber must have selected and be utilizing a certified electronic prescribing computer application that meets all federal requirements. This application had to be registered by the practitioner with the NYS Dept. of Health, Bureau of Narcotic Enforcement (BNE).

UNITED HEALTHCARE (UHC) COMMUNITY PLAN – HARP

Beginning July 1, 2016 UHC Community Plan will start offering a Health and Recovery Plan (HARP). This is a new Medicaid plan benefit for members with significant behavioral health needs.  Any provider that is currently participating in UHC Community Plan will automatically participate in the HARP plan.  However, if you wish to opt out of HARP you must notify UHC in writing by April 15, 2016. The mailing address is:

UnitedHealthcare PCDM
PCDM Fulfillment
780 Shiloh Rd
Plano TX 75074

If you have any questions regarding this new plan, please contact UHC at 866-362-3368

GENERAL COMMENTS

In the near future, I will reach out to you for a convenient time to meet with physicians and your office staff.  My goal is to enhance our current processes to ensure we provide the most comprehensive billing service for all.  Please feel free to contact me prior to our meeting for any questions you may have. I look forward to meeting you in person.

Jackie Lucas

For Billing questions, please contact Jackie Lucas at 716-348-3923 or jackiel@pracfirst.com.

HEALTH REPUBLIC UPDATE

As you know, Health Republic ceased operations effective November 30, 2015. Claims processing and payments ceased in early November.  Due to the non-payment of claims, we have adjusted the outstanding balances owed by Health Republic from your Accounts Receivable. We have a history of each unpaid encounter in case the government makes a determination to issue payments on these claims. The total amount of Health Republic adjustments will be reflected in your month-end reports for March.

If you would like information regarding these adjustments, please contact Becky Amann at 716-348-3902.

CODING CORNER…FEBRUARY 2016

By Betsy Priest, Coding Manager

ADVANCED CARE PLANNING

Two new codes are available to help capture a patient’s advanced care planning.  These can be used in any setting, regardless of the specialty.

99497: Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.

99498: Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)

These codes will be used to capture the time you spend in addition to what is already being done with the patient.  If you have a regular visit with the patient, code that visit with a modifier 25 and then the above codes. If you are only seeing the patient for Advanced Care Planning, you would only use these codes.

These are time based codes.  99497 is for the first 30 minutes of Face to Face time with the patient and the 99498 is for each additional 30 minutes. This is only face to face time with the patient.

The documentation needs to clearly state the total time, that it was face to face, and what was discussed.  (The providers do not need to re-write parts of their note if this information is elsewhere. We need to be able to clearly see what was discussed and that it was advanced care planning).

Reimbursement amounts have not been determined yet. CMS states that in 2016, they will reimburse these services, but no payment amount has been established. This was open for discussion through December 31, 2015 and no final decision regarding the reimbursement amount has been published as of yet.

These services can be performed by physicians as well as mid-levels

If you would like more information about how we can tailor our services to meet your needs, please contact Betsy Priest, Coding Manager at 716.348.3904 or Betsyp@pracfirst.com

BILLING UPDATES FEBRUARY 2016

By Jacqueline Lucas, Medical Billing Director 

IRS INSURANCE COMPANY PAYMENT SUMMARY

PF will aggregate your IRS Form 1099’s through February 15th.  These forms (1099-Misc) represent all of the payments made to you during calendar year 2015.  The IRS matches the aggregate of all 1099’s to the appropriate line of your entity’s tax return, to make sure recipients properly report their income.  In addition, any interest paid on claims is separately reportable on IRS Form 1099-Int.  This information is also matched and it is critical to properly report this income on the correct line of your tax return to avoid IRS scrutiny for under reporting income.

By law, insurance carriers are required to mail them by January 31st.  However, our past experience indicates that they do not comply with the due date and therefore they are not all generally received until the third week in February.  At that time, we will send them to you by mail or through our courier service. If you have any questions, please feel free to contact us.

INDEPENDENT HEALTH

To align with NYS Medicaid, Independent Health (IHA) will be eliminating coverage for immunization administration code 90461. This code is not covered by Medicaid. Effective April 1, 2016, 90461 will not be covered for IHA’s MediSource, Essential Benefit Plan or Child Health Plus members.

UNIVERA

Univera has announced that Telemedicine services will be available to select members effective March 1, 2016. Telemedicine services will be delivered by MDLive, a nation-wide network of physicians who are board-certified in the state in which the patient is located at the time of service. MDLive physicians will be available by phone or secure video 24 hours a day, seven days a week, including holidays to provide advice and/or treatment for non-emergency medical conditions. If you have any questions regarding Telemedicine services, please contact Univera’s Customer Care Dept. at 866-265-5983.

YOURCARE HEALTH PLAN

In-mid January, YourCare issued duplicate EFT payments. They have been identified in providers’ bank accounts beginning on January 19, 2016.  PF has contacted YourCare provider representative, Tina Burns, who indicated they will be reaching out to the various providers requesting a refund check, for the duplicate payments.

RAILROAD MEDICARE

Railroad Medicare’s Medical Review unit will begin a service-specific review of Evaluation and Management CPT Code 99214 (office or other outpatient visit of an established patient). This code was selected based on internal data analysis. At the conclusion of the review, they will publish their findings on their website.

For Billing questions, please contact Jackie Lucas at 716-348-3923 or jackiel@pracfirs

BILLING UPDATES JANUARY 2016

By Jacqueline Lucas, Medical Billing Director

NATIONAL GOVERNMENT SERVICES (NGS)

In order to implement corrections to technical errors discovered after publication of the Medicare Physician Fee Schedule, Medicare Administrative Contractors will hold claims containing 2016 dates of services for up to 14 calendar days. The hold should have minimal impact on provider cash flow as clean electronic claims are held for 14 calendar days, under current law.

The holding of claims does not impact 2015 dates of services.

INDEPENDENT HEALTH  – PREVENTIVE VISITS – CPT CODES 99381-99397

Effective January 1, 2016, IHA will no longer offer coverage for routine physicals (CPT codes 99381-99397) for their Medicare Advantage plans. Claims with dates of service January 1, 2016 and after will be denied as service code not reimbursable.

They will continue to offer coverage for the Annual Wellness Visit as well as the Enhanced Annual Visit in the primary care setting for their Medicare Advantage plans.

MEDICAID ELECTRONIC PRESCRIBING

Effective March 27, 2016, electronic prescribing for both controlled and non-controlled substances will be required in New York State. In order to process Electronic Prescriptions for Controlled Substances (EPCS), a prescriber must select and use a certified electronic prescribing computer application that meets all federal requirements. This application must first be registered by the practitioner with the NYS Dept. of Health, Bureau of Narcotic Enforcement (BNE).

Per the Dept. of Health, the implementation timelines for EPCS software vary and may be lengthy. If you have not already begun this process, it is recommended that you begin immediately.

Information related to electronic prescribing, including frequently asked questions and information regarding the EPCS registration process, can be found on the BNE’s website at: http://www.health.ny.gov/professionals/narcotic/electronic_prescribing/

For Billing questions, please contact Jacqueline Lucas, our Medical Billing Director. Jackie can be reached at 716-348-3923 or jackiel@pracfirst.com.<