Third Edition

Spring Issue

May 2011

President's Message

 

Greetings Maine Chapter of HFMA Members,   

 

As my year as Chapter President comes to a close, I have been reflecting on the exceptionally dedicated and talented individuals I have had the opportunity to work beside these past few years as a volunteer of the Maine Chapter of HFMA.  The relationships that we have built will last a lifetime and I will truly miss the camaraderie that we have shared.

 

Next year the Chapter will be led by Lisa Trundy, President and Melanie Meader, President-Elect.  I am delighted to know that the Chapter will be in such capable and energized hands.  These two individuals along with Anne Cloutier, Vice President and Kathleen Carmichael, Treasurer will be attending the National Leadership Training Conference to be held in New Orleans in mid-May to unite with other Chapter Leaders from around the country and prepare for the coming 2011-2012 HFMA year.  This conference is an amazing opportunity to network with colleagues and gather ideas to help improve our already exceptional Chapter.

 

As you plan your educational activities for the upcoming year, please keep our Chapter events in mind.  When the crew returns from LTC there will be an updated tentative educational calendar made available on the website at http://www.mainehfma.org/ .  Additionally, shortly you will be receiving a Save-the-Date reminder for The Maine Chapter Annual Meeting which will be held at Point Lookout in Northport, Maine on September 15th and 16th, 2011.  Visit their website at http://www.visitpointlookout.com/ to view all that this beautiful location has to offer.

 

I'd like to thank all of our Chapter members for making this past year as president such a fulfilling experience.  I look forward to continued involvement with the Chapter and to seeing you all at a future educational session.

 

For more information on opportunities to join our leadership team and benefit from the wonderful experiences that HFMA has to offer, please contact myself or any of the individuals noted above.

  

Amy A
 

Sincerely,

 

Amy Atherton, President 2010-2011

HFMA Maine Chapter

 

207-973-4857

Maine Integrated Health Management System (MIHMS) Update

On September 1, 2010, MaineCare implemented the Medicaid claims processing system, known as the Maine Integrated Health Management Solution (MIHMS).  To date, MIHMS has paid providers over $50 million in claims.  MaineCare has received feedback from providers on how the system is working through recent statewide Provider Focus Group sessions. There continue to be some known issues that MaineCare is working to improve, which will ensure a stabilized system.  Some of these issues include the Primary Care Case Management (PCCM) Primary Care Provider (PCP) Assignments and MIHMS Remittance Advices (RAs). You can learn more about these resolutions below.   

 

Primary Care Case Management (PCCM) Assignments

MaineCare has been working to correct the Primary Care Case Management (PCCM) Primary Care Provider (PCP) assignments and panel reports.  As a result of the Primary Care Case Management member assignments not being assigned appropriately, referrals from and to some providers were not successful.  MaineCare has worked with a group of pilot providers to determine the best process for correcting member assignments. 

During the week of May 9th, PCCM PCP Providers received a May 2011 member panel report to validate and return back to MaineCare by June 1st. MaineCare will make system corrections based on the updated reports through June.   Once all corrections are made, providers should be able to successfully submit referrals.   During the months of July and August, MaineCare will monitor how successful providers are when submitting referrals.  On September 1st, 2011, there will no longer be a warning on RAs if there is not a referral present.  For claims with dates of service September 1st 2011 and forward, the claim will deny if a referral is required but not on file.

The process and timeline for the correction of the member assignments are:

 

PCCM/PCP Assignment Timeline

May 9-13- Letters to PCCM PCP Providers, panel reports available for validation

June 1st- Panel Reports due back to MaineCare

July 1st - Updates made in system/Providers begin submitting referrals

September 1st- Referral Warning period ends

If you are a PCCM PCP provider and you have questions about the Panel Report Validation Process, please contact Provider Services at 1-866-690-5585.     

                                                                  

Remittance Advice Update

As a result of provider feed back, there have been some changes made to MIHMS

RAs.  During the week of April 25, 2011, providers began receiving the newly formatted RAs.  Some of the formatting improvements included: 

 

  • The dollar value for the adjustment reason code is included with the adjustment reason code.
  • The Claim Total line is highlighted to allow for easier reference.
  • Other formatting changes that reduce the total number of pages in the RA
  • The portal now shows the check date associated with the RA.

   

MIHMS Provider Focus Group Sessions

During the months of March and April, MaineCare held a series of Provider Feedback sessions to gather input from providers about what has been working well MIHMS and what challenges they have experienced.  The sessions were held at various locations throughout the state. A variety of provider types attended the meeting and they were able to have their feedback heard.  In the coming weeks, MaineCare expects to compile the results of those sessions and will update the provider community using the MaineCare Listserv. 

If you do not yet belong to the MaineCare listserv, you can join by following this link: http://www.maine.gov/dhhs/oms/member/innerthird/listserv.shtml.  This listserv is a great way to stay up to date on MaineCare's latest news and changes. 

  

My Health PAS On-line Portal

Keep up to date with MIHMS Known Issues and Statuses by visiting the My Health PAS On-line Portal. Here you will see a list of the Known Issues that have been trending through the Provider Services call center.  You will also find Important Updates that will give up to the minute information on news providers should know about. Visit https://mainecare.maine.gov/ProviderHomePage.aspx to access this information.

Service Location appears on the RA.  If you have any questions about your RA please contact Provider Services at 1-866-690-5585.

CMS Introduces New Provider Enrollment Fees

By Pamela Cook, Senior, Baker Newman Noyes

 

The February 2, 2011 Federal Register established new regulations related to the provider enrollment process.  Per the Federal Register, beginning on March 25, 2011, the Centers for Medicare and Medicaid Services (CMS) began requiring any institutional provider or supplier to submit a fee of $505 with the submission of an 855A, 855B and 855S.  CMS has excluded physicians and non-physician practitioner organizations from the new regulations.  Consequently, a fee is not required to accompany the submission of an 855I or 855R.  CMS released MLN Matters Article on MM7350 on March 23, 2011 to confirm those providers who are required to submit a fee with a provider enrollment application.

 

The Federal Register is clear with regard to the impact on 855A, 855B and 855S submissions.  Any of the aforementioned 855s that are submitted without the newly required fee will be immediately rejected, and CMS could revoke the provider's Medicare billing privileges.  The Federal Register language gives providers the impression the fee will apply to initial enrollment applications, applications to establish a new practice location, and revalidation applications.  Discussions with CMS and NHIC representatives revealed the submission of an 855A, 855B, or 855S for any reason could be subject to the new application fee.  MLN Matters Article MM7350 does not support this approach, and requests for further clarification from CMS and NHIC have not been received to date.

 

Payment of the $505 fee must be submitted to CMS via www.pay.gov using a credit card, debit card, or check.  CMS will not review or approve the 855 until the fee has been deposited into the U.S. Treasury.  Providers should submit a copy of the www.pay.gov receipt with the 855 to confirm payment and avoid unnecessary delays in processing.

 

The provider enrollment fees also apply to Medicaid and CHIP applications, and are the result of legislation passed as part of the Affordable Care Act.  CMS has made a hardship exception request available, however, the exception request must be approved by CMS before the application will be reviewed by a provider enrollment specialist.   

OIG:  Hospital's Complementary Transportation Services Not Subject to Sanctions

 

 Recently, the Office of the Inspector General ("OIG") of the U.S. Department of Health and Human Services indicated it would not subject complementary transportation services between physician offices on or near a hospital campus and the hospital to sanctions under the federal Civil Monetary Penalty ("CMP") or Anti-Kickback Statute ("AKS").  The CMP provides for money penalties against those who give something of value to Medicare or Medicaid beneficiaries to influence their choices of health care providers or services.  The AKS makes it a crime to knowingly or willingly offer, pay, solicit, or receive remuneration to induce or reward referrals of items or services paid for by a federal health care program. 

 

On March 17, the OIG issued an advisory opinion (No. 11-02) at the request of an unnamed non-profit hospital.  Under the hospital's proposed arrangement, the complimentary transportation would be provided for patients and their families present at physician offices located on or near the hospital's campus.  The transportation would be by hospital-owned, wheelchair accessible vans driven by an EMT employed by the hospital.  Patients benefiting from the transportation would be those who required further evaluation and treatment at the hospital and would be unable to transport themselves. 

 

The hospital would provide the service uniformly to all patients regardless of income-level, source of health care coverage, or level of care provided to the patient.  The decision to offer the service would be made by physicians pursuant to a written policy.  The physicians would make the determination of whether a patient is unable to walk the distance from the office to the hospital in accordance.  Moreover, only physicians would be told of the transportation program - the hospital would not otherwise market or advertise the program. 

 

The hospital would not charge patients, bill any third-party payor, or directly or indirectly shift the costs to any federal health care program.  Under the proposed arrangement, the aggregate value of the transportation could exceed $10 for one trip or $50 on an annual basis, and therefore could be of more than nominal value.       

 

Although the OIG concluded that this arrangement could constitute an improper arrangement that implicates the CMP or AKS, it would decline to impose sanctions on the hospital for several reasons:

All patients are eligible for the service, regardless of whether they are beneficiaries of a federal health care program.   

  • The mode of transportation is modest. 
  • The transportation is limited, in that patients would only be moved from physician offices on or near the hospital campus to the hospital.   
  • The hospital would not advertise or market the service, except that it would inform its physicians of the service. 
  • The hospital is located in an area with limited public transportation, and parking close to the hospital is limited. 
  • The cost of the transportation would not be claimed, directly or indirectly, on any federal health care program cost report or claim.

Hospitals and providers considering complementary or low-cost transportation programs for their patients should consult with legal counsel before implementing such programs.

Risk Assessment for HIPAA and HITECH Act

 

Subtitle D of the Health Information Technology for Economic and Clinical Health Act, known colloquially as "HITECH", extends the Privacy and Security Provisions of HIPAA, previously applicable only to covered entities, to the business associates of covered entities as well. The HIPAA Security rule requires organizations to "[i]mplement policies and procedures to prevent, detect, contain, and correct security violations." (45 C.F.R. � 164.308(a)(1). Further Section 164.308(a)(1)(ii)(A) includes a Risk Analysis specification that requires organizations to "Conduct an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of electronic protected health information held by the [organization]." The targeted outcome for both HIPAA and HITECH is to effectively reduce risks and vulnerabilities to a "reasonable and appropriate" level - a vague and subjective term which begs further consideration.

 

A useful method for assessing the "reasonableness", "appropriateness", and "effectiveness" of a HIPAA/HITECH program is to devise a focused risk assessment based on the frameworks provided by the HIPAA Security and Privacy rules.  While HIPAA guidelines provide discourse on the expected outcomes from an effective program, they are not always useful (nor where they designed) to instruct the entity on how to comply. 

 

While this lack of clarity can be frustrating, a risk assessment provided by a third-party consultant can provide the discipline needed to objectively assess the entity against reasonable and appropriate standards by keying in on a few critical aspects of the plan:

 

Risks

 

By crafting a risk assessment plan of attack, an entity is given the tools to think through the "what-if" scenarios that yield insight into the true risks faced by the organization.  If we think of risk being a function of impact X likelihood, a third-party consultant can provide a useful assessment of potential risks and their impact, while Management can best assess the likelihood of the scenario.  In this way, risk is assessed collaboratively, combining the external view with internal knowledge of operations. 

 

Design of Controls

 

Once risks are defined, a review of policies, procedures, and process yields the controls in place that "effectively" mitigate risks to the "reasonable and appropriate" standard.  Once again, the entity's management is best situated to identify processes in place, and the consultant is often better able to identify the controls inherent to these processes and assess "reasonable and appropriate" using their knowledge of other entities and best practices.  Not all controls exist as a neat checklist; the consultant can help identify the processes in place that mitigate risk - including those that management may have overlooked.

 

Effectiveness of Controls 

 

Just as not all controls exist as a checklist, not all checklists are controls.  Locked doors can be bypassed by propping them open, and system access controls can be circumvented by printing PHI to paper.  By designing tests of controls, the consultant can identify instances in which management assertions about controls are not accurate, or not functioning as designed. 

  

A well-designed and implemented risk assessment will likely leave the entity with more questions than answers.  Consideration of the likelihood and impact of risks leads to discussion of proposed solutions and mitigation strategies.  Short-term and long-term strategies are then considered within a well-defined risk environment, with Management better able to plan strategically for risks that have been defined and quantified. 

  

A risk assessment does not need to be a burdensome endeavor.  By partnering with a consultant who understands you, your systems, and your business, a risk assessment is an opportunity to better understand the strengths and opportunities, as well as the weakness and threats, inherent in your environment.  While the need for the assessment is driven by HIPAA and HITECH, a risk assessment is an opportunity to inventory and document your IT systems and scope, enhance your strategic planning base, and leverage external perspectives to better understand your environment.

 

 

 

Pat Morin is a board member of the Maine Chapter of the HFMA and a Principal with Baker Newman Noyes.  Jeff Mansir is a Manager in the IT Consulting group at Baker Newman Noyes.  Pat and Jeff regularly advise organizations on the application of Information Technology regulations and may be reached at [email protected] or [email protected] .

 

MEDICARE ADVANTAGE PLANS GET INCENTIVES

 

Insurance companies are complaining that their payments from CMS are being reduced under the Health Reform law.  However beginning next year, Medicare Advantage (MA) and stand-alone prescription drug plans will be eligible for bonuses based on new "Star" ratings, which include 36 measures divided into five categories for MA plans and 21 measures in four main categories for PDP plans.

 

Among the categories are management of chronic diseases, health plan responsiveness and member complaints. A score of 3 stars out of 5 will generate a bonus in 2012.

 

For the MA plans facing reimbursement cuts from the federal government, the Star-related bonuses give them the opportunity to recapture lost revenue.  For Providers, the incentives provide an opportunity to explore how they can share in the incentives by helping the MA plans achieve their bonuses.

 

 

TWO VIEWS OF COMMUNICATION

 

Primary care doctors and specialists have very different perspectives on how often their colleagues communicate with them about patient referrals and consultations.


According to a
studyby the Center for Studying Health System Change published in Archives of Internal Medicine, 2/3 of primary care physicians (PCPs) reported that they always or most of the time send a patient's history and the reason for the referral to the specialist.  However, only about 35% percent of specialists said they regularly receive such information.  

MEDICARE ADVANTAGE PLANS GET INCENTIVES

 

Insurance companies are complaining that their payments from CMS are being reduced under the Health Reform law.  However beginning next year, Medicare Advantage (MA) and stand-alone prescription drug plans will be eligible for bonuses based on new "Star" ratings, which include 36 measures divided into five categories for MA plans and 21 measures in four main categories for PDP plans.

 

Among the categories are management of chronic diseases, health plan responsiveness and member complaints. A score of 3 stars out of 5 will generate a bonus in 2012.

 

For the MA plans facing reimbursement cuts from the federal government, the Star-related bonuses give them the opportunity to recapture lost revenue.  For Providers, the incentives provide an opportunity to explore how they can share in the incentives by helping the MA plans achieve their bonuses.

 

 

TWO VIEWS OF COMMUNICATION

 

Primary care doctors and specialists have very different perspectives on how often their colleagues communicate with them about patient referrals and consultations.


According to a
studyby the Center for Studying Health System Change published in Archives of Internal Medicine, 2/3 of primary care physicians (PCPs) reported that they always or most of the time send a patient's history and the reason for the referral to the specialist.  However, only about 35% percent of specialists said they regularly receive such information.  

LINK UPDATE

 

One of the most important things we as members of HFMA can do right now is work together to provide the finance perspective on the impact of health reform on our patients, organizations, and communities. Funding and implementation decisions at the state and federal levels will be key determinants of the impact of health reform on all stakeholders. These decisions are being made every day, and the pace is accelerating.  HFMA has formed a Health Reform Advisory Committee to provide input and counsel to HFMA's management team in the development of perspectives on key provisions of the Affordable Care Act. 

 

To ensure that perspectives at all levels are heard and taken into consideration, chapters and regions have been encouraged to develop a Local Information Network (LINK).  The LINK committees will serve as an ongoing committee, and the outcomes of this important initiative will be to:

 

  • Develop a system that encourages alignment of chapters, regions and national volunteers and staff on issues of importance to HFMA members.
  • Provide information to HFMA's Health Reform Advisory Committee on the impact to local communities of proposed regulations and rules.
  • Utilize the summary of information provided to the Health Reform Advisory Committee and HFMA's stated position to drive the transfer of knowledge at a local level.

 

We have asked Benton Cash from The Aroostook Medical Center to lead this important initiative for our chapter. 

 

HFMA's Health Reform Advisory Committee working with HFMA's management team is identifying specific topics to survey chapter and regional LINK Committees on regarding pending regulations related to health reform.  Just last week, the first survey was forwarded to the LINK Committee Chairs to get input for a comment letter HFMA will send to CMS on the proposed shared savings rule.  The final comment letter will be sent back to the LINK Committee Chairs along with a summary of the input received from all the LINK Committees.

 

If you are interested in learning more about the LINK Committee please contact Benton at [email protected].

The Beacon has gone GREEN!!  Welcome to the third edition of the e-Beacon, where Maine HFMA'ers get their news! 

The e-Beacon is looking for fresh faces and ideas! Our committee member numbers are dwindling and we sure could use some help!  If you have a column in mind, even if it's something small like a quarterly healthy recipe, joke or comic strip, or if you would like to coordinate a quarterly ANYTHING (advertisements, want ads, member updates, etc), please contact  Ames Ryba at [email protected]
Comments, questions and concerns are always welcome.  Have a suggestion please send to [email protected].
In This Issue
MIHMS Update
CMS New Fees
OIG - Transport Services
Risk - HIPAA and HITECH
Medicare Incentives
LINK Update
New Members
Sponsors
Upcoming Events
Tiered Networks
Quick Links
Welcome New Members!

Kimberly Halpin,

Audit Staff Accountant, BerryDunn

 

David P. Kennedy, Manager Healthcare Group, BerryDunn

 

Grant Ballantyne, Accountant, BerryDunn
 

 

Sheila Parker, VP Dept of Nursing, Maine Medical Center

 

Keith Morin, Audit Senor, Baker Newman & Noyes 

Thanks

To Our

Sponsors

GOLD SPONSORS

 

Baker Newman Noyes

 

BerryDunn

 

eHC Solutions

 

E-Management Associates, LLC

 

Emdeon

 

Maine Recovery Services

 

Medical Bureau/ROI

 

The Thomas Agency

 

 

SILVER SPONSORS

 

DECO

 

Martin's Point Health Care

 

Ritter Project Management

 

Vierill Dana, LLP

 

 

BRONZE SPONSORS

 

Morris Switzer

Upcoming Events

 

June 10, 2011

9th Annual Patient Financial Services Summit

 

Hilton Garden Inn  Auburn, ME

  

Program runs from 8:30-4:30, registration to starts at 7:30

 

Program put on by:

MGMA, HFMA & AAHAM

ME HFMA Newsletter Committee 

Ames Ryba, co-chair, 860-656-5102, [email protected]

 

Steve Kelleher, co-chair, 207-873-1705, Steve

 

Steve Ryan, Past Chair, 207-942-2844, [email protected]

 

Mark Fisher, 207-287-3160, [email protected]

 

 

Movers and Shakers:

 

Edward Olivier, CHFP has taken the position of Chief Financial Officer at Blue Hill Memorial Hospital effective during January 2011.  He was previously the Chief Financial Officer at Charles A. Dean Memorial Hospital & Nursing Home in Greenville. 

Retiring CEO's

 

Sister Norberta will step down after 29 years as CEO of St Joseph Hospital in Bangor.  Last year, Covenant Health System assumed management activities at St Joseph, clearing the way for Sister to step down later this year. 

 

 Bridgton CEO  David Frum is expected to assume Mr. Welsh's position in addition to his current role.

John Welsh is due to retire on July 1st after 23 years at the helm.   

 

Pen Bay CEO Roy Hitchings is expected to step down next year.  At Pen Bay since 1998, Hitchings says that he and his family intend to stay in the Midcoast area.

 

Submitted by  Steve Ryan, CEO, Maine Network for Health

Do Tiered Networks Really Work?

By Steve Ryan

 

In a recent online article in the journal Health Services Research (www.hsr.org), a survey of Massachusetts state employees was performed to assess how quality ratings and financial incentives affect patients' choice of physicians in tiered health plan networks. 

 

In the study, health plan members were presented with differential copayments for "Tier 1" (Preferred) and "Tier 2" (non-Preferred) physicians. Half of respondents were told they needed to select a cardiologist, and half were told they needed to select a dermatologist. The survey measured preference for a Tier 1 doctor, a Tier 2 doctor, or "no preference".  

 Various scenarios were explored, such as having no further quality information, having a family member or friend recommended a Tier 2 doctor, or having their personal physician recommended a Tier 2 doctor.

 

*

The results showed that copayment differences of $10 to $35 increase the number of respondents indicating they would select a Tier 1 physician by almost 12 percent. Remarkably, coinsurance amounts of over $300 are necessary to offset the recommendation of a lower tiered physician from friends, family, or a referring physician. The effects of the copayments varied with physician specialty.

 

*

The author concludes that tiered provider networks with varying copayment levels appear to have limited influence on physician choice when contradicted by other trusted sources, and that the degree of the effect varies with physician specialty.

Next e-Beacon

Sept 2011