Upload
buinhi
View
219
Download
4
Embed Size (px)
Citation preview
Agenda
Welcome and Introductions
Healthcare Reform
Provider Incentive Program
5010 Electronic Transactions
Provider Enrollment & Screening
Provider Re-Enrollment
Policy & Program Updates
Managed Care Updates
BMS Website
General Billing Information
Innovative Resource Group (APS)
2
BMS/Molina 2011 Provider Workshops
Healthcare Reform
What is Healthcare Reform?
Key areas of Reform
Purpose of PPACA (Patient Protection and Affordable Care Act)
PPACA and the States
PPACA provisions for Medicaid
PPACA funding opportunities
BMS/Molina 2011 Provider Workshops
3
What is Health Care Reform
This presentation provides a high-level overview of the purpose,
provisions, and related funding of the Patient Protection and Affordable
Care Act (PPACA, Act), as well as an overview of how the Act will
affect the West Virginia Department of Health and Human Resources
(DHHR) and Bureau for Medical Services (BMS).
The Act is also referred to as the Affordable Care Act (ACA).
The Obama Administration has stated that the intent of the Act is to “put
individuals, families, and small business owners in control of their
healthcare.”
BMS/Molina 2011 Provider Workshops
4
Key Areas of Reform
Much of the PPACA must be resolved through regulations. Many of the
provisions became effective upon enactment, and requirements of the
Act continue through 2019. Most of the reform activities will occur
between 2010 and 2014.
> Health Insurance Reform
> Employers offering health insurance to employees
> Public Programs including Medicaid, the Children’s Health
Insurance Program (CHIP), Medicare, and Public Health
> Healthcare workforce training
> Elimination of fraud, waste, and abuse in healthcare
> Improving the quality of healthcare
BMS/Molina 2011 Provider Workshops
5
The Purpose of PPACA
PPACA starts to change the way healthcare is delivered. PPACA deals in
great part with insurance reform. Among those reforms:
> Holding insurance companies accountable to keep premiums
affordable and prevent denials of care and coverage, including for
preexisting conditions
> Making health insurance affordable for middle class families and
small businesses with tax credits for health care, and reducing
premiums and out-of-pocket expenses.
PPACA creates powerful incentives so that more healthcare providers
can begin to deliver the kind of coordinated, patient-centered care that
has been shown to get best results.
BMS/Molina 2011 Provider Workshops
6
PPACA and the States
The critical role of State government is in managing and financing the
Medicaid and CHIP Programs. The PPACA creates new requirements for
expanded coverage and accountability mandates for those programs.
States must also create, manage, and regulate new insurance exchanges
for both individual residents and businesses.
The extensive new regulations for the health insurance plans must be
enforced by the States as well.
BMS/Molina 2011 Provider Workshops
7
PPACA Provisions for Medicaid
Continues Medicaid coverage to any individual who has been in foster
care under the age of 26.
Develops a core set of health care quality measures for Medicaid-eligible
adults.
Eliminates fraud, abuse and waste in the system which may require
outside vendor procurement and outside contracting meeting the federal
requirements.
Provides new options to States to provide Medicaid long-term care
services and support.
BMS/Molina 2011 Provider Workshops
8
PPACA Funding Opportunities
The Medical Home State Options offers states enhanced match of 90
percent FMAP (Federal Medical Assistance Program) for two years and
small planning grants may be available to promote the use of medical
homes for enrollees with chronic conditions. West Virginia has been a
leader in developing the medical home concept.
WV has applied and received a planning grant for this opportunity.
Health Homes for Members with Chronic Conditions.
WV has applied and received a Money Follows the Person grant.
BMS/Molina 2011 Provider Workshops
9
Provider Incentive Program (PIP)
The Electronic Health Records (EHR) Provider Incentive Program (PIP)
is a federal program offering financial support to assist eligible providers
to adopt, implement, or upgrade certified EHR technology.
The Medicaid EHR Incentive Program will provide incentive payments
to eligible professionals, eligible hospitals, and critical access hospitals
(CAHs) as they adopt, implement, upgrade, or demonstrate meaningful
use of certified EHR technology in their first year of participation and
demonstrate meaningful use for up to five remaining participation years.
Incentives will be available through both Medicaid and Medicare.
> Eligible healthcare professionals will be required to choose between
Medicaid and Medicare.
> Those in border counties should choose the state from which they
will receive the incentive payments. Hospitals may be able to
receive incentive funds from both programs.
> The Bureau for Medical Services (BMS) will administer the
Medicaid EHR Incentive Program for West Virginia.
10
BMS/Molina 2011 Provider Workshops
Provider Incentive Program (PIP)
Providers eligible for payment are:
> Physicians, Dentists, Pediatricians, Nurse Midwives, Nurse
Practitioners, Physician Assistants who practice in a Federally
Qualified Health Center (FQHC), Critical Access Hospitals, Acute
Care Hospitals
Estimated Go-Live date is July 2011
Payments will be made through the claims processing system
Link for provider attestation will be available through Molina’s
webportal
> www.WVMMIS.com
Payment information will be reflected through provider’s remittance
advice
Questions related to PIP will be handled through Provider Relations
11
BMS/Molina 2011 Provider Workshops
Provider Incentive Program (PIP)
Key dates from Centers for Medicare and Medicaid Services (CMS):
> January 2011 - Medicaid providers can register with the Federal
National Level Repository (NLR).
> July 2011 - Attestations from Medicaid providers can be submitted
through state MMIS portal.
> Late July 2011 - WV State payments to Medicaid providers are
expected to start.
> September 30, 2011- Last day of the federal fiscal year. Reporting
year ends for eligible hospitals and CAHs.
> October 1, 2011 - Last day for eligible professionals to begin their
90-day reporting period for calendar year 2011 for the Medicare and
Medicaid EHR Incentive Program.
12
BMS/Molina 2011 Provider Workshops
Provider Incentive Program (PIP)
Key Dates continued:
> November 30, 2011-Last day for eligible hospitals and CAHs to
register with NLR and attest to receive an incentive payment for
federal fiscal year (FY) 2011.
> December 31, 2011- Reporting year ends for eligible professionals.
> February 29, 2012 -Last day for eligible professionals to register with
the NLR and attest to receive an incentive payment for calendar year
(CY) 2011.
13
BMS/Molina 2011 Provider Workshops
5010 and D.0 Electronic Transactions
CMS is monitoring the States’ compliance with the regulatory
requirement to convert from Health Insurance Portability and
Accountability Act (HIPAA) Accredited Standards Committee (ASC)
X12 version 4010A1 to ASC X12 version 5010 and National Council for
Prescription Drug Programs (NCPDP) version 5.1 to NCPDP version
D.0.
All covered entities are targeted to be fully compliant on January 1,
2012.
The new HIPAA 5010 electronic transaction standard will drive billing,
reimbursement, and many administrative functions, as well as
accommodate the larger ICD-10 code sets. Version 5010 has more than
2,500 generic and 1,000 unique changes ranging from field size increases
to entire new segments of data, resulting in considerably more data than
its predecessor 4010A.
14
BMS/Molina 2011 Provider Workshops
5010 and D.0 Electronic Transactions
Readiness of provider community
Testing process
> Providers will need to test with outside vendor (Edifecs) before
testing with Molina
> If the provider submits through clearinghouse, the individual
provider is not required to test
Testing schedule
> Once the provider/clearinghouse is certified from outside vendor, the
provider /clearinghouse will be required to have three successful tests
before submitting 5010 transactions
Companion guides and comparison XML will be posted on the web
portal
15
BMS/Molina 2011 Provider Workshops
5010 and D.0 Electronic Transactions
The following transactions will be affected by 5010:
> 837 I/P/D Inbound
> 276/277
> 270/271
> 835 Outbound
Direct Data Entry (DDE) into the web portal will not be affected by
5010. All screens will remain the same.
Batch uploads via the web portal will need to be submitted in the new
5010 standard.
All real-time pharmacy transactions will be impacted by the new D.0
standard.
16
BMS/Molina 2011 Provider Workshops
General Policy Updates
National Correct Coding Initiative
New funding opportunities
> Money Follows The Person
> Health Homes for Members with Chronic Conditions
Revised BMS chapter changes
Assistant-at-Surgery
> Must be billed with appropriate modifier (-80) & operative report must reflect services
provided by assistant –at-surgery
Orthopedic update
> Effective 6/1/2011, CPT code 64455 (Nerve Block Injection, Plantar Digit) may now
be billed by physicians that have the specialty of Orthopedics.
Certified Nurse Midwife
> May bill for vaginal delivery in a hospital when facility has approved these services
via credentialing & delineation of services
Radiology services – CTs, MRIs or PET Scans in office setting
> Effective 1/1/2012, CMS requires accreditation by American College of Radiology,
Intersocietal Accreditation Commission or Joint Commission
17
BMS/Molina 2011 Provider Workshops
General Policy Updates (Target Effective Date 9/1/2011)
Anesthesia
> All anesthesia codes, except for 01996 must be billed with a modifier.
> Anesthesiologists must bill AA, AD, QK, QS or QY modifier; CRNAs must bill with
QS, QX or QZ.
> Anesthesia service with time units of 40+ requires paper claim and documentation
(anesthesia and operative reports)
• Reminder 1 time unit = 15 minutes
Mastectomy or related, covered, reconstructive procedures will not
require prior authorization (PA) with diagnosis of breast cancer
Occupational Therapy
> CPT Codes 97003 & 97004 will be restricted to Revenue code 0434
Physical Therapy
> CPT codes 97001 & 97002 will be restricted to Revenue code 0424
Speech Therapy
> CPT codes 92506, 92507 and 92508 must be billed by the speech therapist on a CMS
1500 or 837P
> If employed by hospital or CAH, pay-to must be facility
BMS/Molina 2011 Provider Workshops
18
Managed Care Updates
Effective July 1, 2011, when a Managed Care (MCO) member switches
to fee for service (FFS) while inpatient, the MCO will be responsible
until discharge
You may contact Brandy Pierce at 304-558-1700 for questions related to
this change
BMS/Molina 2011 Provider Workshops
19
Diabetes Education Program Collaborative effort - Medicaid and Bureau for Public Health’s WV
Diabetes Prevention and Control Program
Web-based training program – access thru BMS (www.dhhr.wv.gov/bms) or
CAMC website (www.camcinstitute.org/education)
Based on American Diabetes Association’s Clinical Practice
Recommendations
Primary Care Providers and other health care professionals
> 2 courses
• Initial certification
• Recertification required every 2 years
Must complete/maintain certification to be reimbursed for providing
diabetes education sessions under program
> HCPCS codes for billing• Code S0315 - initial assessment & initiation of self management training session
• Code G0108 – 30 minute (individual) diabetes education session
• Code G0109 – 30 minute (group of 2 or more patients) diabetes education session
> Limited number of sessions per patient per year
BMS/Molina 2011 Provider Workshops
20
Provider Enrollment
Provider enrollment application
> Current application with supplemental pages
> New paper application
> User Manual
Ownership Information
> Owners, managing employees, and agents
> Must provide information for each individual with 5% or more
ownership interest
> Must provide information for owners who are related to each other
> Must provide information if ownership is present in other
organizations that bill Medicaid
> Ownership information must be completed in its entirety
BMS/Molina 2011 Provider Workshops
21
Provider Enrollment
Application fee $505.00 for 2011
> Required for institutional providers
• ICF-MR, Hospitals, PRTFs
> Application fee waived if paid to Medicare or another State’s
Medicaid program or CHIP
> CMS has the authority to change the fee yearly
Hardship Exception Request
> Form must be requested from Molina
> Form and supportive documentation must be submitted with
enrollment application
> Request for hardship exception is sent to CMS by Medicaid
> CMS makes decision and notifies Medicaid
> Enrollment application on hold until CMS decision received
22
BMS/Molina 2011 Provider Workshops
Provider Screening
Risk Levels
> Apply to all providers
> Based on risk of fraud, waste or abuse
Database Checks
> Federal Office of Inspector General’s List of Excluded Individuals &
Entities (LEIE)
> General Services Administrations Excluded Parties List System
(EPLS)
> State Medicaid Exclusion Lists
> State Licensing Boards
Criminal background check
Fingerprinting
Site visits
23
BMS/Molina 2011 Provider Workshops
Risk Levels by Provider Types
24
BMS/Molina 2011 Provider Workshops
Each provider type has been designated as limited, moderate, or high risk
by CMS
> Limited - Physicians or non-physician practitioners and medical
groups or clinics
> Moderate - Community mental health centers, comprehensive
outpatient rehabilitation facilities, hospice organizations, independent
diagnostic testing facilities, independent clinical laboratories,
non-public, non-government owned or affiliated ambulance service
suppliers, and currently enrolled home health agencies and DMEPOS
suppliers
> High - Prospective (newly enrolling) home health agencies and
suppliers of DMEPOS
At State’s discretion, the risk level may change.
Provider Enrollment
Site visits are required for providers in moderate and high risk levels
> States are required to conduct pre-enrollment (unannounced) and
post enrollment (announced) site visits.
> Molina staff will conduct both visits.
> Failure to permit access for site visits would be a basis for denial or
termination of Medicaid enrollment.
> Site visits are waived if conducted by Medicare or another State’s
Medicaid program or CHIP.
25
BMS/Molina 2011 Provider Workshops
Provider Re-Enrollment
Provider enrollment and screening requirements and need for additional
information from providers
> Medicaid providers will need to be re-enrolled
Scheduled to begin in Fall of 2011
> Phased-in approach by provider type/risk level
> Schedule will be placed on the web portal and banner pages
> Providers will be notified by mail
Provider Re-Enrollment will be electronic through web portal
> Providers will receive letter with access code to re-enroll
> Providers will have 30 days to complete re-enrollment or provider
will be placed on pay hold
26
BMS/Molina 2011 Provider Workshops
New BMS Website
BMS has created a new website that provides new navigation features
> www.dhhr.wv.gov/bms
Providers and members may subscribe to feeds related to the changes
within Medicaid
Updated Provider Manual
MediWeb Portal
Mountain Health Choices
State Medicaid Plans
27
BMS/Molina 2011 Provider Workshops
Helpful Websites
Bureau for Medical Services
> www.dhhr.wv.gov/bms
Molina Medicaid Solutions
> www.wvmmis.com
Centers for Medicare and Medicaid Services
> www.cms.gov
BMS/Molina 2011 Provider Workshops
29
Timely Filing
Claims must be received within one year from the date of service
If Medicare is primary, claims must be received within one year from the
Medicare paid date
> One additional year with proof of timely filing
Corrected claims with reversal-replacement form can be submitted within
two years from the date of service
Claims over two years old will not be processed without a back dated
medical card
Original claims and corrected claims with reversal-replacement form that
are over one year are to be sent to:
> Molina Provider Relations, PO Box 2002, Charleston, WV 25327
30
BMS/Molina 2011 Provider Workshops
Common Errors Resulting in Denied Claims
Rendering provider not approved for services billed
Missing/incomplete/invalid HCPCS code
> Validate code is keyed correctly
> Validate code is current for date of service
Missing/incomplete/invalid NDC code
> For resolution refer to the drug code/NDC information on the BMS
website, www.dhhr.wv.gov/bms
31
BMS/Molina 2011 Provider Workshops
Common Errors Resulting in Denied Claims (continued)
Primary payer information not provided with claim
> Paper & Electronic Claims
Charges are covered under capitation agreement or managed care plan
> For members who have a PAAS provider, PAAS approval is
required on the claim
> View member’s card to verify MCO or PAAS
> Utilize AVRS to verify MCO or PAAS
32
BMS/Molina 2011 Provider Workshops
Errors Resulting In Returned Claims
Member ID not 11 digits
NPI and Tax ID not in the appropriate fields
Missing Diagnosis Codes
Missing Dates of Service
Missing Place of Service
Print is not legible and data is not aligned within applicable blocks on the
claim form
33
BMS/Molina 2011 Provider Workshops