February 2007 Client Newsletter

HMO, PPO & OTHER MANAGED CARE AGREEMENTS

We occasionally hear providers express concern that they are not being paid well enough by a particular insurance company (OK – usually “companies”!). Practicing medicine is one profession, doing the business of medicine is another.

One of the most economically challenging business arrangements is the solo practice who negotiates on their own. Often clients are amazed at what they have agreed to do in participation contracts and what they are actually paid for – assuming they are able to find the agreements!

You should periodically review all of your health plan arrangements. If you cannot find your copy of the agreement, contact them for a copy and get the renewal date. If there is no renewal date, contact the insurance representative in writing to start the renegotiation process. Plans should be reviewed at least every 3 years. When it's time to renegotiate ask in advance for a copy of the current fee schedule (needed to compare with other plans) and you may want to get professional help to ensure you are treated fairly. CPB is very familiar with the plans in your area and has the expertise to provide this consulting service.

Things to consider:
-Renegotiate unfair contract arrangements,
-Work around the low payments by designing better office efficiency,
-Drop plans that pay poorly when you can replace them with higher paying plans and have a full patient schedule each day.


2007 Medicare PHYSICAL THERAPY CAP

Beginning on January 1, 2007, the annual limit on the Medicare Allowed Amount for outpatient physical therapy and speech-language pathology combined is $1780; the limit for occupational therapy is $1780.

HIPAA PRIVACY & SECURITY

Just a reminder, if you have questions about HIPAA Privacy or Security issues feel free to call or have your staff give us a call. If you need annual training for your staff to meet Compliance requirements, we have slide programs to meet that need.

Zostavax ® vaccine

From Empire Medicare:
“The Zostavax ® vaccine for prevention of shingles (herpes zoster) is excluded from Medicare coverage. Medicare manual instructions [ Medicare Benefits Manual (Pub 100-02), Chapter 15, Section 50.4.4.2 – Immunizations ] (see below) prohibit coverage unless the beneficiary is at risk directly related to exposure to a pathogen. In the absence of an immunocompromised state, beneficiaries are not at direct risk for developing herpes zoster. In an immunocompromised state, the vaccine is contraindicated and should not be administered. In 2007, the administration of this vaccination can be billed to the local carrier with the HCPCS code G0377 which is the equivalent of CPT 90471. Please note in Item 19 of the CMS-1500 claim or the electronic media claims (EMC) equivalent that you have administered Zostavax.”


Medicare DIAGNOSES

Medicare announced that effective for claims processed July 1, 2007 and later the Part B standard systems and the carrier claims processing systems will capture and process up to eight diagnosis codes on all of your claims (both paper and electronic). Accordingly, starting with July 1st processing we encourage all providers to begin sending as many diagnoses as appropriate (up to 8) that demonstrate the medical conditions the patient is being seen for that day. The increased number will help to show the wider picture of a patient’s medical complexity to justify various levels of E&M codes.


United Healthcare (UHC)

UHC announced 2 new policies affecting providers:

Only 1 initial inpatient consult (hospital & nursing home) will be paid per admission for the same patient. Thus, whenever possible be sure to get yours to CPB quickly. Feel free to fax the hospital card and indicate on the card that the insurance is “UHC” and CPB will process it immediately.

“Seven new reimbursement policies will become effective in second quarter of 2007. These policies will define when specific services are reimbursable based on ICD-9 diagnosis codes(s) reported. The policies were developed by first identifying areas of convergence across the Centers for Medicare and Medicaid Services (CMS) Local Carrier Determinations (LCDs) on each topic. A coding matrix of CPT and ICD-9 diagnosis codes based upon the LCD policies was then submitted to various specialty societies for comment. A list of applicable ICD-9 diagnosis codes for each of these policies.” CPB has a copy of these new policies.