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 Advance/Advantage EPO

Wednesday, December 11 from 12:00 P.M.-1:00 P.M.

Speaker: Kevin Jennings from Horizon BCBSNJ 

Join MSNJ for a webinar on "Horizon Advance/Advantage EPO." Learn Horizon's new product offerings for 2014 that will comply with the Affordable Care Act. Horizon will review and compare the network structure, key features, benefits, and reimbursement for these plans. Please submit all questions to info@msnj.org with "Horizon EPO Webinar" in the subject line. General questions will be addressed during the webinar and practice specific questions will be addressed individually.

This event is free for MSNJ members, $25 for PAHCOM & NJMGMA members, and $75 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. 

MSNJ and AMA Support Repeal of SGR Now

MSNJ's delegation to the AMA participated in discussions about the repeal and replacement of Medicare's flawed SGR formula during the AMA Interim Meeting this week. AMA and MSNJ agree that Congress has never been closer to the possibility of a repeal. We joined with organized medicine to support the repeal and to align with the AMA on the following goals:

• Positive updates
• Limitations of any penalties
• Broadening of the definition of "small practices" to allow more time and support to adopt new payment models. 

MSNJ also met with members of Congress to support repeal of the SGR with the above provisions.

Alert! Terminations of Physicians from UHC's Medicare Advantage Networks

We have learned that some physicians have not been successful on their appeals from UHC's terminations from the Medicare Advantage networks. Some have sought reconsideration, but any physician who has lost his/her appeal should consult their agreement to determine the next step. Many physicians have a contract with UHC which requires that disputes be arbitrated within a year. Read more. 

This past week, MSNJ's delegation met with  Senator Menendez, Congressman Pascrell and Congressman Pallone to discuss various issues, including the need for SGR repeal, positive updates to the interim medicare fee schedule, ICD-10 implementation testing and flexibility and UHC Medicare Advantage network terminations at the AMA Interim Meeting. 

MSNJ will keep members apprised of of the situation.

We have learned that it is up to each state to decide to allow for this change. At an event this week, New Jersey Department of Banking and Insurance Commissioner Kobylowski said that New Jersey is seeking clarification from the federal government, as certain parameters still apply. For example, it may be the case that the roughly 100,000 residents who had basic plans under the State's Individual Health Coverage Program (IHC) may NOT be able to go back to them. And, plans that did not offer mental health coverage (ones that would not comply with the new mental health parity mandate), could not be revived. The Commissioner said that 800,000 lives are in the balance, with 150,000 individuals in the IHC and 650,000 individuals in the Small Employer Health Benefits Program (SEH). MSNJ will closely monitor developments in this matter. Read more.   

New Mental Health Efforts

Senator Richard Codey and his wife, Mary Jo, announced this week that they have created a private foundation to support programs benefitting families, homeless people and profoundly ill patients committed in psychiatric hospitals. The Codey Fund for Mental Health already has raised $200,000 in private donations and will fund programs that raise awareness of mental illness and services that reach children, homeless people, mothers and people with severe psychiatric conditions.

Physician Loan Redemption

The Senate passed S-162 passed in the Senate by a vote of 35-1 on Monday. The bill establishes a Physician Loan Redemption Program and provides for redemption of qualifying loan expenses for physicians in primary care or specialties that are projected to experience a significant shortage in the State, if they work in the State for 10 years at an approved site (shortage specialties and sites would be set later).  Program participants must be State residents, have graduated from a NJ medical school and have completed an accredited residency training program.  Though MSNJ supports this bill in concept, we had hoped to work with the sponsor on changes to the bill. In its current form, it has no funding source.  And, since we already have an underutilized loan redemption program, we hoped to analyze the flaws of the current program before creating a new one. MSNJ will continue to work with the sponsor, and stakeholders like the Council of Teaching Hospitals, in hopes to improve the bill in the Assembly.

Self-Referral Laws

The Assembly Health and Senior Services Committee passed A4222, which allows practitioner with financial interest in health care service providing lithotripsy to refer patients to that health care service if certain conditions are met. MSNJ supports this bill, which is a "clean up" to the reforms made to self-referral laws (the Codey Act) in 2009. Lithotripsy was left out of the exemptions in 2009. The Senate Health Committee passed this bill in June, 2013.

Higher Education Epinephrine Emergency Treatment Act

The Assembly Higher Education Committee passed S2448, which allows public and independent institutions of higher education in New Jersey to develop a policy for the emergency administration of epinephrine to a member of the campus community for anaphylaxis when a medical professional is not available.  Institutions of higher education that develop such policies must designate an appropriately licensed physician, physician assistant, advanced practice nurse, or registered nurse to serve as the "licensed campus medical professional," who will oversee the institution's epinephrine administration and train designees in the administration of epinephrine via a pre-filled auto-injector mechanism.  The Secretary of Higher Education is to establish guidelines for the development of a policy for the emergency administration of epinephrine, which will be disseminated to the president of each institution of higher education.  In addition, the bill provides immunity for a licensed campus medical professional, a trained designee, and a prescribing physician for good faith acts or omissions committed in accordance with the bill's provisions.   MNSJ supports this bill, which has already passed the Senate.

Medicaid Provider Rates

A-3409 / S-2241, which would prohibit Medicaid managed care organizations from reducing certain provider reimbursement rates without approval from DHS, was reported out of the Assembly Appropriations Committee and now heads to the full Assembly for consideration.  The bill stems from an attempt by Horizon last year to slash home care provider rates after the Governor began moving most Medicaid services from fee for service to managed care. The insurance companies oppose the bill and stated that the bill would create a regulatory situation that is not used by any other state and that it will ultimately increase costs to the state. They also stated that the record of managed care in New Jersey is very good and the system is fair. The Senate already passed the bill, which MSNJ supports.

Medicaid Therapy Management

The Assembly Appropriations Committee passed A-3716, which would require coverage of medication therapy management in Medicaid and NJ FamilyCare.  The bill is being pushed by pharmacies, which will see a larger share of Medicaid dollars through this bill.  According to the sponsor, the bill should save Medicaid dollars because medications will be better managed.  The insurance companies opposed the bill, saying it was too prescriptive, by placing too many unnecessary regulations and restrictions on elderly patients' medication. The bill's Senate counterpart is pending a vote in the Senate Budget Committee. MSNJ is monitoring this bill.

Medicaid Fraud Prevention

The Assembly Health Committee passed A4062, which creates a Medicaid Smart Card Pilot Program.  The goal of the bill is to reduce fraud through the new cards, but there are concerns about cost and technology. The insurance companies have concerns as well. MSNJ supports fraud prevention measures, but will analyze the concerns and opposition.

Registration Open for NJ Medicinal Marijuana Program's Third Alternative Treatment Center

A third Alternative Treatment Center (ATC) called Garden State Dispensary began accepting registrations on November 18, 2013 for patients and caregivers enrolled in New Jersey's Medicinal Marijuana Program. Garden State Dispensary, formerly known as Compassionate Care Center of America is located in Woodbridge, New Jersey and expects to be open by the end of the year. There is no cost to change ATC registration and it does not require a new identification card. Patients can only be registered with one ATC at time. Currently, the two operating ATC's are Greenleaf Compassion Center of Montclair and Compassionate Care Foundation of Egg Harbor.

For questions relating to the new ATC, the Garden State Dispensary customer service department can be reached by calling (848) 999-2005 or visiting its website. Appointments with Garden State Dispensary can be scheduled via e-mail. 

Physician Resources on the Medicinal Marijuana Program include:

• Introductory webinar for physicians developed by the New Jersey Department of Health's Medicinal Marijuana Program.
• FAQ's on the Medicinal Marijuana Program.
• List of scholarly articles related to medicinal marijuana research.

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.

2014 Medicare Deductible, Coinsurance, and Premium Rates

The new Medicare premium, coinsurance and deductible rates are available for Calendar Year (CY) 2014. The 2014 Part B Supplementary Medical Insurance (SMI) Rates are as follows:

• Standard Premium - $104.90 a month
• Deductible - $147.00 a year
• Coinsurance - 20 percent

For more information, read the MLN Matters article.

Medicare ICD-10 Testing with Providers through the CEM and CEDI

For dates of service of October 1, 2014, and after, providers are required to submit ICD-10 codes on their claims. Novitas (NJ's Medicare Contractor) must provide the opportunity for providers and suppliers to submit test claims through the Common Edits and Enhancements Module (CEM) or the DME Common Electronic Data Interchange (CEDI) during the testing week. The testing week is March 3 through March 7, 2014 and will be conducted virtually. Read more.

Medicare Revalidation of Provider Enrollment Information

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.

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.

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.

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.

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.