BILLING UPDATES – APRIL 2014

MVP NEWS

MVP Health Care is offering Child Health Plus (MVP Option Child) in Genesee, Livingston, Monroe and Ontario counties, effective April 1, 2014.

EXCELLUS NEWS

MEDICAID MANAGED CARE AND FAMILY HEALTH PLUS PROGRAMS

Excellus will withdraw their Medicaid Managed Care and Family Health Plus programs from Cayuga, Clinton, Essex, Franklin, Madison, Onondaga and Tompkins counties effective April 1, 2014.

 

PROVIDER FILE UPDATES

Over the course of the next few months, Excellus will be conducting demographic data verification to ensure provider information on file is current.  If your office is contacted by Sutherland Global Services, please provide them with the necessary information.

 

MEDICAID – PRIMARY CARE RATE INCREASE (PCRI)

The NYS Dept. of Health recently revised the Primary Care Rate Increase. Eligible providers who missed the Aug. 1, 2013, attestation deadline for retroactive qualification may now re-attest and change their qualifying effective date for the PCRI program. To re-attest and change your PCRI effective date, use the PCRI Change/Update Attestation and Qualification form available via the eMedNY website at: www.emedny.org/info/ProviderEnrollment/physician/Option1.aspx.

The effective date must be between Jan. 1, 2013, and Dec. 31, 2014. The form should be submitted as soon as possible so that retroactive payment adjustments can be processed. If the original attestation included nurse practitioners/nurse midwives, you also need to complete and sign the form with an effective date within the supervising physician’s qualification period. If you are unsure of your effective date, check the Physician’s List spreadsheet available via the NYSDOH website at: www.health.ny.gov/health_care/medicaid/fees/.

The Physician List is updated on a regular basis and contains the effective date of each physician, labeled as

“PCRI Begin Date.” Most physicians already have an effective date of Jan. 1, 2013.

If your effective date is Jan. 1, 2013, you do not need to do anything. Physicians who are attesting for the first time must use the Primary Care Rate Increase Attestation form and specify an effective date for your qualification.

As a reminder, the PCRI applies to Evaluation and Management (E/M) and vaccine administration services and applies to Medicaid, Medicaid Managed Care and Family Health Plus members.

The managed care payment schedule has been updated to reflect a delay in PCRI funding for managed care plans. The delay is due to the Department working with CMS to secure federal funding and to set base rates. The Department´s anticipated payment date for Q1-Q3 2013 is May 30, 2014. This delay was unanticipated.

For additional information on PCRI, including access to the most current payment schedule and the provider attestation form, visit www.health.ny.gov/health_care/medicaid/fees/.

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

The Effect of The “Two-Midnights Rule” on Your Practice

By Emilie DiChristina, MBA for PracticeFirst

If your practice accepts Medicare and your providers admit those Medicare patients to hospitals you are aware of the Two-Midnight Rule for observation. The real question is…Is your practice ready for the ramifications of this rule’s effect on your patients?

Before we discuss the ramifications to the practice, we need to consider the what and why of the two-midnights rule. The why is that Medicare, in reviewing inpatient “admissions”, came to a conclusion that many of the admissions were not necessary. They did not go so far as to say that treatment or care in a higher level setting was not necessary, just that the conditions did not warrant admission.

As potential patients yourself, you may at this point be scratching your head and saying “Huh?”, but from this CMS finding arose the term “observation status” and since then, the ratio of observation stays to inpatient admissions increased at the rate of about 34% per year with current  discussion indicating that almost 20% of Medicare patients sent to the hospital for treatment are admitted under “observation status” versus “inpatient” stays.

Early on, hospitals and providers found that even though they were initially admitting patients as inpatients, retrospective reviews by CMS were resulting in a finding that “observation status would have been more appropriate”. The hospitals had money taken back for these admissions, the providers heard from the hospitals that observation should be used, and the system began to muddle as the financial ramifications clashed with the previously defined standards of care.

For Medicare patients sent to a hospital, they filled out paperwork, received admission packets, had a bed, treatment, tests and medications so for all they knew, they had been admitted.

But just like the hospitals and providers facing the financial ramifications of observation versus inpatient, the patients who thought they had been “an inpatient” now found out about this “observation” status when they started receiving bills for medications, provider visits, labs, diagnostic tests, and more. If the patient was unfortunate enough to have had an observation admission for a condition requiring rehab, or a stay in a SNF, the patients also found out that would not be fully covered by Medicare.

When a Medicare patient is admitted as “observation” their care is not covered by Medicare Part A — which covers a complete hospital stay once a one-time deductible is met; but Part B, instead, meaning that patients must pay part of their provider’ fees, and co-payments for labs, scans and hospital drugs. Medicare also does not cover rehab at a skilled nursing facility for observation patients. .

On Oct. 1, 2013, and recently upheld by a new law, Medicare created a rule dubbed the “two midnights rule” went into effect as a method of clarifying what is an observation stay and what is an inpatient stay.

The Connecticut-based Center for Medicare Advocacy, which has long opposed the Medicare observation policy, has said the new rule does nothing to help patients. “Prior to this two-midnight rule, if you thought someone was sick enough to spend the night in the hospital, then the hospital got reimbursed,” said Dr. Dan Fisher, a surgeon and the chief of staff at Erlanger Health System.

“Now you have to be sick enough to spend two nights in the hospital for it to count toward that. If you’re not sick enough to spend two nights, then Medicare is starting to say that you’re not very sick at all.”

So what effects of the “Two-Midnights Rule” may hurt your practice?

Your providers have more paperwork, and hassle at the hospital:

  • If your provider feels that a patient really needs an inpatient admission, they may have to complete a “medical necessity” form justifying the admission and somehow guessing the expected findings of tests, the success of treatment, the rapidity of the patient’s improvement.
  • The hospital Utilization Review staff may be calling asking that an inpatient visit be changed by the provider to an order for observation status.
  • The doctors may decide to refer patients to Hospitalists, avoiding this one more hassle

Your patients will not be happy and translate this unhappiness to your practice:

  • When the patient receives the first packet of bills, or finds out that their rehab is not covered, the complaints will be directed to the physician who admitted them. After all, you sent them to the hospital, you directed their care, you had the power of writing “inpatient” versus “observation”.
  • Your practice will also suffer from the customer satisfaction measures required as part of the ACA, as an unhappy patient who does not understand the reasons they are bearing all of the costs will certainly blame you.

Your practice finances suffer:

  • Reimbursement for observation is lower than for inpatient, critical care, etc.
  • A patient who is on a fixed income now has to pay co-pays, and lab fees, and drug costs, and possible SNF fees, so paying you may not even be possible, let alone high on the list of importance.

 

You may want to think about preparing a packed for your Medicare patients advising them of the role CMS plays in directing how any potential hospital admissions or care may be “named” and subsequently billed.

Be prepared to document any patient refusal to go to the hospital, which is a good rule for any patient, but in the case of the Medicare patient who may be refusing because of fear of an inability to pay. As word of the two-midnights rule begins to be discussed in senior communities, senior magazines and even in families, you may face more patients making this difficult