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August 2019 Client Newsletter

Audits: Co-pays, Deductibles & Co-Insurance Must Be Billed
As we all know, many patients do not want to pay their balance that are not covered by insurance. Unfortunately, it is not an option for providers to not collect co-pays, co-insurance & deductibles.
If the patient has Medicare, collecting co-pays, co-insurance, & deductibles is required for participation and is considered "fraud" to routinely not collect the patient assigned amounts. The patients MUST be billed if the amount due is not paid on the day of service.
If it is for other insurances, either your contractual participation agreement requires those balances be paid, or state law.
Patient balances are considered by insurers to provide an opportunity for patients to not over-utilize services. High deductible plans can certainly be a burden on patients - but that is the insurance they have. Unless you wish to provide free services, you should not feel any reason to apologize for requiring a patient to pay these balances. It is the current reality of healthcare today - and you did not create the problem.
The ONLY exception is if a patient qualifies, in writing, for financial hardship. There are specific requirements for this. Call me if you wish to set this up.
Ciox Medical Records Requests
Ciox is a data mining company that does work for various Medicare HMO plans. They request medical records in order to help the HMO obtain greater payment based on patient acuity. If you get one of these requests, UNLESS your participation contract requires it, you are NOT required to provide these records for free. Some providers charge $25 per medical record and are paid for it.
If they say you are required to provide the records for free, challenge them to show you where it says that - in writing. If it isn't in writing, it isn't worth the "paper" it is written on.
Changes to the Management of the Horizon Behavioral Health Program
Starting January 1, 2020, Horizon BCBSNJ will transition the administration and clinical management of behavioral health services from Beacon Health Options to their internal operations for all Horizon BCBSNJ plans that offer behavioral health benefits through the Horizon Behavioral Health program in the following phases:
  • January 1, 2020: Horizon Medicare Advantage, Horizon NJ Health and Horizon NJ TotalCare (HMO SNP) plans
  • April 1, 2020: Horizon BCBSNJ fully insured plans/products, self-insured (Administrative Services Only) employer group plans including the State Health Benefits Program (SHBP) and the School Employees' Health Benefits Program (SEHBP) and the Federal Employee Program® (FEP®)
See how this will effect provider agreements, claims and services, recredentialing, and member access in Horizon's notice. Read the FAQs.
MIPS Audits: What You Need to Know
Last month, CMS began audits of clinicians and group practices who participated in the MIPS in 2017 and 2018. CMS' contractor, Guidehouse, will randomly select participants for audit and data validation and send initial requests for information in June or July, with ad hoc data validation and audit work running through December. If selected, MIPS clinicians will have 45 days to respond.
Whatever you do, do not ignore the request. Otherwise the likely result is for Medicare to take back the entire MIPS bonus.
For more information on the audit process and data validation substantiation, review CMS' new resource.
 EMS Clients - ET3 Model Infographic Now Available from CMS
EMS Clients interested in learning more about the new Emergency Triage, Treat and Transport (ET3) care model are encouraged to review this newly-released infographic from the CMS Innovation Center. This resource is intended to help potential applicants ahead of the official request for applications (RFA), which is expected to be released later this summer. The goal of the ET3 model is to offer alternative interventions following a 911 call. In return, Medicare will pay for patients who otherwise would only be a "Respond, Treat, But No Transport."
Specifically, the model will offer reimbursement to participating ambulance care teams to:  
  • Transport an individual to a hospital emergency department;
  • Transport to an alternative destination such as a doctor's office or clinic; or
  • Provide treatment in place. 
If you need assistance with this, contact Rich.
CIGNA & United Healthcare - Consults No Longer Paid
Reminder: As mentioned in the June 1 Client Newsletter, effective June 1, 2019 United Healthcare will no longer pay Office or Hospital Consults.
CIGNA has adopted the same - their effective date is October 19, 2019
In those cases, use the appropriate office or hospital E&M visit code.
2019 Client Newsletter Archive