September 2011 Client Newsletter

WorkWell

WorkWell is a Pennsylvania Workman’s Comp Carrier which is expanding into NJ. Their rates look reasonable. They are looking for the following specialties:
Family Practice
Internal Medicine

If you are interested, let me know and I’ll forward additional information to you.

Medicare NEW Patients definition

Effective August 15, 2011, WPS Medicare Part B will turn on an edit that will deny a new patient visit within 3 years of any professional face-to-face service, e.g. other evaluation and management (E/M) or surgery service. WPS Medicare conducted a 30-day data analysis and identified more than 300,000 potential claim payment errors in all WPS claims processing jurisdictions. The identified claims were for a new patient visit billed within 3 years of a surgery procedure performed by the same person or a member of the same group with the same specialty.The Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM), Publication 100-04, Chapter 12, Section 30.6.7 states, "Interpret the phrase "new patient" to mean a patient who has not received any professional services, i.e. E /M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years."The above IOM statement is not new. Please conduct data analysis to determine if you have received payment for a new patient visit following a surgery by the same person or a member of the same group with the same specialty. If so, please refund Medicare. You can use the voluntary refund form from our website:http://www.wpsmedicare.com/j5macpartb/forms/_files/nonmsp_voluntaryform.pdfYou can find more information on E/M services on our website at http://www.wpsmedicare.com/j5macpartb/resources/provider_types/evalandmngmnt.shtml

HORIZON FEE SCHEDULE INCREASE

In a letter dated July 27, 2011 (received by CPB on 8/10/11) Horizon states:
“Effective October 1, 2011, Horizon Blue Cross Blue Shield of New Jersey will base our
managed care and PPO fee schedules primarily on Resource-Based Relative Value Scale
(RBRVS) methodology and the 2011 Centers for Medicare &Medicaid Services (CMS)
fee schedule. Our current fee schedules are based primarily on RBRVS methodology and the
2007 CMS fee schedule.

The impact of basing our fee schedules primarily on RBRVs methodology and the 2011 CMS fee schedule will vary by specialty and services rendered. Reimbursements for specific
services may increase, decrease or remain the same. On average, however, this change will
represent an approximate:
• 6 percent total increase in reimbursement.
• 10 percent increase in reimbursement for Evaluation and Management (E&M) Services.
• II percent increase in maximum per visit reimbursement for physical therapy services.

To obtain a sample of the new fee schedule applicable to your specialty; please e-mail a request to Fee_Requests@HorizonBlue.com or contact your Network Specialist.”

While this sounds good, keep in mind that some specialties have not had an increase for quite a few years. So the above may not even be keeping up with inflation. But it is better than nothing.

Medicare Provider Revalidation

Just announced by Medicare:

“All providers and suppliers who enrolled in the Medicare program prior to Friday, March 25, 2011, will be required to submit their enrollment information so they can be revalidated under new risk screening criteria required by the Affordable Care Act (section 6401a). Providers/suppliers who enrolled on or after Friday, March 25, 2011 have already been subject to this screening, and need not revalidate at this time.Do NOT submit your revalidation until you are notified to do so by your MAC. You will receive a notice to revalidate between now and March 2013.This will allow MACs to process revalidations in a timely fashion and allow providers to take advantage of innovative technologies and streamlined enrollment processes now under development. Updates will be shared with the provider community as these efforts progress.”

ABN’s – THEY ARE CHANGING, AGAIN!

A new ABN format has been released by CMS with an effective date 11/1/11. If you use an ABN, let Rich know and we will create an updated version.