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California HME Update

Medi-Cal Provider Rates and the Special Session  

 

The Legislature has taken its summer recess adjourning at the end of last week and returning on August 17th. They will then be in session for about thirty days and adjourn for the year in mid-September. Some provider groups like DME/medical supply remain at risk of a claw back in Medi-Cal payments to June 1, 2011. DHCS has already announced that they would begin the claw back on pharmacy providers, including drugs and enteral, no earlier than August 1st with no definitive date yet announced.

  

The Governor did call a Special Session to look at Medi-Cal program funding which could include both the claw back and the restoration of the 10% provider rate reductions. That Special Session runs in concurrence with the regular session, thus also ending in mid-September. There have been informational hearings in both the Senate and Assembly focusing on the Managed Care Organization Tax (MCO Tax) and other potential sources of new revenue to increase Medi-Cal funding. The MCO tax which currently only applies to plans that cover Medi-Cal enrollees provides about $1.3 Billion to the Medi-Cal program. CMS has informed California and other states with an MCO tax that it has to be more broad based and apply to all plans. The current MCO tax would expire in June of next year without acceptable revisions. That is not new funding but the absence of the MCO tax would create another deficit hole. If the MCO tax were applied to all plans and enrollees it would generate a larger pool of funds. A bill introduced in the Special Session would do just that and create a flat MCO tax of $7.25 per month on all premiums and generate about $2.3B in revenue to the Medi-Cal program.

  

There was also a package of bills introduced in the Special Session dealing with tobacco, several aimed at further restriction on access to cigarettes and smoking areas, but several others raising the state tax on cigarettes by $1.00 a pack. Those new taxes would be earmarked for the Medi-Cal program and program rate increases. On the issue of rate increases the Administration and DHCS representatives have been sending a consistent message that rate increases should not be across the board but targeted to providers and services where it can be documented that access to services will increase or that these providers will serve a greater number of Medi-Cal patients.

  

The MCO tax expansion has drawn flak from the plans and business interests who worry about increasing overall premium costs. Likewise Republicans have been resistant to tax increases and tax increases require a 2/3rds vote in each House which presents its own challenges. Special Session hearings will resume again when the Legislature reconvenes.

  

A coalition led by the California Medical Association and SEIU is proceeding with qualifying a ballot initiative for the 2016 ballot to increase cigarette taxes and dedicate those funds to the Medi-Cal program.

 

 

Noridian Posts Article on Physician Documentation on O2 Orders  

Noridian Healthcare Solutions has posted the following article to promote compliance and collaboration between physicians and oxygen suppliers. This article can be found in the latest updates section of the Oxygen DMEPOS Category page. The article stresses the importance of clear medical documentation, CMN usage, and how working together will help patients and the Medicare program as a whole.

  

  

Physicians! Are You Ordering Oxygen For Your Patient?

Your medical record documentation determines whether your patient can receive the oxygen equipment and supplies you have prescribed and the amount of the patient's out of pocket expenses.


Your medical record documentation must show that other alternative treatments (e.g., medical and physical therapy directed at secretions, bronchospasm and infection) have been tried or considered and deemed clinically ineffective. The documentation must show the patient was seen within 30 days prior to the start of oxygen therapy. The medical record must show the medical condition necessitating the home use of oxygen therapy. The medical record and/or prescription would indicate the oxygen flow rate (e.g., two liters per minute), and the estimation of the frequency (10 minutes per hour), duration of use (12 hours per day) and duration of need (six months). You must specify the type of oxygen delivery system to be used (i.e., portable/stationary concentrator, compressed gas portable/stationary, liquid portable/stationary).

  

Medicare can make payment for home oxygen supplies and equipment when the patient's medical record shows the patient has significant hypoxemia and meets medical documentation, test results, and health conditions as specified in the CMS Internet-Only Manual (IOM) Publication 100-03, Section 240.2. 

You must complete and sign Form CMS-484 (Certificate of Medical Necessity (CMN): Oxygen). However, the CMN itself is not considered part of the medical record. All information included in the CMN must be supported by the contemporaneous medical record. You can find instructions on completing this form in the CMS IOM Publication 100-08, Chapter 5.

  

The Comprehensive Error Rate Testing (CERT) contractor has identified multiple errors in the claims received for oxygen equipment and supplies. These errors include missing physician clinical records showing the patient's condition and the continued need for oxygen, missing signed and dated order from the physician when changing the oxygen liter flow rate, missing copy of the oxygen saturation testing, and missing treating physician's re-evaluation for recertification CMN.

  

Help your patients and the Medicare program by verifying you have the medical record documentation to support the order and supply of oxygen for your patients. This allows Medicare to pay claims appropriately.

 

Victims/Volunteers of ZPIC Audits

Two members of the Dixon School of Accounting at the University of Central Florida, Jared Koreff and Steve Sutton, are conducting a research study to better understand ZPIC audits and how providers prepare and respond to such audits.  If you have undergone a ZPIC audit and are willing to participate or if you have any questions please contact Jared (jared.koreff@ucf.edu , 516-557-4937 or 407-823-2957).  All of the interviews will be kept confidential, and results will only be presented in the aggregate with non-identifiable information. If you wish to remain anonymous you can contact Jared by signing into a Gmail account he has set up, zpicstudy@gmail.com, password JaredKoreff2015.  Participation is completely voluntary and you may withdraw at any time without penalty.

  

Jared Koreff is a Doctoral Student in the Kenneth G. Dixon School of Accounting at the University of Central Florida.  His research interests include fraud and abusive practices within the healthcare industry. Dr.  Steve G. Sutton is the KPMG Professor of Accounting in the Kenneth G. Dixon School of Accounting at the University of Central Florida.  Steve has served as the Editor for various journals.  His primary research interests are the impact of accounting practice and information technology on individuals, organizations and society.

 

 

Mark Your Calendars for CAMPS 2nd Annual Fall Conference 

We are in the process of finalizing content and speakers for a one-day membership meeting in Long Beach on September 3rd. Come join your colleagues for an information-packed agenda including update on Medi-Cal and ICD-10 implementation, potential CCS redesign, accreditation and HMDRF compliance and readiness issues. Registration information will be posted shortly. 

  




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