By Emilie DiChristina MBA for PracticeFirst

“Snowvember” and Your Medical Practice

If you were a medical practice in the South Towns or to the East of Buffalo your practice may have been adversely impacted by the recent snow storm for anywhere between 2 – 5 days.

So how did you handle the storm?

Employee Payroll:

Medical practices, like all small businesses have to have a set policy for human resource issues causes by weather events. If you listened to the radio or the TV you heard countless people worrying about their paychecks due to missed days, and/or disciplinary action if they could not get into a business that was open.

So? What is your practice policy? If you were closed did you pay your staff? Did you require them to use PTO or vacation time?

It gets more complicated if your practice remained open, but staff could not get in because of weather, closed roads, states of emergency. What is your policy for paying those who really could not get in safely?

Do your policies match both Federal and NY State Labor Law? The U.S. Department of Labor (DOL) has guidance regarding payroll obligations and rights when bad weather affects employee attendance. This guidance particularly warns employers to exercise caution in docking the pay of exempt employees who miss work because of inclement weather.

Exempt EmployeesPay when an employer closes because of inclement weather is governed by The Fair Labor Standards Act which prohibits you from reducing the pay of any exempt employee based on the quantity or quality of his work or when he is ready, willing, and able to work but no work is available.

As a rule, the Department of Labor takes the position that employers that decide to close because of weather conditions must pay exempt employees their regular salaries for any shutdown that lasts less than one full week. The good news is that nothing prevents the practice from requiring employees, including exempt ones, to use accrued vacation time or other time off to cover the missed work.

As most medical practices are considered private-sector employers, they may deduct absence due to bad weather from an employee’s remaining vacation or leave time, whether the absence is a full day or a partial day, so long as it pays exempt employees their regular salaries for that time.

The bad news is that if an exempt employee has no time off remaining, she still must be paid her regular salary when the organization is closed because of bad weather for less than a week. The The DOL states that employers must pay exempt employees for weather emergencies even if employee has no remaining accrued leave available.

But what if your practice was still open and exempt employees couldn’t make it in to the office?  The situation changes because even though the employee may experience bad weather conditions, if the office is open,she isn’t considered “ready, willing and able” to work meaning the basic FLSA rule applies: If an exempt employee fails to report to work because of inclement weather for an entire business day when you’re open for business, he may be docked that day’s pay. As a practical matter, many employers pay anyway or allow employees to use available vacation or PTO to cover the absence.

An employer that remains open for business during a weather emergency may lawfully deduct one full-day’s absence from the salary of an exempt employee who does not report for work for the day due to the adverse weather conditions.

Partial day deductions are not allowed, so the employee must receive a full-day’s pay for the partial day worked.”

Hourly Employees: Your practice can decide whether to pay non-exempt employees for snow days because the FLSA doesn’t have the same requirements as for Exempt Employees.  You may allow or require non-exempt employees to use vacation or PTO to cover the absence, but that isn’t a requirement.

Work From Home?: With the advent of EMR and EPMs, there is some work that may be able to be done from home in the event of a weather emergency. But…what is your policy? Do you have secure VPNs to avoid potential HIPAA violations? What about the on-call schedule?

So it makes sense for an hour or so per day to be worked at home for an assigned receptionist or manager to call and reschedule patients – is this done in a secure fashion?  How are your tracking staff time?

What about your transcriptionists or coders? Do you have a policy and VPN setup for that?

And then there is the on-call schedule. One person can handle call when there is receptionist triage, and patient appointments haven’t been cancelled, but what about the calls coming in from patients who may have been cancelled for an entire week and/or cannot be seen for a month or more after being rescheduled? What is your plan for secondary and tertiary call? What about pain scripts?

Accomodating Cancelled Patients: It is extremely important to have a plan to accommodate patients who have been cancelled, particularly when they may be post-op, or have time driven issues for medications, tests, etc. Will you expand your office hours until caught up? Can you add a Saturday or two?

In closing, it is important to have policies and a plan! Minimally, your plan should include:

  • Annual review of your policies and practices so all of your employees understand how absences due to bad weather will be handled from a payroll and attendance-tracking standpoint.
  • Information for employees and patients on how office or facility closures will be communicated and who decides whether to close or remain open;
  • Policies for handling employees who are able to report to work but have children whose schools or daycare facilities are closed (can children be brought to work?)
  • Which employees are permitted to work from home and what conditions apply (e.g., use of VPN, requirements for remaining available via computer or telephone);
  • How eligibility for pay will be determined if you choose to pay employees who are unable to report to work because of bad weather conditions, even when the office is open for business and the law doesn’t require you to pay them (employees who’s regular commute would involve travel through a county where a snow emergency was declared or over roads that were closed by local law enforcement authorities)
  • Whether non-exempt employees who miss work because of weather conditions and aren’t eligible to be paid may make up some or all of the time missed within the same workweek.<


By Lisa Kropp, Coding and Credentialing Manager


As you know, each year there are updates to CPT and HCPCS codes. During December, we will provide you with a list of the discontinued CPT codes effective January 1, 2015. The 2015 HCPCS code books are also not yet available.  However, CMS has published files for 2015 which can be found by visiting: http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html


As a reminder…..CMS has established four new HCPCS modifiers to define subsets of the -59 modifier

CPT Definition of -59 Modifier: Distinct Procedural Service

Purpose of Subsets:

  • Prevent Fraud & Abuse
  • Reduce number of reviews & appeals
  • Help providers assign this code properly

New Modifiers & Meanings:

  1. XE Modifier: Separate encounter i.e. a service that is distinct because it occurred during a separate encounter.
  2. XS Modifier: Separate structure i.e. a service that is distinct because it was performed on a separate organ/structure.
  3. XP Modifier: Separate Practitioner i.e. a service that is distinct because it was performed by a different practitioner.
  4. XU Modifier: Unusual Non-Overlapping Service i.e. the use of a service that is distinct because it does not overlap usual components of the main service


  1. Implementation date is January 5, 2015.
  2. CMS will continue to recognize the -59 modifier, but it should NOT be used in addition to these new modifiers because they are more descriptive.
  3. CMS may make the use of these modifiers mandatory when used to bill certain codes that are considered at high risk for incorrect billing.

These modifiers are valid even before national edits are in place.  Providers are encouraged to use the more selective modifiers. MAC’s are not prohibited from requiring the use of selective modifiers in lieu of the general -59 modifier.

If you would like more information about how we can tailor our services to meet your needs, please contact Lisa Kropp; Coding & Credentialing Manager at 716.348.3904 or lisak@pracfirst.com<


By Becky Amann, Compliance Officer



MVP has issued letters to the provider community regarding provider’s attestation to monitoring of the Exclusionary Databases on OIG’s website. MVP implemented a new policy requiring provider groups to attest that they are monitoring their employees, staff and agents associated with the group, against the exclusionary database on a monthly basis. This policy is located in section 4.17 of MVP’s Provider Resource Manual, which can be located on their website at:https://www.mvphealthcare.com/provider/documents/MVP_Health_Care_ProviderResourceManualSection_4_ProviderResponsibilities.pdf

The attestation form must be completed and returned to MVP by December 31, 2014.

The form can be faxed to 585-327-5747. The attestation is located on their website at:http://www.mvphealthcare.com/provider/documents/MVP_Health_Care_Provider_Attestion_Monitoring_Exclusionary_Databases.pdf


Univera has also notified the provider community in a bulletin dated November 10, 2014 regarding Medicaid Employment Compliance Requirements. This notification refers to monitoring the exclusionary database on a monthly basis. The notification included an attestation to be completed by providers. Unfortunately the attestation is not located on their website. If you did not receive this notification from Univera, please contact your provider relations representative at Univera or Becky Amann at Practicefirst for a copy.

OIG 2015 WORK PLAN – Released 10/31/14

The Office of Inspector General (OIG) has issued their Work Plan for 2015 which summarizes new and ongoing reviews and activities that they will pursue.

New investigations in 2015:

MCO payments for services after beneficiaries’ death: The OIG will identify Medicaid managed care payments made on behalf of deceased beneficiaries. They will also identify trends in Medicaid claims with service dates after the beneficiaries’ dates of death. Prior OIG reports have found that Medicare paid for services that purportedly started or continued after the beneficiaries’ date of death.

MCO payments for ineligible beneficiaries: The OIG will identify Medicaid managed care payments made on behalf of beneficiaries that were not eligible for Medicaid. Prior OIG work has found that Medicaid paid for services that purportedly started or continued during periods where the beneficiary was not eligible for Medicaid.

Continuing investigations in 2015:

Nursing Home Stays: The OIG will continue to identify questionable billing patterns associated with Medicare providers for Part B services provided to nursing home residents during stays not paid under Part A. For example, stays during which benefits are exhausted or the 3-day prior-inpatient-stay requirement is not met. Several broad categories of services, such as foot care will be examined.

Hospitalizations of nursing home residents for manageable and preventable conditions: The OIG will determine the extent to which Medicare beneficiaries residing in nursing homes are hospitalized as a result of conditions thought to be manageable or preventable in the nursing home setting. Hospitalizations of nursing home residents are costly to Medicare and may indicate quality-of-care problems in nursing homes.

Anesthesia Services: The OIG will continue to review Medicare Part B claims for personally performed anesthesia services to determine whether they were supported in accordance with Medicare requirements. They will also determine whether Medicare payments for anesthesiologist services reported on a claim with the “AA” modifier met Medicare requirements. Reporting an incorrect modifier on the claim, as if services were personally performed, when they were not, will result in Medicare paying a higher amount.

Ophthalmological Services: The OIG will continue to review Medicare claims data to identify potentially inappropriate payments and/or questionable billing for ophthalmological services during 2012. The OIG will determine the locations and specialties of providers with questionable billing.

Place of Service Coding Errors: The OIG will continue to review physicians’ coding on Medicare Part B claims for services performed in ambulatory surgical centers and hospital outpatient departments to determine proper coding of the place of service. There is concern that physicians are reporting the place of service as non-facility (office), when in fact services were rendered at a facility which would generate a lower payment.

Payments for outpatient drugs and administration of drugs: The OIG will continue to review Medicare outpatient payments to providers for certain drugs (e.g. chemotherapy drugs). Review of billed units will determine if overpayments have occurred due to incorrect coding or overbilling of units.

All practices and facilities should read the OIG Work Plan in its entirety and take steps to identify and rectify any potential issues they may have, before the OIG does.

The full 2015 Work Plan can be accessed at: http://oig.hhs.gov/reports-and-publications/archives/workplan/2015/FY15-Work-Plan.pdf

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


By Sarah Howarth, Billing Manager



The Medicare Part B annual deductible for 2015 remains at $147.00 for the third straight year. Co-insurance remains at 20%.


On April 1, 2014, President Obama signed into law the Protecting Access to Medicare Act of 2014. This new law prevented a schedule payment reduction for physicians and other practitioners in 2014. It also provides a zero percent update to the 2015 Medicare Physician Fee Schedule through March 31, 2015.


As the New Year approaches please keep in mind patient insurance coverage and benefits may change.  Please review each patient’s insurance card for updated subscriber information.

Subscriber Information

Beginning December 1, 2014 please include subscriber name and relationship to patient in the patient demographic information.  Effective December 1, 2014 some carriers are requiring this information be provided on claims when the patient is the dependent.

All providers submitting demographic information to Practicefirst via paper format will need to include subscriber name, patient relationship to subscriber and responsible party name.  Patient information forms will need to be updated to include this information.

Practicefirst will be working with software vendors for our upload clients to ensure this information is included.  Claims submitted without this information will be rejected for “patient billed as the subscriber, no patient information is provided.”

These carriers also remind providers of the importance of accurate patient information on claim submission.  This includes patient name spelling, date of birth and gender.



Effective 11/18/2014 for 30 days or until the state of Emergency has been lifted, Excellus and Univera will implement the following processes for Cattaraugus, Chautauqua, Erie, Franklin, Genesee, Herkimer, Jefferson, Lewis, Oswego, Wyoming and neighboring counties

  • Preauthorization: We will relax preauthorization requirements for all applicable health care services (as required by the member’s contract) if you are unavailable to obtain or request preauthorization. We will also allow you to backdate preauthorization requests for dates of service beginning November 18, 2014 through the 30-day window, or until the state of emergency has been lifted. Please contact our Medical Intake Unit at 1-800-610-1113 (Univera Healthcare) or 1-888-638-7149 (Univera Community Health) to request a backdated preauthorization.
  • Out-of-network access: Members can use out-of-network facilities if they are unable to access in-network facilities due to weather conditions.
  • Concurrent and prospective reviews: Beginning November 18, 2014, and through the 30-day window, or until the state of emergency has been lifted, we will allow late requests for concurrent reviews, or for prospective reviews that need a decision sooner than our standard three business day time frame.


Excellus member benefit/cost-sharing may be obtained via Excellus website or customer service call.

  • PCP copay applies to the majority of Excellus products
    • ID numbers have a 3 letter prefix and start with “20”
      • ie: VYP201436920 or VND201576335
  • Specialist copay applies to Medicare Advantage members
    • ID numbers start with VYM or VYU
  • No copay for Medicaid or Child Health Plus products
    • ID numbers start with VYT or VYB (or no prefix for Premier Option products)
  • $5 copay for Family Health Plus products
  • Urgent Care specific copay applies to members with insurance coverage through:
    • Federal Employee Plan (ID number starts with “R”)
    • Paychex (ID number starts with “PAY”)
    • Rochester General Hospital System (ID number starts with “HVL”)
    • IBEW (ID number has no prefix – identify by ID card)
    • Constellation Brand (ID numbers start with CSP & CBL)

Excellus and Univera Evaluation and Management Coding

The Centers for Medicare & Medicaid Services has identified Evaluation and Management coding as an area that has significant opportunity for improved accuracy (e.g. lower level coding in their estimation).

Effective with dates of service on and after January 1, 2015, Excellus and Univera are implementing new clinical edits that will adjust the level of E/M codes when they deem appropriate, using the following methodology.

The claim edit will compare all of the diagnosis codes on the claim with the procedure codes billed.  If the E/M code is not supported by the diagnosis codes, the E/M will be reduced 1 or 2 levels.  As always, your documentation should support the E/M billed, thus a clinical editing dispute may be filed on your behalf.

Provider Relations Representatives from these insurance carriers are meeting with offices that have billing patterns that vary from medical peers.  The new clinical edits will be effective on November 15, 2014, for providers who received notices from Excellus and/or Univera.  Please notify Practicefirst if you receive any communication from one of these carriers regarding a request to meet with you to review your coding practices.

The edits will be used for all other providers beginning January 1, 2015.  It is not expected that this clinical edit will impact the majority of providers.  The stated intention of the edit is to ensure accuracy of your coding efforts.

Facility Network Policies

Insurance carriers are offering plans tailored to a specific network of facilities.  These products are developed through a collaborative partnership with a group of hospitals and providers.  The plans are designed to provide members with lower cost insurance options.  Patients must receive services at a participating facility for the services to be covered by their insurance.  Please check plan benefits for specific facility networks.  Two examples are below.


Blue Cross BlueShield of Western New York Senior Blue HMO Select Medicare Advantage (effective 1/1/2015)

  • Product includes every doctor and specialist in the Senior Blue network and local hospitals such as Buffalo General Hospital, Gates Vascular Institute, Roswell Park, and Erie County Medical Center (ECMC).
  • Product does not include facilities of the Catholic Health System such as Sisters of Charity, St. Joseph Campus, Kenmore Mercy and Mercy Hospital of Buffalo.
  • Emergency room visits are covered anywhere, regardless of the patient’s product or where the patient presents.
  • This is the only Blue Cross Medicare Advantage product that does not include the Catholic Health System facilities.

Independent Health Network Advantage

  • Tier A Network includes Bertrand Chaffee, Brylin, Buffalo General, Buffalo Mercy, DeGraff Memorial, Eastern Niagara, Kenmore Mercy, Millard Fillmore, Mount St. Mary’s, Roswell Park Cancer Institute, Sisters of Charity, Sisters of Charity – St. Joe’s Campus, Women’s & Children’s and All Outpatient Ambulatory Surgical Centers (in Erie and Niagara County).
  • Tier B Network includes ECMC, Niagara Falls Memorial, network hospitals and outpatient Ambulatory Surgical Centers outside of Erie and Niagara County.

Other insurance carriers are offering similar policies.  Please check plan benefits for specific facility networks.

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