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October 2016 Client Newsletter

ICD-10 Reporting Flexibility Ended  Oct. 1: New Guidance 

CMS has updated its guidance on ICD-10 claims auditing and quality reporting flexibility, affirming that the flexibility ended as planned on October 1. As part of a one-year transition period immediately following ICD-10 implementation, the agency provided flexibility in the claims auditing and quality reporting process for 12 months after ICD-10 went live on Octobert 1, 2015.

For example, up to this point Medicare review contractors have not been denying claims based solely on the specificity of the ICD-10 diagnosis code, provided the practitioner used a valid code from the correct family of codes.  In preparation for the end of the flexibility period, practices should review their use of unspecified ICD-10 codes and avoid use whenever the clinical documentation supports a more detailed diagnosis code.  Use of unspecified codes will likely result in denied or downcoded claims for dates of service October 1, 2016 and after. 

Taxonomy Codes 

MACs (Medicare) are required to obtain the most recent Healthcare Provider Taxonomy Code (HPTC) set and to update their internal HPTC tables and/or reference file. MACs that have the capability to do so will implement the October 2016 HPTC set as early as October 1, 2016, for claims received on or after October 1, 2016. All MACs will implement the HPTC set by January 3, 2017.  Cape Medical Billing anticipated this several years ago and added Taxonomy codes for all clients and referring providers at that time.  If you have made ANY changes to your provider enrollment file, particularly the Taxonomy code, be sure to notify Cape Medical Billing ASAP so we can update out data files to prevent denied claims.  

Phase 2 of Medicare Revalidations

You will want to warn your office staff to be on the lookout for Medicare revalidation letters.  For this phase, there is no grace period if the necessary paperwork is not completed and returned on time.

For Phase 2 revalidation (began in March 2016 or after), CMS stated:

  • Providers should be receiving notifications six months prior to revalidation due date. They are sending to two locations.
  • There will no longer be a 120 day grace period for missed revalidations - providers will be deactivated immediately after the due date.
  • If a provider is deactivated, they will no longer reactivate. A new application must be done, and they will not retroactively reimburse for the lapse.

In such a case, any Medicare patients seen after the deactivation will not be paid for the period between the deactivation and the reactivation.  A new application must be received and approved for reactivation.  The gap between will also be known, "unaffectionately," as  "free care." 


Virtual Credit Cards - Here We Go Again!

We have recently noted some insurers are unilaterally paying with what is known as a Virtual Credit Card.  They often use different names but that is the generic industry name.  These cards "pay" the fee minus about 3% - same as a credit card.  BEST BET is to contact Cape Medical Billing so we can work with you to select the best option.  If you do not accept credit cards, you cannot "cash" virtual credits cards anyway.

Here are your options:

  • Some payers, like Geisinger, are sending "Claim Payment Cards" (CPCs) when the provider is not registered with InstaMed.  Different name, but they are still Virtual Credit Cards!  This is a Payer Payment that can be processed like any other mailed in credit card.  The Provider is then prompted to either:  1. Process the card as a credit card (if you accept credit cards), 2. Register with InstaMed for free ERA/EFT, or  3. Opt-out completely.  If you opt out completely you will continue to receive paper checks and paper remittance. 
  • Other payers, like AmeriHealth Administrators, only have two options:  1. Register with InstaMed for free ERA/EFT, or 2.  Continue to receive paper check and paper remittance. 

Cape Medical Billing has recommended EFT and  ERA for over 15 years.  If you select that option, please be sure to contact Rich Papperman first so we can make the change with you.  Otherwise, Cape Medical Billing  will not have access to EOB information or the ability to call the insurer until we are approved separately to do so. 


 More On the Dreaded Virtual Credit Cards

The Workgroup for Electronic Data Interchange (WEDI), a multi-stakeholder group that serves as an adviser to the Department of Health and Human Services, released a new industry resource, Electronic Payments: Guiding Principles, aimed at addressing health plan and vendor payment abuses. Physician practices are experiencing an increase in the use by health plans of "virtual" credit cards (VCCs) and fees associated with claims paid via electronic funds transfer (EFT). The cost to practices can be as high as 5% of the claim amount.

The principles established industry best practices with recommendations that include:

  • Before a provider may be paid via an electronic payment method other than EFT (such as a VCC), the provider should give explicit agreement ("opt-in"), be informed about the availability of an EFT payment option, and be notified regarding any fees associated with any payment option. 
  • Health plans, or any of their clearinghouses or payment-related vendors, should offer an EFT payment option with no fees. 
  • Providers should be given a minimum 90-day notice before the effective date of the electronic payment mandate and must opt-in to any nonstandard electronic payment method scheduled to replace a paper-based payment.
  • Providers must give explicit authorization prior to use of the EFT debit transaction by a health plan for recoupment purposes.

One IMPORTANT consideration if you decide to accept EFT or VCC - LET Cape Medical Billing  know in advance of signing up so we can coordinate how EOB's/ERA's will be received.  Without contacting Cape Medical Billing  IN ADVANCE, you could be left with no way for us to post payments - so balance billing secondary and tertiary insurances, and patients, will not be available. Thus, LOSS of cash flow.

We have heard from peers in the billing industry that some health plans or third-party vendors are now even charging fees for the EFT transaction. These fees typically range from 1% to 3% (of the total EFT payment), with some vendors contending that they are offering "value added" services for these fees. First determine if your practice is incurring any fees for your EFT transactions and if your organization is receiving any true "value added."

Once you identify those entities that are unfairly charging you for EFT, contact them and request the "no cost" version of the EFT transaction. Should they refuse, consider lodging an official complaint with CMS directly. Some providers have reported that simply requesting the "no cost" EFT option was sufficient.

For more information on electronic payments, practice rights, and action steps to automate your revenue cycle, contact Rich Papperman for a copy of the MGMA member-benefit EFT ERA Guide and sample letter requesting EFT.

Health Republic of NJ, OSCAR & Oxford Health Plans

As announced in September, Health Republic of NJ is being taken over by state regulators due to $46.3 million owed for the risk adjustment program.  If you participate with them, you may want to seriously consider terminating your agreement ASAP.  They will not be part of the Affordable Care Act insurers in 2017 anyway. 

It is also noteworthy that both OSCAR & Oxford Health Plans have both also pulled out of the NJ Marketplace for 2017.  The only two ACO plans to remain in 2017 are Horizon and AmeriHealth. 

Patient Declined to Show Insurance Card

 Recently one of our clients had a patient who gave handwritten insurance information but declined to give a copy of their insurance card.  RED FLAG!  While this certainly does not mean they are not insured, it DOES mean you need to verify their insurance with the insurer BEFORE receiving any service.  You will also want to make sure the patient properly signs your NEW patient paperwork indicating that they accept full responsibility to provide valid insurance and for any patient balances.  If they refuse to provide both, we would strongly advise that you consider whether this is a good patient for your practice.  Remember, once you treat them, you are stuck with them unless you formally discharge them from the practice. 

Open Payments Program - Designating as "Authorized Representative"

Following recent CMS changes to the Open Payments Program, practice administrators are now permitted to become authorized representatives in order to review a physician's Open Payments data. In order to become an authorized representative, the provider must nominate that person. Should practices notice any inaccuracies in the data, they may file a dispute, which involves working toward a resolution with the drug and device manufacturers. Open Payments data for 2015 is currently public, however, practices have the opportunity to review and dispute records that have been published for the first time through Dec. 31, 2016.

If you need help with the data review and dispute process, or have any questions about the Open Payments Program in general, you can email the CMS Open Payments Help Desk at , or call at 1-855-326-8366 

2016 Client Newsletter Archive