By Tom Mahar, President and CEO
NEW YEAR, NEW INSURANCE
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 and forward any pertinent changes to Practicefirst to ensure claims are submitted correctly.
CENTERS FOR MEDICARE AND MEDICAID (CMS)
PQRS INFORMAL REVIEW PROCESS
We have received numerous letters from CMS for our clients that indicate PQRS criteria has not been met and payment adjustments will occur, reducing Medicare payments by 2% for 2016 dates of service. We have forwarded the letters to the applicable clients.
If you received a letter from CMS regarding reduction in payments and believe you have been incorrectly assessed, you have until the end of the day on December 16, 2015 to submit an informal review. Requests must be submitted via the Quality Reporting Communication Support Page at: https://www.qualitynet.org/portal/server.pt/community/pqri_home/212
As mentioned in previous communications with our providers, Practicefirst recommended to report via a PQRS Qualified Registry. By utilizing a registry, providers become eligible for measures group reporting, thus decreasing the required number of patients to report on.
As a reminder, due to the increasing requirements of PQRS reporting, Practicefirst no longer provides PQRS reporting services to providers at a reasonable cost.
MEDICARE PART B DEDUCTIBLE / CO-INSURANCE
The Medicare Part B annual deductible for 2016 has increased to $166.00. Co-insurance remains at 20%.
COLORECTAL CANCER SCREENING – CLAIMS PROCESSING ISSUE
Due to an increase in inappropriate denials, CMS has expedited an update to National Coverage Determination (NCD) 210.3, Colorectal Cancer Screening Tests. CMS is taking action to have Medicare Administrative Contractors correct inappropriate denials of HCPCS code G0105 with ICD-10 code Z86.010 where they exist. Appropriate payment will be made for these procedures within 45 days. No action is needed by providers.
NATIONAL GOVERNMENT SERVICES (NGS)
CHANGE IN PROCESSING CLAIMS FOR NON-COVERED ICD-10 DIAGNOSIS CODES
Effective for claims received January 1, 2016, with dates of service 10/1/2015 and after, claims submitted with a combination of non-covered routine diagnosis codes and payable diagnosis codes will be considered for payment. Providers that submit claims with the intent of denial for supplemental insurance will no longer be able to submit a routine diagnosis for denial unless all of the reported diagnosis codes are routinely non-covered. A combination of the routine diagnosis and the use of “GY” modifier will be required for denial.
PRE-OPERATIVE TESTS DENIED IN ERROR
NGS announced on November 13th, that some claims for pre-operative tests, (e.g., EKGs, chest X-rays), denied in error due to an editing issue. These pre-operative services are covered, if there is medical necessity as reflected by a clinical diagnosis on the claim and they are not simply being performed as routine pre-operative tests. The claims which denied for these tests incorrectly, will be reprocessed by NGS. No provider action is required.
Railroad Medicare will be conducting a service-specific review of E&M CPT code 99223. Railroad Medicare selected this code based on internal data analysis. Please be aware that medical documentation may be requested to review these particular services. At the conclusion of their review, they will publish their findings on their website.
HEALTH REPUBLIC INSURANCE
It was previously announced that Health Republic would be closing as of December 31, 2015. However, the NYS Dept. of Financial Services and CMS have announced Health Republic is closed effective November 30, 2015.
The sudden closure of Health Republic meant their 200,000 members had to find another plan for the remainder of 2015 before November 15th. The NYS Departments of Health and Financial Services announced agreements with three health insurers (Excellus, Fidelis and MVP) to enroll Health Republic members who did not voluntarily pick a new plan by November 15th.
NYS indicated that claims processing payments would cease on or around November 5, 2015 and are hopeful that “modest payments” on outstanding claims may be made in the future.
The Greater New York Hospital Association indicated it will “aggressively push for legislation to establish a health insurance guarantee fund that would not only protect health care providers in the event of an insurer insolvency, but also be able to make retroactive payments.”
INDEPENDENT HEALTH (IHA) NEWS
MEDSOURCE PRODUCT ENDS 12/31/15 IN NIAGARA COUNTY
IHA will no longer be offering their MediSource (IHA’s Medicaid Managed Care product) in Niagara County effective December 31, 2015. All other IHA products, including Child Health Plus will remain in effect. They are in the process of notifying their members of other options to continue their coverage through another Medicaid Managed Care plan.
ESSENTIAL PLAN EFFECTIVE 1/1/16
IHA has been approved by NYS to administer a new plan beginning January 1, 2016, named the Essential Plan. This is a new program through the NYS of Health and should help fill the gaps that were created by the discontinuance of Family Health Plus and certain Medicaid plans. IHA will offer four versions of the Essential Plan in Erie and Niagara counties. The same reimbursement applies as this plan is part of IHA’s portfolio of Government Funded Programs.
Members will have “Essential Plan Program” on their identification cards, followed by the number 1, 2, 3 or 4. Member copays will vary, so please check WNY Healthenet for benefit details for your patients.
The plan covers essential health benefits, including inpatient and outpatient care, physician services, diagnostic services and prescription drugs. There is no annual deductible and has low out-of-pocket costs. Preventive care such as routine office visits and recommended screenings have no out-of-pockets expenses for members.
If you have any questions regarding this new plan, please contact IHA’s Provider Relations Department at email@example.com.
CHANGE IN MEDISOURCE / CHILD HEALTH PLUS COVERAGE FOR NURSE PRACTITIONERS
Effective January 1, 2016, Independent Health will be updating services that Nurse Practitioners (NP’s) may perform to align with NYS Medicaid coverage for their MediSource and Child Health Plus members. Some of the services that will be affected by this coverage change include:
- Providers of Consultation E&M Services
- Providers of Critical Care E&M Services
- Select OB and GYN Services
- Select Psychotherapy Services
- Select Laboratory/Pathology Services
For a complete list of services that will be covered when performed by NP’s, please reference the Nurse Practitioner Provider Manual on the NYS Medicaid Provider Portal at www.emedny.org.
UNIVERA NEWS – MOBILE ID CARDS
Mobile Identification cards are now available to Univera members. If a member uses his or her mobile ID card at your office, the mobile ID card will display exactly like a hard copy of the ID card. You will be able to view the front and back of the ID card. If you have questions regarding these new cards, contact Customer Care at 1-866-265-5983.
For Billing questions, please contact Tom Maher at 716-834-1193 or tom@pracfir