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 – 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.

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

A SIMPLIFIED EXPLANATION OF A MSO – MANAGEMENT SERVICES ORGANIZATION

By Emilie J DiChristina, MBA for Practicefirst

In every practice, regardless of size, operational costs are increasing, capital expenditures (such as those for an EMR) are increasing, human resource costs are increasing, supply costs are increasing, utility costs are increasing, and the providers do not have the time to look for the best deals or negotiate with payers to offset these costs.

What to do? What to do?

One of the ways medical providers (including hospitals and physicians), and many other organizations such as schools, small businesses and not-for-profits are dealing with these challenges are through the development of a MSO – Management Services Organization.

While MSOs are often hospital driven, locally we are seeing a push  to develop MSO which bring together similar specialties, or specialties which will be supportive through a referral base and/or one-stop-shop model. The providers who join the MSO have some degree of financial buy-in either as part of the overall MSO umbrella, or through the purchasing of certain “menu” items such as billing, human resources, payroll, IT, purchasing, etc.

While very large practice may have their own Practice Administrator, their own in-house IT support, compliance personnel, Meaningful Use specialists and HR generalists, most practices do not have the size and scope to offer all those services internally, leaving practices at real risk, Likewise, even the largest practice does not have to bargaining power to achieve hospital sized discounts when purchasing, or negotiate higher rates from third-party payers.

Physician practices are suffering from rising costs and decreasing revenues, and individual practitioners are suffering from a decreased quality of life, particularly if they are trying to be the provider and “chief cook and bottle washer” for the practice.  Increased numbers of physicians are seeking out alliances in droves, looking for help and benefit without giving up their autonomy to practice as they see fit.

So whether seeking to work with other providers of the same specialty, or with a wider range of provider types, the goal is to become more collaborative and more integrated while avoiding any potential regulatory risks (price fixing, anti-trust, inurement, fraud and abuse) and the MSO is generally thought to be the most flexible option. MSOs bring together providers into beneficial alliances without requiring the provider to give up their autonomy.

The way a MSO is set-up (simply described) is to have a management team and an executive director run a business if which the customers (providers buying into the MSO) help define the services which will be provided, the most cost effective way to provide those services, and then to collect fees for those services from the client providers and insure that the services meet the needs of the clients.

For example the MSO usually offers a purchasing department. For a fee, providers who wish to use this centralized purchasing department will receive greater purchasing power when buying the everyday practice items including paper and pens, exam table paper, otoscope tips, and will also have greater power in negotiating for the high ticket items such as capital equipment. The goal is to standardize where possible, negotiate with the greater volume and decrease cost to the client practices.

The whole purpose of an MSO is to offer a specific menu of services made available to practices and structured in a cooperative fashion.  What we are seeing in WNY are MSOs which involve physician equity positions with a stated goal of assistance and guidance without interference.  The physicians are involved in an advisory policy-making capacity, to prioritize efforts and to pick services which will have universal appeal, are apolitical, and offer immediate payback.

The menu of services of an MSO frequently include overall management and consultative practice services, billing and collection, purchasing, equipment and personnel pooling, risk management and human resources/r

BILLING UPDATES – MARCH 2014

By Sarah Howarth, Billing Manager

Exchange Claim Processing

There are four levels of health insurance plans offered by each carrier through the Health Insurance Exchange.   Bronze plans hold the lowest cost with the highest out-of-pocket patient responsibility.  Platinum plans have the highest monthly premium with the lowest out-of-pocket responsibility.  Claim submission and payment processing will be handled the same way as all other insurance claims.  The carrier will follow their standard commercial fee schedule. 

If a patient fails to make their premium payment:

  • 90 day grace period for all carriers.
    • During the first 30 days, claims will be processed as normal.
    • 31-90 days of payment lapse, claims will be suspended (not denied) until premium payment is made.
      • Patients may not be billed for claim balances outside of copay amounts during this time.
    • After 90 days, if the premium payment has not been received, carriers may terminate the patient’s insurance policy and the patient will be held responsible for outstanding claim balances.

 Univera Exchange plans

New members enrolling in Child Health Plus as of January 1, 2014 must enroll through the NYS health plan marketplace.  Although enrollment is completed through the marketplace, the Affordable Care Act rules do not apply to Child Health Plus.  Members will be assigned one ID number per household, patient names will serve as a unique identifier. 

 Independent Health

Last month we notified you that Independent Health will no longer offer MediSource in Niagara County.  In February, IHA was able to obtain the funding to continue to offer MediSource in Niagara County.  Patients have been notified that there are no actions necessary to continue their insurance coverage. 

PQRS REMINDER

Medicare has released the 2014 requirements for PQRS reporting.  To avoid the 2016 payment adjustment, individual providers must report a minimum of 3 measures for at least 50% of eligible Medicare fee for service patients throughout the reporting period.  Providers interested in obtaining the 2014 PQRS payment incentive must report on 9 measures for at least 50% of Medicare fee for service patients throughout the reporting period. The reporting period begins January 1st and ends December 31, 2014.

  • Measure requirements are driven by diagnosis and procedure codes.
  • Providers may opt to report through a 3rd party registry, an EMR or by adding appropriate coding to their claims when billed.
  • Billing clients who select claim reporting must add the appropriate numerator quality-data code to the claim.
  • Providers must meet the requirements of the measure, add the appropriate numerator to the claim and ensure supportive documentation has been completed.

Medicare has a dedicated service line to answer questions specific to PQRS: 1-866-288-8912.

Additional information may be found at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html

Practicefirst will be happy to provide billing clients with the following upon request:

  • Summary of Medicare payments from 2013 to estimate the impact of the 1.5% payment reduction.
  • A report of ICD-9 and CPT codes billed in 2013 for cross-reference with the qualifying requirements of each measure.Additional assistance in determining appropriate measures and claims reporting is available.  Please contact Practicefirst for more information.

 For Billing questions, please contact Sarah Howarth at 716-348-3923 or sarahh@pracfirst.com<

BILLING UPDATES – FEBRUARY 2014

By Sarah Howarth, Billing Manager

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 2013.  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 payers should mail them by January 31st.  However, our past experience indicates that they do not comply by the due date and therefore they are not all received until the third week in February.  At that time, we will send them to you by mail or through our courier service.

INDEPENDENT HEALTH

Effective February 28, 2014 Independent Health will no longer offer MediSource in Niagara County.  Patients will be notified of options to continue Medicaid managed care coverage through Fidelis Care New York and United Healthcare of New York.

If a provider does not participate with a patient’s new plan, the following circumstances will allow for reimbursement according to the fee schedule and policies of the new plan:

Patient is currently receiving ongoing care for a serious condition.  The new plan will reimburse you for services up to 60 days after enrollment in the new plan.

If the patient is three or more months’ pregnant as of February 28, 2104, the new plan will reimburse you for treatment of the patient until the baby is born and through post-partum care.

FLU VACCINES

Please notify Practicefirst of any changes to the type of flu vaccine administered at your office.  We will confirm the appropriate CPT code is applied based on the brand, dosage and source of the vaccine.

COLLECTION AGENCY CHANGE

Effective February 1, 2014 HoganWillig will no longer be providing collections services to clients of Practicefirst.  Unless you tell us otherwise, all collection accounts formally placed with HoganWillig will be transitioned to Tice Associates, Inc.  Should you have any questions or concerns regarding this transfer, please contact Practicefirst prior to February 15, 2014.

PQRS

Medicare has released the 2014 requirements for PQRS reporting.  To avoid the 2016 payment adjustment, individual providers must report a minimum of 3 measures for at least 50% of eligible Medicare fee for service patients throughout the reporting period.  Providers interested in obtaining the 2014 PQRS payment incentive must report on 9 measures for at least 50% of Medicare fee for service patients throughout the reporting period. The reporting period begins January 1 and ends December 31, 2014.

  • Measure requirements are driven by diagnosis and procedure codes.
  • Providers may opt to report through a 3rd party registry, an EMR or by adding appropriate coding to their claims when billed.
  • Billing clients who select claim reporting must add the appropriate numerator quality-data code to the claim.
  • Providers must meet the requirements of the measure, add the appropriate numerator to the claim and ensure supportive documentation has been completed.

Medicare has a dedicated service line to answer questions specific to PQRS: 1-866-288-8912.  Additional information may be found at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html

Practicefirst will be happy to provide billing clients with the following upon request:

  • Summary of Medicare payments from 2013 to estimate the impact of the 1.5% payment reduction.
  • A report of ICD-9 and CPT codes billed in 2013 for cross-reference with the qualifying requirements of each measure.

Additional assistance in determining appropriate measures and claims reporting is available.  Please contact Practicefirst for more information.

VERIFYING PATIENT COVERAGE IN A HEALTH INSURANCE MARKETPLACE PLAN

As mentioned in last month’s client memo, it is the beginning of the New Year and you’ll be verifying your patient’s insurance status when they come to your office. With the beginning of the Health Insurance Marketplace, also known as Health Insurance Exchange, over a million people will have a new insurance plan. In many cases, this will be the first time they have had insurance in years.   Many of these people will have signed up for their plan within the past few days. They may not have received their card yet or they may be unaware of the need to carry their insurance information. You may find your office needing to verify their coverage.

How do you verify their coverage?

If the marketplace in your state is run by the Federal government, it is best to call their plan’s customer service line, a list of all plans and their customer service numbers can be found at: https://data.healthcare.gov/dataset/QHP-Customer-Service-Phone-Numbers/vryg-tdzf

A fact sheet can be utilized for using the data base which is located:  http://marketplace.cms.gov/getofficialresources/publications-and-articles/contact-health-plan.pdf

If you can’t find the number, call the Marketplace Call Center (1-800-318-2596).

If your state has its own health insurance exchange, contact your state. To find the website for your state exchange, select the name of your state in the box at the left hand side of the health care website at: https://www.healthcare.gov/marketplace/individual/#state=alaska

How else can you help your patient?

Remind your patients to keep all of their paperwork and receipts from all of their doctor’s appointments and from the pharmacy as well. They may need them for their insurer. Remind them they should carry their card at all times. If they don’t have a card, they can contact their plan to get a card.

If the patient is uninsured, 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. The vast majority of uninsured will qualify for financial assistance to reduce their costs. You can also download copies of various fact sheets or educational material for your patients at: http://marketplace.cms.gov/getofficialresources/publications-and-articles/publications-and-articles.html

AETNA SETTLEMENT

We have received notification of a proposed settlement in a class action lawsuit: In re Aetna UCR Litigation. This lawsuit pertains to providers considered Out-of-Network who provided covered services to Aetna Plan Members and whose resulting claims for reimbursement included partially allowed claims.  Providers may be eligible to receive payment for improper reimbursement.  This settlement may apply to you if you were an Out-of-Network provider from June 3, 2003 through August 20, 2013.  Providers must complete and submit a claim form no later than March 28, 2014.  Providers may opt to make a claim from the General Settlement Fund or from the Provider Settlement Fund.  General Settlement Fund claims are anticipated to result in a payment of less than $40 per year for each year Out-of-Network covered services were provided.  Provider Settlement Fund claims are expected to make payment of up to 5% of the allowed amount for qualifying claims.  Please contact Sarah Howarth for additional information.

For Practicefirst to file a claim on your behalf, you must certify that you have provided Out-Of-Network services to Aetna Plan Member(s). Practicefirst will charge a flat fee of $25.00 for solo physicians and $50.00 for group practices. Please contact Sarah Howarth at Practicefirst by March 1, 2014 to file a claim form on your behalf. As always, you are free to file the claim on your own.  Additionally, if you have received a notice from Aetna, you may forward that to Sarah indicating you would or would not like to be included in this Class Action Lawsuit.

For Billing questions, please contact Sarah Howarth at 716-348-3923 or sarahh@pracfirst.com

BILLING UPDATES – JANUARY 2014

By Sarah Howarth, Billing Manager

CHART RETURNS

Charge slips / Encounters that cannot be submitted to the insurance carrier due to pertinent billing information that is lacking are returned to your office on a weekly basis, as a Chart Return. For PF’s non-PBS Medcode Corp. clients, examples of lacking information can pertain to missing CPT codes, diagnosis codes, modifiers, dates of service, etc. For PF’s PBS Medcode Corp. clients, examples of lacking information can pertain to size of laceration, final diagnosis missing, chart pages missing, etc.

At the end of each month, you will receive a summary of all outstanding Chart Returns. These claims have not been paid or submitted to the insurance carrier. Please keep in mind that any Chart Returns that you have recently addressed may not have been reviewed by our staff yet and subsequently still appear on the month-end Chart Return summary.  

If you do not have an understanding of why the Charge slip / Encounter has been returned to you, please contact us.

UNIVERA

Beginning January 1, 2014, you may begin to see some Univera Healthcare member identification cards bearing the TPA (Third Party Administrator) logo.  Referral and preauthorization requirements for this line of business will be indicated on the back of the ID card.  Please provide Practicefirst with copies of the new insurance cards to ensure claim processing runs smoothly for your practice. 

CENTERS FOR MEDICARE & MEDICAID (CMS)

REMINDERS – MEDICARE EHR INCENTIVE PROGRAM

If you are participating in the Medicare EHR Incentive Program, you must attest to demonstrating meaningful use of the data collected in 2013 by February 28, 2014. 

2014 is the last year to begin participation in the EHR Incentive Program. The first year of participation requires reporting for a continuous 90-day period.  Reporting for following years involves meeting the requirements for the entire calendar year.

PQRS

January 1, 2014 will mark a new reporting period for the Medicare Physician Quality Reporting System. To avoid a payment reduction of 1.5% in 2016, providers must fulfill the reporting requirements for PQRS.  Providers must report on 3 measures or 1-2 measures for at least 50% of Medicare Part B patients seen in 2014. Additional information regarding the requirements for 2014 will be posted on the CMS website by December 31, 2013. 

FINALIZATION TO PHYSICIAN PAYMENT RATES FOR 2014

One of the provisions included in the CY 2014 Physician Fee schedule final rule includes a separate payment for chronic care management services which will begin in 2015.

Primary Care and Chronic Care Management: As part of CMS’s ongoing efforts to appropriately value primary care services, Medicare will begin making a separate payment for chronic care management services beginning in 2015. In last year’s final rule, CMS established separate payment for transitional care management services for a beneficiary making the transition from a facility to the community setting. In this final rule, CMS further emphasized their support for advanced primary care through their establishment of policies to facilitate separate payment for non-face-to-face chronic care management services for Medicare beneficiaries who have multiple (two or more), significant chronic conditions.

Chronic care management services include the development, revision, and implementation of a plan of care; communication with the patient, caregivers, and other treating health professionals and medication management. Medicare beneficiaries with multiple chronic conditions who wish to receive these services can choose a physician or other eligible practitioner from a qualified practice to furnish these services over 30-day periods.

To review the final policy fact sheet, please access:

http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-Sheets/2013-Fact-Sheets-Items/2013-11-27-2.html

VERIFYING PATIENT COVERAGE IN A HEALTH INSURANCE MARKETPLACE PLAN

CMS has issued the following guidance for the Health Insurance Marketplace:

It is the beginning of the New Year and you’ll be verifying your patient’s insurance status when they show up in your office. With the beginning of the Health Insurance Marketplace, also known as Health Insurance Exchange, over a million people will have a new insurance plan. In many cases, this will be the first time they have had insurance in years.   Many of these people will have signed up for their plan within the past few days. They may not have received their card yet or they may be unaware of the need to carry their insurance information. You may find your office needing to verify their coverage.

 How do you verify their coverage?

If the marketplace in your state is run by the Federal government, it is best to call their plan’s customer service line, a list of all plans and their customer service numbers can be found at: https://data.healthcare.gov/dataset/QHP-Customer-Service-Phone-Numbers/vryg-tdzf

 A fact sheet can be utilized for using the data base which is located:  http://marketplace.cms.gov/getofficialresources/publications-and-articles/contact-health-plan.pdf

If you can’t find the number, call the Marketplace Call Center (1-800-318-2596).

If your state has its own health insurance exchange, contact your state. To find the website for your state exchange, select the name of your state in the box at the left hand side of the health care website at:

https://www.healthcare.gov/marketplace/individual/#state=alaska

How else can you help your patient?

Remind your patients to keep all of their paperwork and receipts from all of their doctor’s appointments and from the pharmacy as well. They may need them for their insurer. Remind them they should carry their card at all times. If they don’t have a card, they can contact their plan to get a card.

 If the patient is uninsured, 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. The vast majority of uninsured will qualify for financial assistance to reduce their costs. You can also download copies of various fact sheets or educational material for your patients at: http://marketplace.cms.gov/getofficialresources/publications-and-articles/publications-and-articles.html

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FINANCIAL RISK FROM HIGH DEDUCTIBLES AND CO-INSURANCE – DECEMBER 2013

By Emilie DiChristina for PracticeFirst

In our last issue of our practice newsletter we discussed the financial risks associated with the Affordable Care Act related to the extraordinarily long grace periods for non-payment of premiums. Refer back to our PracticeFirst Blog to review.

By now, we hope that you have advised all of your front end staff of the importance of getting financial agreements signed at the start of 2014, regardless of the type of insurance or length of time an individual has been your patient, AND we hope that you have amended your financial agreement to include “failure to pay premiums resulting in loss of coverage”.

So…now on to a yearly reminder which can also adversely affect your practice’s finances – this of course is the fact that at the start of the year many people start with high-deductibles and co-insurances which may  essentially mean that the patient should in fact be paying the entire cost of a visit up-front.

What has your practice done in preparation for this yearly event of increased risk? Are patient’s advised at the time appointments are scheduled that they will be responsible for their deductible or co-insurance? Have you a payment plan established for your office and your patients? Have you updated your fee schedule for self-pay patients? Do you have a credit-card on file policy?

Remember that this is a yearly rite of passage for practices which has been getting more difficult and places practices at more financial risk each year because co-insurances and deductibles are rising each year!

The impact on the patient of increasing health plan deductibles and co-pays is bad, but for your practice it can be financially devastating because collecting these (essentially self-pay) amounts is difficult to say the least.

This cost-shifting to patients has been increasing each year, but is also expected to be a major concern under the ACA because the law requires people to have insurance while allowing plans such as the “Bronze” or catastrophic plan. These plans have a high deductible and a lower premium. So, just as employers see the benefit in having their employees enrolled with a high deductible plan (although they often offered an HSA to balance the effect on the employee), the ACA allows these “Bronze” plans to allow people to meet the mandate but at lower cost.

It all shapes up to another risk to your practice, unless you have a strong front end staff, a dedicated collections program and a practice administrator who understand the issues related to balancing customer service with effective revenue management.

So what do you need to do?

  • Ask us for help, if you need it!
  • Remember that ANY owed amount should be collected at the time of the service (or that signed agreements to pay and payment plans are in place at the time of the service).
  • Remember that deductibles, unlike co-pays, are often harder to collect as the office may not know what the deductible is – UNLESS, the front end staff verify insurance and patient responsibility BEFORE the visit! This requires your front end staff to understand the value and risk of performing or failing to perform the verification.
  • Make sure that insurance verification is done for EVERY visit because as we noted, under the ACA, patients may change insurance coverage frequently or not have paid their premium and be under the last 60 days of the grace period (which means service at your own risk!).

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HOW THE ACA GRACE PERIOD MAY PUT YOUR PRACTICE AT FINANCIAL RISK – NOVEMBER 2013

By Emillie J DiChristina, MBA for PracticeFirst

Whether you are a fan of the Affordable Care Act or take some other view, we at PracticeFirst want to make sure you are prepared for some of the potential financial risk arising from all of the newly insured patients your practice may encounter.

Most providers are worried about reimbursement rates being offered by insurers participating in the exchanges, as well as the greater number of people being covered by Medicaid and the potential for decreased Medicare rates.

With all this on your mind, it may have been easy to miss the potential financial risk caused by “the premium grace period” which is significantly different under the ACA for any person covered under a tax-subsidized health insurance.

For those people who are low-income, yet who do not qualify for Medicaid, they will be covered under tax-subsidized health insurance. In writing the ACA, there was an expectation that these lower income people may not have the money to pay their premiums without the tax subsidy, and even more likely that they will need to wait for the tax subsidy to be able to afford the premium at all.

So where is the risk?

Currently, when we confirm insurance on our patients prior to providing service we know the date when their insurance lapsed for any reason. Statutorily, private insurers offer a grace period of 10 days for premium payment to insure continued coverage so occasionally we will request the patient sign an agreement to pay, or more likely request a cash payment at the time of service – refunding if the patient offers proof of continued coverage.

Therefore currently, even if you did not request cash up-front, good front office technique reduces your risk of bad debt for services rendered to a potential 10-day grace period,

Unfortunately for healthcare providers, the ACA comes with s proverbial “rub” resulting in much greater bad debt risk when you care for anyone who receives a tax-subsidy for their health insurance. Actually, it comes with two “rubs” leaving you at greater risk.

The first issue placing you at risk is the fact that while you will be able to confirm your patient has insurance, even insurance purchased through the exchange, you are likely to not know if they receive a tax-subsidy to help pay for the insurance,

The second issue placing your practice at financial risk is the real kicker. As part of the ACA, people who qualify for tax-subsidies to purchase health insurance through online marketplaces, or exchanges, are allowed a three-month grace period if they don’t pay their premiums.

Furthermore, a federal rule allows health plans to suspend claims for services that delinquent enrollees receive during the second and third months of the grace period. That means that health-care providers will have to absorb the costs for services provided to people who didn’t pay their premiums and you will have no way of knowing if their premiums have been paid, or where there are in their grace period.

While both the American Hospital Association and the Association of American Medical Colleges have sent letters requesting the government to force health insurers to pay for delinquent enrollee’s claims during the entire three-month grace period there has been no movement toward enacting the proposed changes. This leaves providers in a potentially bad place as they have a high potential for accruing bad debt on services provided between 31 and 90 days of the allowed grace period.  

The American Hospital Association was quoted as saying, “Whatever the cost of the grace period, it went from 100 percent liability for the health plans to only a third of the liability,” the association said in a statement. “For providers, it went from zero liability (other than deductibles and cost-sharing) to two-thirds of the liability for all the services.”

So what can you do to decrease this liability, short of refusing to participate in the insurances on the exchanges? The most significant action you can take is to strengthen your front end practices and agreements to pay.

You will have to assume that anyone participating in the exchanges may be tax-subsidized (consider it “universal precautions” for your bottom line) and amend your financial agreement forms to include language in which the patient agrees to pay for any services rendered to them should their insurance coverage lapse for any reason including non-payment of premiums.

You should also look at your fee schedule for self-pay patients (which may be what someone becomes if they have received services and have not paid their premiums). We all know that self-pay often translates into no-pay, so it may be worth considering setting your self-pay fees at the level which you would have received from your average payer potentially increasing your likelihood of receiving payment from patients whose insurance has lapse

INCREASED MEDICAID PAYMENT FOR PRIMARY CARE

For Immediate Release:               Thursday, November 1, 2012

Contact:                                          CMS Office of Public Affairs 202-690-6145

INCREASED MEDICAID PAYMENT FOR PRIMARY CARE

Overview

On November 1, 2012, the Centers for Medicare & Medicaid Services (CMS) issued a final rule to implement a provision of the Affordable Care Act that provides increased payments to certain primary care physicians for specified Medicaid primary care services.  Under this provision, certain physicians who provide eligible primary care services will be paid the Medicare rates in effect in calendar years (CY) 2013 and 2014 instead of their usual state-established Medicaid rates, which may be lower than federally established Medicare rates.  The payment increase applies to primary care services delivered by a physician with a specialty designation of family medicine, general internal medicine, or pediatric medicine or related subspecialists.  States will receive 100 percent federal financial participation (FFP) for the difference between the Medicaid state plan payment amount as of July 1, 2009, and the applicable Medicare rate.

The rule provides information about how CMS and states will work together to make the increased payments operational.  The rule includes information about the identification of eligible providers and services and how to meet the statutory requirements when making these payments for services provided through managed care. The rule also provides important information on how this policy applies to the Vaccines for Children (VFC) program, which has its own statutory requirements for billing and payment, and updates the administration fees that may be billed under VFC based on medical inflation rates.

Qualifying Providers

Through the Affordable Care Act, primary care services eligible for the higher Medicaid payment must be delivered by a physician who specializes in family medicine, general internal medicine, or pediatric medicine. This rule specifies that certain physician subspecialists (for example, pediatric cardiologists) who are board certified in those specialties or provide primary care within the overall scope of those categories also qualify for the enhanced payment. The rule also clarifies that the higher payment will be made for primary care services rendered by practitioners—including, for example, nurse practitioners—working under the personal supervision of any qualifying physician.

Implementing the Increased Payments in Fee for Service and Managed Care

The rule provides multiple options for states to allow for flexible implementation in fee-for-service and managed care settings. The rule permits states to either “lock” rates at the level of the Medicare physician fee schedule in effect at the beginning of 2013 and 2014 or modify the rates in alignment with all updates by Medicare.  For operational ease, it does not require states to make site of service adjustments, permitting them instead to make payments at the Medicare rate applicable to the office setting.  It also permits states to either pay in accordance with all Medicare locality adjustments within the state or to develop a rate for each code based on the mean Medicare rate over all counties in the state to be paid on a statewide basis.  The regulation provides that all of the requirements related to the increased payments apply to services reimbursed by Medicaid managed care plans.  States must incorporate the increased payment into contracts with such entities.

Interaction with the Vaccines for Children Program

The rule provides for payment of vaccine administration fees under the VFC program at the lesser of the VFC regional maximum administration fee (the VFC “ceiling”) or the Medicare rates in 2013 and 2014.  This is consistent with VFC program rules which limit payments to the VFC ceiling, which is the state’s regional maximum amount, and to one payment per vaccine administered.  Because the VFC ceiling rates were issued on an interim basis in 1994 and have never been updated, the rule also updates these rates using the Medicare Economic Index, which is a measure of medical practice cost inflation.

The rule can be found at http://www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1