REVISIONS IN EXCELLUS CUTS DISCUSSED IN NOVEMBER 2013 BILLING UPDATES

In our November Billing Update we advised you of the following regarding Excellus based Medicaid Managed Care and FHP Programs. The area which would have affected practices who are clients of PracticeFirst would have been those servicing Orleans County.

As of the first week of November, 2013 – Excellus has reversed its decision after having worked out a plan with health-care providers that will allow it to continue offering coverage for more than 100,000 individuals covered through the Medicaid Managed Care and Family Health Plus programs in seven counties, including 2,300 in Orleans.

While these cuts have been adverted through collaborations between Excellus/Monroe Plan and Rochester area hospitals to cut costs, but this will still be of benefit to those of our clients who care for patients under these plans.

EXCELLUS

On October 8, 2013, Excellus announced that they notified the NYS DOH that it will be withdrawing from the Medicaid Managed Care and Family Health Plus programs during the first quarter of 2014. The health plan has been incurring losses in 2013 and expects the same to occur in 2014, which they cannot sustain. The county withdrawals are planned with the following time frame:

  • January 1, 2014: Jefferson, Lewis, St. Lawrence, Schuyler, Steuben, Chemung and Oswego
  • February 1, 2014: Livingston, Ontario and Wayne
  • March 1, 2014: Monroe, Yates and Orleans
  • April 1, 2014: Broome, Onondaga, Seneca, Madison, Cayuga, Otsego, Tompkins, Herkimer, Clinton, Essex, Franklin and Oneida

Members of these plans will be transitioned to Medicaid fee-for-service where no health plan choice exists or to another managed care plan where one does. The decision to withdraw from these programs does not apply to Child Health Plus or their Medicare products.

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

PRACTICEFIRST’S BILLING UPDATES – NOVEMBER 2013

By Becky Amann, Billing and Compliance Manager

Physician Quality Reporting System (PQRS) Requirements for Medicare Claims

To avoid the 2015 Medicare payment reduction of 1.5%, providers must fulfill the  reporting requirements for PQRS.   Preventing this payment reduction is as simple as reporting on one quality reporting measure for one Medicare patient by the end of 2013.  All Practicefirst clients are eligible to report as an individual provider.*  Providers are not required to register in order to report as individuals.

Medicare has offered eligible providers a variety of reporting options.  Below is a brief summary of important points that may apply to you:

  •  Providers may opt to report through a 3rd party registry, an EMR or by adding appropriate coding to their claim when billed
  • Providers who select claim reporting must add the appropriate numerator quality-data code to the claim
  • There are 328 quality reporting measures to select from.
  • Measure requirements are driven by diagnosis and procedure codes
  • 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.

For additional details on PQRS reporting requirements visit the following link: http://www.cms.gov/apps/ama/license.asp?file=/pqrs/downloads/2013_PQRS_MeasuresGroupsSpecs_ReleaseNotes_SupportingDocs_03042013.zip
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Select the option to open the documents

Open: 2013_PQRS_MeasuresGroups_SpecificationsManual_12192012.pd

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

·     Summary of Medicare payments from 2012 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.

 

Providers must notify Practicefirst by November 15, 2013 if they intend to meet the requirements to avoid the 2015 Medicare payment reduction.

 

*The deadline for group reporting has passed, providers must report individually to avoid the 2015 payment adjustment.

 

UNIVERA

UPCOMING ELECTRONIC PREAUTHORIZATIONS

Univera will soon be introducing their Clear Coverage electronic preauthorization capability. This tool will be accessible via the provider portal of their website. Univera indicates that this feature will provide faster turn-around times to ensure appropriate responses for service requests that require preauthorization. A pilot program will be rolled out to a small group of providers in the last quarter of 2013 and should be operational for all providers in 2014.

FAX NUMBERS FOR MEDICAL RECORDS

Medical records that have been requested by Univera should be faxed to 1-877-220-7323. The fax should include a cover letter, Univera’s medical record request letter (allows electronic sorting of your fax), followed by the medical record. Each medical record request should be faxed separately. Medical records submitted for the purpose of claim adjustments should not be faxed to the above number, but handled per the instructions on their claim adjustment form.   

MVP HEALTH CARE

In a FastFax dated October 15, 2013, MVP Health Care announced they will not be offering Individual Products in Erie and Niagara counties in 2014. They have not extended contracts to providers in these two counties for those products. This means that providers in these two counties will be non-participating for MVP members in Individual Products offered by MVP in other counties. MVP participating providers in Erie and Niagara counties will continue to be participating with MVP for the products for which they are currently contracted. For most providers, those products include Group Commercial Business and Medicare. MVP will be providing ID card templates during the latter part of October and into November in order to educate providers on MVP’s new products.

EXCELLUS

On October 8, 2013, Excellus announced that they notified the NYS DOH that it will be withdrawing from the Medicaid Managed Care and Family Health Plus programs during the first quarter of 2014. The health plan has been incurring losses in 2013 and expects the same to occur in 2014, which they cannot sustain. The county withdrawals are planned with the following time frame:

  • January 1, 2014: Jefferson, Lewis, St. Lawrence, Schuyler, Steuben, Chemung and Oswego
  • February 1, 2014: Livingston, Ontario and Wayne
  • March 1, 2014: Monroe, Yates and Orleans
  • April 1, 2014: Broome, Onondaga, Seneca, Madison, Cayuga, Otsego, Tompkins, Herkimer, Clinton, Essex, Franklin and Oneida

Members of these plans will be transitioned to Medicaid fee-for-service where no health plan choice exists or to another managed care plan where one does. The decision to withdraw from these programs does not apply to Child Health Plus or their Medicare products.<