by Becky Amann, Compliance Manager



CMS’s website contains a Provider Compliance section that provides Compliance-related and Fraud and Abuse-related resources. This section includes a link to their “Fast Facts” that is updated regularly. Some of the topics include Preventive Services, Evaluation and Management Services, Hospital Discharge Day, Medical Necessity Documentation…. just to name a few.

These resources are located at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ProviderCompliance.html


CMS in conjunction with the NYS Office of the Medicaid Inspector General (OMIG) will be measuring improper payments for Medicaid and Child Health Plus programs, under the Payment Error Rate Measurement (PERM) program.

Documentation for medical review of randomly selected claims will be requested by Chickasaw Nation Industries Advantage, LLC, who is the new CMS review contractor. Requests for documentation began in May and could be requested for claims paid during the timeframe of October 1, 2016 through September 30, 2017.

Failure to provide the requested documentation will result in a determination of erroneous payment and OMIG will pursue recovery.

Please ensure your staff is aware of these documentation requests.



A recent report issued by the Office of the Inspector General (OIG) has indicated that providers may not be informing CMS of ownership changes. Providers must update their enrollment information within 30 days of any changes in ownership.

Owners are individuals or corporations with a 5 percent or more ownership or controlling interest. Failure to comply could result in revocation of your Medicare billing privileges. Please refer to the following MLN Matters Article for further information:


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


by Becky Amann, Director of Compliance


In June, the OIG reported that Medicare has paid millions of dollars in Electronic Health Record (EHR) Incentive Payments that did not comply with Federal Requirements.

As an incentive for using certified EHR technology, the Federal Government makes payments to Eligible Professionals (EP’s) that attest to “meaningful use” of EHR’s, by self-reporting data to the Centers for Medicare and Medicaid Services (CMS).

The OIG reviewed EHR incentive payments that Medicare issued to EP’s from May 2011 to June 2014 and selected a random sample of EP’s who received payment. Based on the sample reports, the OIG has estimated that CMS inappropriately paid $729.4 million to EP’s who did not meet the meaningful use requirements.

The OIG has recommended that CMS recover $291,000 in payments made to the sampled EP’s who did not meet meaningful use requirements. In addition, the OIG recommends that CMS review EP incentive payments to determine which EP’s did not meet meaningful use for each program year to attempt to recover the $729.4 million in estimated inappropriate incentive payments.

For OIG’s full report, please access their website at: https://oig.hhs.gov/oas/reports/region5/51400047.asp

For Compliance questions, please contact Becky Amann at 716-389-3202 or beckya@pracfirst.com


By Becky Amann, Compliance Manager


The Centers for Medicare and Medicaid Services (CMS) has recently reminded providers regarding their MLN publication pertaining to HIPAA Basics for Providers: Privacy, Security and Breach Notification Rules.

PF will be utilizing this document as part of our ongoing employee training regarding HIPAA.

This publication is located: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/HIPAAPrivacyandSecurity.pdf

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




As part of its continued efforts to assess compliance with the HIPAA Privacy, Security and Breach Notification Rules, the HHS Office for Civil Rights (OCR) has begun its next phase of audits of covered entities and their business associates.

The audit process begins with verification of an entity’s address and contact information. This is handled through an e-mail sent to covered entities (CE) and business associates (BA) requesting that their contact information be provided to OCR in a timely manner. Once verification has been received, a pre-audit questionnaire will be transmitted to gather data from the CE. OCR will ask that the covered entity identify their business associates. They are encouraging covered entities to prepare a list of each business associate with their contact information, so they are able to respond to this request. The data that is gathered will be used along with other information to create a potential audit subject pool.

If a CE or BA does not respond to OCR’s request for verification or their pre-audit questionnaire, OCR will use publically available information about the entity to create its audit subject pool. Therefore, if no response is received, the entity may still be selected for an audit or be subjected to a compliance review.

Please check your junk or spam e-mail for any e-mails from OCR. As your business associate, please notify Becky Amann at Practicefirst, should you receive any e-mails from the OCR regarding a Phase 2 audit. This will allow us to watch for any e-mails from OCR as well.

Additional information regarding Phase 2 of the HIPAA Audit Program is available at: http://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/audit/index.html

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


by Becky Amann, Director of Compliance


The Office of Inspector General (OIG) has issued their Work Plan for 2016 which summarizes new and ongoing reviews and activities that they will pursue.

New investigations in 2016:

  • Physicians – Referring/ordering Medicare services and supplies:

The OIG will review select Medicare services and supplies referred/ordered by physicians and non-      physician practitioners to identify whether the payments were made in accordance with Medicare       requirements. CMS requires that physicians and non-physician practitioners who order certain services       and supplies are required to be Medicare-enrolled physicians or non-physician practitioners and legally       eligible to refer/order services and supplies. If they are not eligible, Medicare should not make payment       on the claims.

  • Anesthesia non-covered services

The OIG will review Medicare Part B claims for anesthesia services to determine whether they were       supported in accordance with Medicare requirements. Specifically, they will review anesthesia       services to determine whether the beneficiary had a related Medicare service. Medicare will not pay for items or services that are not “reasonable and necessary.”

  • Prolonged services – reasonableness of services

            The OIG will determine whether Medicare payments to physicians for prolonged evaluation and  management (E&M) services were reasonable and made in accordance with Medicare requirements. Prolonged services are for additional care provided to a beneficiary after an E&M service has been performed. Physicians submit claims for prolonged services when they spend additional time beyond  the time spent with a beneficiary for a usual companion E&M service. The necessity of prolonged             services is considered to be rare and unusual.

Continuing investigations in 2016:

  • Imaging Services: The OIG will review Medicare Part B payments for imaging services to determine whether they reflect the expenses incurred and whether the utilization rates reflect industry practices. For selected imaging services, they will focus on the practice expense components, including the equipment utilization rate. The report on their findings is expected to be issued in 2016.
  • 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. The report on their findings is expected to be issued in 2016.

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 2016 Work Plan can be accessed at:


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


By Becky Amann, Compliance Manager

Medicare – Exclusions From Coverage

National Government Services (NGS) recently published an article regarding: Charges Imposed by Immediate Relatives of the Patient or Members of Household. NGS has recently identified claims submitted by providers who furnished services to their immediate relatives or to members of their household. Medicare does not pay for these services, since they are ordinarily furnished gratuitously because of the relationship between the Medicare beneficiary and the provider. Immediate relatives are defined as:

  • Husband or wife
  • Natural or adoptive parent, child and sibling
  • Stepparent, stepchild, stepbrother or stepsister
  • Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law or sister-in-law
  • Grandparent or grandchild
  • Spouse

A step-relationship and an in-law relationship continue to exist even if the marriage upon which the relationship is based terminates through divorce or death of one of the parties.

Members of Household are defined as:

Persons sharing a common abode with the patient as part of a single family unit, including those related by blood, marriage or adoption, domestic employees and others who live together as part of a single family unit. A mere roomer or boarder is not included.

This Medicare exclusion applies whether the provider is a sole proprietor who has a relationship (as identified above) to the patient, or a partnership in which one of the partners is related to the patient.

Please refer to the Medicare Benefit Policy Manual, Chapter 16, Section 130 for further information regarding these exclusions from coverage. The Medicare manuals are located on CMS’s website under their Guidance section at:


*** Please note: These exclusions also pertain to Medicare Advantage Plans ***

Univera – Risk Adjustment Review of Medical Records

Univera has contracted with Verisk Health to retrieve medical record documentation from providers. The record retrieval is a necessary part of their Risk Adjustment Program that is designed to capture the medical complexity of their Medicare Advantage members. CMS requires Medicare Advantage plans to confirm that the diagnosis codes submitted via claims are supported in the medical records. The record review also ensures the documentation properly reflects the clinical conditions of the patient.

Verisk Health will begin contacting selected providers in July to schedule the retrieval of medical records reflecting services rendered from January 1, 2014 to present.

For Compliance questions, please contact Becky Amann at 716-348-3902 or beckya@pracfirst.com<


By Sarah Howarth, Billing Manager

Univera News

Univera & Excellus ID Cards

Members enrolling in the Univera Medicare or Excellus Medicare coverage on or after June 30, 2015 will be issued identification cards with subscriber ID numbers that begin with the letter “M”.  There will be no change to ID numbers for existing Medicare members.

Univera Community Health

On or after July 1, 2015, Univera Community Health will be changing its name and launching a new website.  No other information is available at this time.  Practicefirst will keep you updated as information is released.


DXA Scan Screening:


Effective July 1, 2015, Univera Community Health will adopt the New York State Department of Health policy regarding DXA scan reimbursement limitations for members who have Plus Med Coverage.


Reimbursement for medically necessary DXA scans will be limited to once every two years for:

  • Women ages 64 and older and men ages 70 and older
  • Women and men ages 50 and older who have significant risk factors for osteoporosis (e.g. post-menopause; family history of osteoporosis; use of certain medications, including some steroids and chemotherapy agents, etc.)
  • Individuals regardless of age, preparing to or currently taking Depo-Proveraa

Copay Update Reminder For Ultrasounds Rendered to Medicare Advantage Members

Univera has updated its claims processing system to apply an X-Ray copay to ultrasounds rendered to Medicare Advantage members. This service was previously applying a Diagnostic Radiology copay, which was inaccurate. Diagnostic radiology copays should only apply to higher-cost tests such as CT, MRI and PET Scans.

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



To protect seniors from identity theft, President Obama recently signed a bill that requires the Dept. of Health and Human Services (HHS) to issue new Medicare cards that do not display beneficiaries Social Security Numbers.

The new bill gives HHS four years to issue new cards to new beneficiaries and four more years to issue new cards to existing beneficiaries. This will take time, planning and effort for HHS to develop an identifier to replace the SSN and then issue new Medicare cards.

The announcement can be viewed at the Office of Inspector General’s, Social Security Administration website at: http://oig.ssa.gov/newsroom/blog/apr29-medicare-card-SSN

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


By Sarah Howarth, Billing Manager

On March 27, 2015 electronic prescribing of all controlled and non-controlled prescriptions will be mandatory for all prescribers in New York.  E-Prescription is defined as a prescription that is created, recorded and transmitted electronically.  E-Prescriptions are transmitted directly from the prescriber to a pharmacy or pharmacist.  Prescriptions generated on an electronic system that is printed out or faxed prescriptions do not meet the requirements of E-Prescribing.

Providers may request a waiver to E-Prescribe if they meet one of the following criteria:

  • Economic hardship
  • Technological limitations that are not reasonably within the control of the practitioner
  • Or other exceptional circumstance demonstrated by the practitioner

Waivers are granted for a time period of one year.  To request a waiver from E-Prescribe contact the New York State Department of Health at 866-811-7957, option 1.


Currently, Univera Healthcare and Monroe Plan for Medical Care are partners in Univera Community Health.  In July of 2015, Monroe Plan for Medical Care will become the sole owner of Univera Community Health.  A new name for the Community Health product will be released at that time.  Univera Community Health encompasses the PlusMed and Child Health Plus products.  Additional information will be released closer to the transition date.

UNIVERA Medicare Advantage

Effective January 1, 2015, if observation services are required for Univera Medicare Advantage patients, the member cost-sharing for these services will be included in the cost-sharing for hospital outpatient services.  The member will not pay a separate copayment for observation services.  If the patient’s status is changed to inpatient, only an inpatient copayment will be applied.

Independent Health Medicare Advantage

IHA Medicare Advantage is introducing a new “Enhanced Annual Visit” (EAV) for patients seen between January 1 and June 30, 2015.  The visit incorporates many of the services that are already provided during preventive and wellness visits, with an expanded focus on assessment and management of chronic diseases.  The EAV is reimbursed only once per calendar year for Primary Care Practitioners only, using the HCPCS code G8496. Reimbursement for the EAV performed between January 1 and June 30, 2015 is $300.00. Any additional preventative or wellness visits performed during the same calendar year, by the same provider group will be denied.  The EAV will be denied if a preventative and annual wellness visit has already been performed during the same calendar year by the same provider group.

In order to receive payment for the Medicare Advantage Enhanced Annual Visit (EAV), all of the following criteria must be met. Upon record review, if all criteria are not met and well documented the payment may be retracted.

  • Completion of a Health Risk Assessment (Independent Health form or other CMS compliant form).
  • Review of the patient’s Health Risk Assessment (HRA) and make it part of your permanent clinical record.
  • Document discussions related to issues noted by the patient on the HRA.
  • Document the status of each and every medical condition (even those identified and managed by specialists), including goals for treatment and management plans for each active problem.
  • Document standard visit elements: vital signs, interval history, past history, family history, medication reconciliation, review of systems, physical examination, update medication, problem and health maintenance lists, impression/assessment, plan and counseling of patient.
  • Provide a summary of the visit to the patient, including when to expect follow-up on test results Medical and Chronic Condition Management (must be performed by a physician, nurse practitioner or physician assistant).
  • Documentation of the entire visit including the Health Risk Assessment from your medical record must be submitted with the claim.

To assist providers in ensuring all of the requirements of the EAV are met, the Enhanced Annual Visit Program Guide is available on the IHA website.  Please contact Sarah Howarth at 716-348-3923 or sarahh@pracfirst.com for assistance in obtaining these materia


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<