April 2011 Client Newsletter

Medicare EMR PAYMENTS

Recently we were asked what is required to qualify for the Medicare EMR funds for qualified providers:
Be using one of the 200+ ONC 2011 Certified EHR applications,
Use the product in a “meaningful way” for 90 days starting anytime after 01/01/2011, and
Go on-line to register with CMS.

CMS has asked that we remind eligible professionals that they must register in order to participate in the Medicare and Medicaid EHR incentive programs. At least 90 days of reporting is required to qualify. Registration opened on Jan. 3, 2011, at http://www.cms.gov/EHRIncentivePrograms/20_RegistrationandAttestation.asp.


MEDICARE eRx

In November, the Centers for Medicare and Medicaid Services (CMS) announced that, beginning in calendar year 2012, eligible professionals who are not successful electronic prescribers based on claims submitted between January 1, 2011 - June 30, 2011, may be subject to a payment adjustment on their Medicare Part B Physician Fee Schedule covered professional services. If you are a physician (with Medicare patients) who has not started to use eRx yet & wants to avoid a negative payment adjustment in 2012, you will want to get started ASAP. If you are using an eRx program but have not notified CPB, it is CRITICAL that you do so we can ensure that the correct eRx code is being sent with your charges to Medicare. That is how Medicare finds out you are actually using it on patients. The code must be billed at the time of the E&M visit – office, home, hospital, nursing home, etc..

Several of our clients are already using an electronic prescription program and will be able to benefit from the Medicare payment. Some are using a standalone product and others are looking at EMR programs that include this feature. Be sure it is certified with both CMS and Surescripts. The following website includes all products certified by Surescripts – both standalone & included with an EMR program: http://www.surescripts.com/connect-to-surescripts/prescriber-software/all.aspx?mode=viewAll&fullscreen=true&background=off

For a free product: http://www.nationalerx.com

CREDIT CARDS & eCHECKS FOR PATIENT PAYMENTS

As many of you know, high deductible insurance plans are becoming much more common. We are seeing deductibles as high as $5000 per year which is significantly changing insurance paradigm. Instead of receiving payment from an insurance company, we are seeing an increase in balances being applied to those deductibles and in the number of requests from patients for credit card payments.

In response to several requests by clients to set them up with the ability to accept credit card payments, CPB is investigating this option. The process works as follows:
Each client is set up so that the credit card payment goes directly to their bank account.
Patients send the required credit card information either on their statement or fax to us.
Our staff will enter the information on the secure website provided by the vendor with payment only to your bank account. Our staff will enter the payment information into the patient's account as usual.

If you if you are interested in participating in this, please contact Rich.

PROVIDER RELIANCE ON PRECERTIFICATION

NJAC 11:24A-3.4 2(e) which is applicable to all carriers using utilization management programs: "provides that a carrier shall not deny reimbursement retroactively for a covered service provided to a covered person by a provider who relied upon the written or oral authorization of that carrier (or its agents) prior to providing the service to the covered person, except in cases where there is material misrepresentation or fraud."

The New Jersey Department of Banking and Insurance further states "carriers may not circumvent these provisions through the use of quote disclaimers" purporting to reserve the right to retroactively revise utilization management determination."

This should solve the occasional denial but it is important that the billing diagnoses match whatever was used to obtain the precertification.

Medicare Annual wellness visits (AWV) – railroad medicare

Railroad Medicare is stating that they will not be ready to process either of the AWV codes until April 4, 2011. We will automatically resubmit any denied claims. Believe it or not, the RRMC rep told us that they “just received the memo yesterday” (3/7/11)! Funny how everyone else knew about this last Fall.

Ambulance Mileage

On February 23, 2011 UMWA Health and Retirement Fund announced that effective January 1, 2011 (yep, retroactive!) they will also follow the Medicare policy using Load Miles rounded to the nearest tenth of a mile.

NJ PIP PATIENTS

There are 3 medical specialties which are subject to the daily $99.00 NJ PIP Cap – Chiropractors, Therapists (PT & OT), and Osteopaths (for manipulation codes only). The FAQ’s on the NJ PIP website:

Q. “Is the $99.00 a per-provider cap or does it apply to all treatment on that day?
A. The $99.00 is the limit of the insurer’s liability for the CPT codes listed in the rule per day. Therefore, it applies regardless of the number of providers that the injured person visits.”

The only exception is found in N.J.A.C. 11:3-29.4 (m) Application of Medical Fee Schedules:

“… The daily maximum applies when such services are performed for the same patient on the same date. The daily maximum applies to all providers, including dentists. However, when the provider can demonstrate that the severity or extent of the injury is such that extraordinary time and effort is needed for effective treatment, insurer shall reimburse in excess of the daily maximum. Such injuries could include, but are not limited to, severe brain injury non-soft tissue injuries to more than one part of the body. Such injuries would not include diagnoses for which there are care paths in NJAC 11.3-4. … Unless already provided to the insurer as part of a decision point review or precertification requests, billing shall be accompanied by documentation of why the extraordinary time and effort for treatment was needed."

The above indicates that the documentation can be provided as part of the precertification process or documentation can be sent with initial claim. Please be sure to specify on the charge form if, during the preauthorization process (which is the best time to address this issue with the insurer), you were approved to exceed the daily cap, or attach a cover letter supporting "extraordinary time and effort for treatment was needed" as required above.

We believe that in group practices represented by more than one specialty, e.g., PT & OT, that this issue should be addressed during the preauthorization process and request this in writing. This ensures that you are aware prior to treating the patient, rather than after the claim has been denied, whether the insurer has agreed to waive the cap.

This approach is further supported by NJAC 11:24A-3.4 2(e) which is applicable to all carriers using utilization management programs: "provides that a carrier shall not deny reimbursement retroactively for a covered service provided to a covered person by a provider who relied upon the written or oral authorization of that carrier (or its agents) prior to providing the service to the covered person, except in cases where there is material misrepresentation or fraud."

The New Jersey Department of Banking and Insurance further states "carriers may not circumvent these provisions through the use of quote disclaimers" purporting to reserve the right to retroactively to revise utilization management determination."

If the insurer refuses to allow each provider to be paid for treating the patient on the same date of service, we recommend that patient's only be treated by one provider each day in order to avoid the second provider providing unreimbursed care.

In addition, if you see any patient being treated under NJ PIP, you should ask if the patient has an appointment to see any other providers that day. If so, scan or fax the charges to CPB as fast as possible AND call to notify us so we can bill before the other provider does.

Finally, when scheduling appointments for NJ PIP patients, ask if they already have an appointment scheduled with another provider on whatever day you would see them. If possible, schedule them a different day.

If you have any questions, please contact Rich.