Top Ten Tips for Physicians Facing RAC and Private Payer Audits

Wednesday, December 4 from 12:00 P.M.-1:00 P.M.

Deborah Winegard, Whatley Kallas, LLP

Join us for a webinar on "Top Ten Tips for Physicians Facing RAC and Private Payer Audits."

This event is $25 for MSNJ members, $50 for PAHCOM & NJMGMA members, and $100 for non-members.

Register online.

Horizon BCBSNJ - Physician Outlier Programs

Wednesday, December 18 from 12:00 P.M.-1:00 P.M.

James A. Dell'Arena, Horizon BCBSNJ

Join us for a webinar on "Horizon BCBSNJ - Physician Outlier Programs."

Learn an overview of the post payment and pre-payment programs with a focus on high level evaluation and management codes as well as modifiers 25 and 59.

Register by November 27 and receive a $10 discount! The early bird pricing is $15 for MSNJ members, $40 for PAHCOM & NJMGMA members, and $90 for non-members.

Register online. 

University Medical Center of Princeton at Plainsboro (UMCPP) presents the First Annual Snider Symposium:

"Updates in Medicine for the Older Adult"
November 22, 2013
8:30 A.M. - 4:30 P.M.

UMCPP Education Center, Conference Rooms A-E
One Plainsboro Road, Plainsboro, NJ 08536

This activity has been approved for AMA PRA Category 1 Credit™.
This symposium is free of charge. Seats are limited.
Click for details and registration.  

One-Year Coverage Extension for Individuals and Small Group Health Insurance Policies

Yesterday, the Obama Administration outlined the plan to allow insurers to renew individual and small group health insurance policies for a year, whether or not said policies are in compliance with the requirements under the ACA. This one-year "fix" will allow affected individuals and small employers to re-enroll in their prior coverage, as long as the coverage was in effect on October 1, 2013. State insurance laws may apply to this transitional coverage. MSNJ encourages all individuals and small group employers to contact their insurance agencies to see if this will affect them. Read more.  

New Jersey Sees High Application Rate in First Month of Marketplace Enrollment 

In a press release this week, HHS released a report detailing national and state-specific results from the first reporting period (October 1 - November 2, 2013) of the Health Insurance Marketplace Open Enrollment. Of the 846,184 completed applications in states with HHS-supported marketplaces, 23,021 are from New Jersey. Nationally in this first month, 106,185 individuals have selected plans and an additional nearly 400,000 individuals are projected to have 2014 health coverage. New Jersey sees a high number of individuals eligible for Medicaid or CHIP (Children's Health Insurance Coverage Program), at a total of almost 17,500. In the first month, New Jersey reports 741 individuals who have selected a marketplace plan. Read the full report and view the infographic of the results.

Mental Health & Substance Abuse Parity Rules

Last week the Federal Government issued a final rule to implement the Paul Wellstone & Pete Comenici Mental Health Parity & Addiction Act that requires health plans to increase parity between mental health/substance use disorder benefits and medical surgical benefits in group and individual health plans. The rule addresses copays, deductibles and visit limits which may be more restrictive for mental health and substance abuse disorders than for medical/surgical benefits. 

The rule is effective for plan years beginning on or after July 1, 2014, but will be effective for most on January 1, 2015 since most plan years end on December 31. The rule notes the primary enforcement authority by the states. It does not apply to Medicaid Managed Care Organization, Children's Health Insurance Programs (CHIP) or alternative benefit plans such as Medicaid Expansion Plans under the ACA. Comments are due on January 8, 2014. 

Medicare SGR Status Update

Last week we reported that the Senate Finance Committee and the House Ways & Means Committee released a discussion draft proposal that would permanently repeal the Medicare SGR formula and replace it with payment reforms that reward quality through alternative payment models. Since that time, the AMA has held conference calls for physicians to learn more about the draft and to provide in-put. More progress has been made toward a permanent repeal of the SGR this year than has been made over the last decade. This week AMA submitted its comments on the discussion draft. While the movement in Congress is positive, MSNJ shares concerns over the lack of positive payment updates and availability of resources for small practices to be ready to conform to the requirements of new practice/payment models. The SGR repeal will be a topic of discussion during AMA's interim meeting this weekend.  

United Healthcare Discontinues Dual Complete Plan for 2014

MSNJ was recently notified by the NJ Division of Medical Assistance and Health Services (DMAHS) that United Healthcare (UHC) will no longer offer its Dual Complete plan starting in 2014. The Dual Complete plan provided both Medicare Advantage and Medicaid Managed Care coverage to dual eligibles. DMAHS reports that there are more than 10,000 affected beneficiaries. Beneficiaries enrolled in this plan will have the option to choose another Medicare Advantage plan or traditional Medicare. Likewise, these dual eligible beneficiaries will also have to choose a Medicaid Managed Care plan. Beneficiaries may contact NJ FamilyCare at any  time to change plans (800.701.0710). Beneficiaries, who take no action, will be automatically transferred to traditional Medicare and UHC's Medicaid Managed Care plan. Please see the DMAHS letter and FAQ for more information. Read UHC's notice to patients. 

Members Urged to Continue Appeals from UHC's Medicare Advantage Terminations 

UHC has agreed to rescind the termination of one of our member small group practices. Each of the five physicians had received termination notice letters. Each appealed. We asked CMS to review the situation because of our network adequacy concerns. Subsequently, UHC rescinded the terminations. MSNJ continues to send appeal letters to CMS for network adequacy testing. We encourage members to supplement their appeal letters and to continue to check our resources on the MSNJ web site. We continue to advocate and work with the AMA on a comprehensive solution that would prevent Medicare Advantage network reductions during the open enrollment period. 

More Election News

MSNJ enthusiastically congratulates Nancy Pinkin on her win as the new Assemblywoman in the 18th Legislative District.  Nancy will be the only woman representing the district with Assemblyman Patrick Diegnan and Senator Peter Barnes.  A former East Brunswick Council President, Nancy worked as a well-respected lobbyist MBI-GluckShaw representing healthcare, education and other non-profit agencies.  She currently serves as the Executive Director of the Middlesex and Mercer county medical societies. We are very proud of Nancy and wish her great success.

Contested Election

Assemblyman Tim Eustace, a practicing chiropractor representing the 38th legislative district, was in a race too close to count.  Votes were recounted this week, resulting in a narrow win. We congratulate Assemblyman Eustace, who is a member of the Assembly Health and Senior Services Committee.

New FDA Rules on Opioids

The FDA has proposed a rule that would reclassify hydrocodone products like Vicodin as Schedule II drugs. Currently labeled as Schedule III drugs, this means patients would have to have a written prescription from a doctor -- instead of a prescription submitted orally over the phone -- to access the drugs. And refills would be prohibited; patients would have to check in with the doctor to get another prescription. A Schedule II classification would also put manufacturing quotas in place for these hydrocodone products. (Pure hydrocodone is already a Schedule II substance.)  

The FDA's proposal is scheduled to be submitted to the Department of Health and Human Services by early December, but the DEA has the final decision on whether to reclassify the drugs. In September, the FDA took another step to reduce painkiller abuse with new labeling regulations, which are set to go into effect at the end of this year. Currently, the labels on the drugs say they are for "the relief of moderate to severe pain in patients requiring continuous, around-the-clock opioid treatment for an extended period of time." The new labels will say the drugs should be used only when "alternative treatment options are inadequate." Please see AMA's reaction.

AMA and AHA Urge CMS to Delay Enforcement of  "Two Midnight" Policy

Last week, the American Medical Association and the American Hospital Association wrote to CMS requesting that it delay enforcement of its new "two midnight" policy until October 2014 and that it meet with affected stakeholders to develop alternate policy solutions. At issue is CMS's requirement that admitting physicians document their expectation that a patient will remain in the hospital for at least two midnights, this in response to growing concerns about the rise in observation care. On September 5 CMS released new guidance on physician orders and certification for inpatient admissions. 

Policy Brief on Medicare's Hospital Readmissions Reductions Program

Health Affairs and the Robert Wood Johnson Foundation have release a new health policy brief. The brief describes the Medicare Hospital Readmissions Reductions Program (HRRP), established as part of the Affordable Care Act. HRRP imposes financial penalties on hospitals with higher than expected readmissions, in order to incent hospitals to reduce the number of patients who return to the hospital within 30 days for treatment of heart attacks, heart failure, or pneumonia. Some of the topics covered include the background of HRRP, the law itself, the debate and policy reasons for initiating HRRP, and what will be in store for the program. The brief itself can be found online.

Medicaid Primary Care Incentive Payments Set to Begin

The New Jersey Division of Medical Assistance and Health Services (DMAHS) announced in its October newsletter that traditional Medicaid retroactive payments for the primary care incentive will be made in bulk payments and processed by mid-December 2013. Incentive payments will begin processing on a claim by claim basis as of November 4, 2013. Under Traditional Medicaid, physicians had until April 30, 2013 to file attestation forms in order to receive retroactive incentive payments going back to January 1, 2013. Physicians who submit the attestation after April 30th will receive incentive payments starting from the first day of the month the attestation was submitted. For example, if the attestation is submitted on October 17, 2013, then the incentive payments will apply to claims starting October 1st. Please note: the fee-for-service deadline does not apply to physicians in the Medicaid Managed Care Organizations (MCO); a deadline should be provided directly from the plan.

MSNJ has heard reports from members that some MCOs have already begun processing retroactive incentive payments. Once caught up with retroactive payments, the MCO incentive payments will be made in quarterly bulk payments and will not be claim specific. Please let us know if your practice encounters any issues with these incentive payments by writing to us at info@msnj.org with "Medicaid Incentive" in the subject line. 

Horizon Exchange Product

Horizon notified MSNJ that participating physicians should expect to receive letters regarding participation in their exchange product, Horizon Advance EPO. Physicians should be on the lookout for a letter from Horizon that indicates whether the practice will be participating in the plan.  If you have questions or concerns regarding the letter your practice received, please write to us at info@msnj.org, put "Horizon Advance EPO" in the subject line, and we will ask a Horizon representative to get in touch with you.

Is Your Practice Being Audited by a Payer? Take Heed!

Payers are auditing practices more frequently with an eye toward recovering overpayments, detecting fraudulent, wasteful or abusive billing practices, or simply correcting billing and coding errors. Services that are not documented are deemed to not have occurred and payers are monitoring for these deficiencies. All payers, government and private, have developed post- and pre-payment audits to detect coding errors, correct billing practices, and recover payments.  

MSNJ is concerned that many physicians may not be aware that they are in a post- or pre-payment review. When coding errors continue through a post-payment audit the practice will be placed

If you are currently in a payment review please write to info@msnj.org, put "Payment Review" in the subject line, and describe your situation. We have been working with payers in an effort to make these reviews more transparent and meaningful to physician practices. We plan a series of webinars in the fall to provide further information.

Medical Chart Audit Webinar Series 

• Top Ten Tips for Physicians Facing RAC and Private Payer Audits - December 4 from 12:00 P.M. to 1:00 P.M. Register online.
• Horizon BCBSNJ - Physician Outlier Programs - December 18 from 12:00 P.M. to 1:00 P.M. Register online.

Medicare Revalidation of Provider Enrollment Information

CMS Issues New Influenza Virus and Hepatitis B Virus Vaccine Codes

Per Change Request (CR) 8249, payment and Common Working File (CWF) edits need to be updated to include influenza virus vaccine codes 90653, 90672, 90685, 90686, 90687, 90688, and Q2033; and hepatitis B virus vaccine code 90739 for claims with dates of service on or after January 1, 2013, but processed on or after October 7, 2013. Payment and CWF edits need to be updated to include influenza virus code 90661 for claims with dates of service on or after November 20, 2012, processed on or after October 7, 2013. Read the MLN Matters article.

Update on Medicare Claims Payment for Services Provided to Incarcerated Beneficiaries

Medicare will generally not pay for medical items and services furnished to a beneficiary who was incarcerated or in custody under a penal statute/rule at the time the items and services were furnished. CMS has created a new fact sheet that outlines the policy regarding claims for Medicare beneficiaries in custody under a penal authority.

Medicare Ordering and Referring Denial Edits Implemented on January 6, 2014

CMS will instruct contractors to turn on Phase 2 denial edits on January 6, 2014. These edits will check the following claims for a valid individual NPI and deny the claim when this information is invalid:

• Claims from clinical laboratories for ordered tests;
• Claims from imaging centers for ordered imaging procedures;
• Claims from suppliers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) for ordered DMEPOS; and
• Claims from Part A Home Health Agencies (HHAs)

For more information, read the MLN Matters article.

OSHA Training Requirements

December 1, 2013 is the deadline for training staff on the new OSHA requirements. The new Hazard Communication Standard  requirement is applicable to medical practices and was updated in 2012 to make it uniform with the global chemical labeling system that manufacturers follow. The Hazard Communication Standard will be phased in through June 1, 2016. Training can be done in the office by using materials from OSHA. View OSHA's QuickCards on safety data sheets and labeling.

2012 PQRS Feedback Reports Available

Feedback reports are now available for physicians who submitted PQRS data from Medicare Part B Physician Fee Schedule claims with dates of service between January 1, 2012 and December 31, 2012. Individual eligible professionals (EPs) who submitted 2012 PQRS data can retrieve their 2012 PQRS Feedback Reports using the following options:

• NPI-level reports can be requested through the Communications Support Page by creating an NPI-level feedback report request. (The report will be sent electronically and could take 2-4 weeks.)
• TIN-level reports, which contain NPI-level detail, are available for download on the Physician and Other Health Care Professionals Quality Reporting Portal via QualityNet. TIN-level reports on the portal require an IACS account. View step by step instructions on how to request an IACS account.

Group practices who participated in 2012 PQRS GPRO can access their feedback reports though the 2012 Quality and Resource Use Reports (QRURs). Authorized representatives of practices with 25 or more EPs can access the QRURs by clicking here using an IACS account with one of the following group-specific PV-PQRS Registration System roles:

• Primary PV-PQRS Group Security Official
• Backup PV-PQRS Group Security Official
• PV-PQRS Group Representative

For more information, read the 2012 PQRS Feedback Report User Guide.

PQRS Reporting is Easier than you Think

The last day to submit to the PQRS data registry is February 28, 2014. There are four easy steps to submit your PQRS data.

1. Use your current data
2. Choose one Measures Group relevant to your practice
3. Enter data for 20 patients
4. Receive your incentive payment and avoid penalties. More information. 

EHR Incentive Programs Reporting Period Ends December 31

December 31, 2013 is the last day of the 2013 meaningful use program year for eligible professionals (EPs) participating in the EHR Incentive Program. If you are an EP participating in the Medicare EHR Incentive Program, you have until February 28, 2014 to attest to demonstrating meaningful use of the data collected during the reporting period for the 2013 calendar year. If you are participating in the Medicaid EHR Incentive Program, you should refer to your state's deadlines for attestation information.

January 1, 2014 marks many important milestones for EPs participating in the EHR Incentive Program, including:

• The start of Stage 2 for EPs who have already completed at least two years of Stage 1.
• The last year that Medicare EPs can begin participation and earn an incentive.
• A 3-month reporting period in 2013, regardless of the stage of meaningful use, to allow time to upgrade to 2014 certified EHR technology.
  • Medicare EPs beyond their first year of meaningful use must select a 3-month reporting period fixed to the quarter of the calendar year.
  • Medicare EPs in their first year of meaningful use may select any 90-day reporting period that falls within the 2014 calendar year.
  • Medicaid EPs can select any 90-day reporting period that falls within the 2014 calendar year.

Resources include:

• Meaningful Use Attestation Calculator 
• Attestation Worksheet for EPs 
• Attestation Guide for Medicare EPs

Avoiding the 2015 EHR Penalty

Beginning January 1, 2015 Eligible Professionals (EPs) participating in the Medicare EHR Incentive Program may be subject to a penalty. The penalty will be determined by CMS based on meaningful use data submitted prior to the 2015 calendar year. EPs must demonstrate meaningful use prior to 2015 to avoid the penalty. Determine if you are subject to the penalty by your participation start year:

• If you first demonstrated meaningful use in 2011 or 2012, you must demonstrate meaningful use for a full year in 2013 to avoid the penalty in 2015.
• If you first demonstrated meaningful use in 2013, you must demonstrate meaningful use for a 90-day reporting period in 2013 to avoid the penalty in 2015.
• If you first demonstrate meaningful use in 2014, you must demonstrate meaningful use for a 90-day reporting period in 2014 to avoid the penalty in 2015. This reporting period must occur in the first 9 months of calendar year 2014, and EPs must attest to meaningful use no later than October 1, 2014 to avoid the penalty.

To avoid the penalties in the future, you must continue to demonstrate meaningful use each year. If you are eligible to participate in both the Medicare and Medicaid EHR Incentive Programs, you must demonstrate meaningful use to avoid the payment adjustments. You may demonstrate meaningful use under either Medicare or Medicaid. If you are only eligible to participate in the Medicaid EHR Incentive Program, you are not subject to these penalties. View the Payment Adjustments and Hardship Exemptions Tipsheet for EPs.

Public Comment on Potential CQMs for Stage 3

CMS requests that the public provide input on new clinical quality measures (CQMs) for potential use by eligible professionals in the EHR Incentive Programs. Comments are now being accepted and must be received by Monday, November 25 at 5:00 P.M. In particular, CMS is interested in obtaining feedback on:

• Relevance of the measures to the mission of public reporting under the EHR Incentive Programs for eligible professionals
• Usefulness of the measures to improve quality of care for patients
• Feasibility of data collection via EHRs for public reporting under the EHR Incentive Programs for eligible professionals

Click here to read the measure specifications and instructions on how to comment.

Open Payments Sunshine Rule Webinar

CMS will host a webinar on the "Open Payments Sunshine Rule" on Tuesday, November 19, 2013 from 12:00 P.M. to 1:00 P.M. This webinar will include an overview of the Physician Payments Sunshine Rule for CMS Regions 1, 2, 3, & 4. Registration is not required (NJ is in Region 2). Click here to join the webinar. The Dial-in telephone number is 1-877-267-1577; Meeting ID Number: 998 023 973.  

Are you Ready for ICD-10?

A study of 20,000 physician notes was released by the American Academy of Professional Coders (AAPC). Coders and practice managers are showing great concern that their physicians' documentation will not support the new code set. Accurate coding and proper payment will not be possible without improved clinical documentation. The following are steps to prepare your doctor:

1. Share the results of the AAPC's 20,000-record study
2. Show your physician an example of ICD-10 readiness documentation 
3. Ask them to consider ICD-10 Documentation Training.
4. Watch the 2 minute video.

Webinar on Comparing ICD-9 to ICD-10

MentorHealth will host a webinar on Comparing ICD-9 to ICD-10 on Wednesday, November 20, 2013 at 1:00 P.M. This 90-minute webinar will provide an overview of the changes from ICD-9 to ICD-10 chapter specific guidelines, documentation requirements for ICD-10 in each chapter, and examples using the most frequently reported codes in each chapter. The cost to register is $175 for one participant (group pricing also available). Register online.

Code-A-Thon: Professional Coder Volunteer Sign-Up and Survey

NJHA and the NJ DOBI have been hosting stakeholder ICD-10 planning meetings to help the industry prepare. From this group, a plan has been created to conduct a Code-A-Thon to provide them with valuable information prior to go-live. Coders who have been trained in ICD-10 are urged to help by volunteering and participating in a survey. Click here for more details.

View November's Coding Tip of the Month on ICD-10 Signs and Symptoms 

If you would like your questions addressed in an upcoming edition of e-News or you have a coding question specific to your practice, please email your questions. We will work with a certified professional coder to help answer them.

CMS 1500 Claim Form Revised to be ICD-10 Friendly 

The CMS-1500 Claim Form has been revised to more adequately support the use of the ICD-10 diagnosis code set. The form will now give physicians the ability to indicate whether they are using ICD-9 or ICD-10 diagnosis codes. ICD-9 codes must be used for services provided before October 1, 2014, and ICD-10 codes should be used for services provided on or after October 1, 2014. Only physicians who qualify for exemptions from electronic submission may submit the CMS 1500 Claim Form to Medicare. Medicare will start accepting the revised form on January 6, 2014 and will only accept the revised version of the form starting April 1, 2014.