December 2020 Client Newsletter

After 6+ weeks of billing 99072 for the PPE supplies, we are getting some clarity from more insurers.

 

Since 9/8 we have billed 99072 1,164 times. Only 40 have paid (3.4%). Most frequent payment is $6.75.

 

At this point we have given it a pretty good test and will be discontinuing billing that code for now. Lots of work and minimal return. The Message Boards are also not reporting any good news either.

 

I would be VERY interested in talking to Dr. Ricketti's biller to see how he is getting paid by all insurances except Medicare. I suspect he is not getting a true picture. If he is adding a modifier (59?), we have not seen any direction by insurers to do so.

 

 

 

The 2021 Medicare Part B deductible is $203.

 

 

 

President Trump’s health policy agenda greatly emphasizes price transparency to help lower the cost of healthcare. His administration began this effort by requiring hospitals to disclose the prices of the services they offer, first in a “machine-readable” format but gradually increasing the requirements to provide price information in “consumer-friendly” formats. A new final rule issued on October 29th further expands the Trump Administration’s price transparency effort by requiring commercial health plans to publish information about in-network rates, out-of-network rates and out-of-pocket costs for covered services and prescription drugs.

 

The final rule requires similar information that would be found on an explanation of benefits (EOB) form that beneficiaries receive after a service was provided to be made available to consumers in advance through a searchable online tool.

 

Physician practices have thus far been spared from price disclosure regulations. However, despite the fact that practices do not need to take action to disclose prices, it is important to understand that health plans will soon begin to publish their negotiated rates.

 

The “Transparency in Coverage” final rule takes effect on January 1, 2022, with a requirement for health plans to publish information in a machine-readable format. A consumer might not understand this raw data. However, other health plans, researchers and product developers would be able to interpret and make use of the information. Health plans are required to begin making this information accessible in a user-friendly format on a searchable online tool beginning January 1, 2023. Health plans only need to include a list of 500 services in 2023 but will need to include all covered services by 2024.

 

 

 

Section 1115A of the Social Security Act established a new Center for Medicare and Medicaid Innovation (the Innovation Center) within the Centers for Medicare & Medicaid Services (CMS) to test new payment and service delivery models that have the potential to reduce Medicare, Medicaid, and Children’s Health Insurance Program expenditures while maintaining or improving the quality of care for beneficiaries. In addition to special payment provisions for primary care services, there are special waivers under the model that allow for payment of other Medicare benefits under conditions that would not otherwise be paid for. When claims are paid under these special “waived” conditions, the claims are also to be tagged with the demonstration code.

 

Effective January 1, 2021 and extending through December 31, 2025, CMS is exercising its authority under the Primary Care First (PCF) model to waive Section 1861(s)(12) of the Act and the implementing regulations at 42 CFR 410.12 to allow nurse practitioners to certify that an order for diabetic shoes is required according to Section 1861(s)(12). Under this waiver authority, beneficiaries with diabetes are eligible for the standard Medicare diabetic shoe and shoe inserts benefit if a nurse practitioner refers or certifies the beneficiary. Normally, these items are only paid under traditional Medicare Fee-For-Service (FFS) if a physician (MD or DO) refers or certifies the beneficiary. The model is not changing the benefit coverage or limits in any way other than that of loosening the requirement for the referring or certifying provider to include nurse practitioners as well as physicians. Volume limits on supplies, any requirements regarding who can bill for the shoes and supplies, and any other edits that may be applicable to current FFS claims processing for these items shall not change under the model.

 

The Center for Medicare and Medicaid Innovation will launch the PCF model in 26 regions: Alaska (statewide), Arkansas (statewide), California (statewide), Colorado (statewide), Delaware (statewide), Florida (statewide), Greater Buffalo region (New York), Greater Kansas City region (Kansas and Missouri), Greater Philadelphia region (Pennsylvania), Hawaii (statewide), Louisiana (statewide), Maine (statewide), Massachusetts (statewide), Michigan (statewide), Montana (statewide), Nebraska (statewide), New Hampshire (statewide), New Jersey (statewide), North Dakota (statewide), North Hudson-Capital region (New York), Ohio and Northern Kentucky region (statewide in Ohio and partial state in Kentucky), Oklahoma (statewide), Oregon (statewide), Rhode Island (statewide), Tennessee (statewide), and Virginia (statewide). Additional information on the PCF model may be found here: https://innovation.cms.gov/innovation-models/primary-care-first-model-options 

 

Suppliers servicing beneficiaries in the 26 model demonstration regions should be alert to this information to ensure that documentation from nurse practitioners serving as certifying physicians for therapeutic shoes and inserts are participating in the PCF demonstration project. Only nurse practitioners participating in the PCF demonstration or are billing “incident to” a physician’s services are eligible to serve as the certifying physician for therapeutic shoes and shoe inserts. For additional information on nurse practitioners billing “incident to” see the article titled Nurse Practitioners and Physician Assistants as Certifying Physicians for Therapeutic Shoes and Inserts.