By Karin Bajak, Director, Billing at PracticeFirst



In early February, NGS identified that the 1099 forms issued for calendar year 2012 reflect the year as 2011. All other information on the form is correct. All 1099 forms were reprinted and reissued on Friday, February 1, 2013.


Per Medicaid’s January Update, published in early February, there is a two-week lag between the date of the Medicaid check and the date the check is actually issued. Therefore, the 1099’s for 2012 will reflect check date 12/19/11, released on 1/4/12 through check date 12/10/12 released 12/26/12.


Physicians will see a 2 percent reduction in Medicare payments effective March 1, 2013 unless Congress can agree on a plan to prevent the across-the-board federal sequestration budget cuts.


Electronic Payments and Statements are changing the way it identifies and tracks users in EPS. WHY? To provide a better user experience and greater security for all users.

This change will require that all current users complete a registration process to activate their access to EPS after February 11th. The registration process will include the set-up of a password, establish security questions, validate contact information and review/accept the terms of use. Between February 9th and February 11th, all current contacts received an e-mail with instructions to complete the registration process. The e-mail was sent from and the subject line was “EPS Pre-Registration Notice – Provider Action Required – Electronic Payments and Statements (EPS)”.

New features for EPS:
Two access levels to control who within your organization has the ability to create new users and view bank account info.

  • Administrator: Has the ability to create, edit and delete users. Has the ability to associate a TIN(s) to individual users. The Administrator will have access to the new ‘Manage User’ tab to complete these activities. Has the ability to view bank account information in ‘Maintain Enrollment.’
  • General User: Has the ability to view TIN and NPI claims data when associated to that TIN/NPI

The ‘My Profile’ tab will allow users of the Optum branded portal to manage their own contact information (name, phone, email address) as well as manage their password and security questions. The ‘My Profile’ tab will not display on Payer branded sites.

Review and update your contact information.

  • If your name or e-mail address as displayed in your contact record is out of date, please update it!
  • If your contact record is missing a phone number, add it!
  • If you are a contact for two (2) or more TINs ensure that your contact information is exactly the same on each contact record.
  • Delete any old contacts that are no longer with your organization or that should no longer have access to EPS.

Review the User Guide located under ‘Resources’ for full functionality after February 10th.

One, VERY IMPORTANT NOTE: EPS will no longer allow different users to use a shared e-mail address. Going forward all users will be required to use a unique e-mail. As part of the conversion process EPS will look to match an e-mail, phone and first/last name to create a new user. If multiple contacts share the same e-mail address only ONE new user will be created based on the most recent contact update.

The new user will then have the responsibility after February 10th, to add users that were not converted.

If you are an enrollment contact for two (2) or more TINS it is very important that your contact information is exactly the same. If your contact information is not the same there is a possibility that EPS will not be able to associate your new user account with all TINs that you currently have access to!

For Providers that access EPS from a Payer website, your login credentials to that Payer site remain the same. The user name that you will be assigned and the password you create during the registration process will be used to activate your account and to access the Optum EPS portal via



Adequate and proper medical documentation is essential for quality medical care. Emblem Health conducts audits to review practitioner documentation and ensure compliance with Centers for Medicare & Medicaid Services (CMS) and New York State Department of Health (NYSDOH) regulatory requirements and to meet National Committee for Quality Assurance (NCQA) standards of patient care.

Emblem Health works with their practitioners to review medical records and identify concerns, as well as offer tips for correct medical documentation when needed. They also provide appropriate preventive health guidelines to discuss with members. Here are some of the audits you can expect in 2013:

HEDIS 2013

Emblem Health’s Quality Management Department will soon begin its annual Healthcare Effectiveness Data and Information Set (HEDIS®) audit. HEDIS results are an integral part of the NCQA accreditation process. HEDIS measures allow consumers to easily compare the performance of health care plans.

HEDIS packets will be mailed to network providers in February 2013, requesting a total of approximately 40,000 medical records for standards of care measures, such as well-child visits and preventive breast cancer screenings, and for chronic illnesses including diabetes and hypertension. Strict procedures are followed during all phases of data collection, and the data is audited by NCQA-certified auditors to ensure that data requirements are followed.

NCQA has implemented new policy changes for 2013, including completion of the medical record review process by May 15, 2013, and the addition of the following new measures for 2013:

  • Asthma Medication Ratio
  • Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications.
  • Diabetes Monitoring for People with Diabetes and Schizophrenia.
  • Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia.
  • Adherence to Antipsychotic Medications for Individuals with Schizophrenia.

If you are asked to submit medical records, please make sure that you follow the standards set by NCQA and NYSDOH and submit the records within the requested timeframes. Please refer to the Emblem Health Provider Manual for medical record documentation requirements.

Higher HEDIS scores are usually the result of members receiving recommended health services and preventive health screenings. Emblem Health asks you to remind your patients to schedule yearly exams and follow-up visits.


NYSDOH requires all Medicaid Managed Care plans to provide all pregnant members with comprehensive prenatal care services through their participating practitioners. To meet this requirement, Emblem Health annually reviews a sampling of medical records for their pregnant Medicaid members. This year’s audit, covering service year 2012, will begin in March 2013.

For medical records reviewed in 2011, covering service year 2010, Emblem Health found an overall improvement in the number of practitioners meeting the benchmark score of 90 percent or greater.

Emblem Health’s practitioners did not fare so well in assessing high-risk factors and documenting them in patient medical records. This warrants further improvement. Assessments must include a notation of discussion and counseling with the pregnant member on the following:

  • Dental care
  • Newborn HIV testing
  • Food/shelter resources
  • Parenting skills
  • Newborn screening

Additional prenatal information and resources, as well as many other topics, may be found on the New York State Department of Health Web site at:


Collection of medical records for the 2013 Primary Care Physician audit has ended, but the review and evaluation continues for year 2012. To comply with NYSDOH regulations, as well as NCQA accreditation requirements, Emblem Health performs an annual review of the medical records of a sample of network practitioners specializing in internal medicine, pediatrics and obstetrics/ gynecology.

To meet the NCQA standards and fulfill audit requirements, a practitioner must obtain a score greater than 90 percent. For the 2012 audit, covering service year 2011, 86.3 percent of their network practitioners met the benchmark for standards of care.

The largest observed improvement in documentation for adult records was in the High Risk Behavior and Anticipatory Guidance category for practitioners who documented a discussion on violence and abuse. There was an increase in documentation of 21.31 percent from 2010 to 2011. An area that still requires improvement is in the category of Preventive Health Guidelines for documenting a hearing screening annually. Please access their Clinical Practice Guidelines for a complete list of age-appropriate screenings.


IHA will also begin its annual HEDIS audit. From February through mid-May, IHA will be reviewing a random sample of IHA members’ medical records from various providers and practitioners. If your patients fall into this random sampling, you will receive a letter from IHA requesting medical record documentation.

For Billing questions, please contact Karin Bajak at 716-348-3923 or