Horizon BCBSNJ - Physician Outlier Programs

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

James A. Dell'Arena, Horizon BCBSNJ

 

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. This webinar will not be archived.

 

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

 

Register online.  

 

 

Amerihealth's Exchange Products

Wednesday, January 29 from 12:00 P.M.-1:00 P.M.

Michael Zollenberg, Amerihealth New Jersey

 

Join MSNJ for a webinar on "Amerihealth's Exchange Products" to learn about Amerihealth's products both on/off the Healthcare marketplace and the differences in their networks. Please submit all questions to info@msnj.org with "Amerihealth's Exchange Products" 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.  

Valley Hospital Grand Rounds and the Dermatological Society of New Jersey - North Region will present, "Unusual Genital Presentations/BCE Too" by Ted Rosen, MD. This event will take place on Thursday, December 19, 2013 at the Stony Hill Inn in Hackensack.

Cocktails:  6:30 P.M.; Dinner: 7:30PM. RSVP - Dr. Marcus (201) 891-4373

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.

 

 

 

Medicare: First Positive Update Since 2010

 

 

Summary of 2014 Medicare Physician Fee Schedule Final Rule

On November 27, the Centers for Medicare & Medicaid Services (CMS) released the 1,369-page 2014 Medicare Physician Fee Schedule final rule, which was published in the December 10 Federal Register.  Most provisions take effect January 1, 2014, although a few issues are open for public comment by January 27, 2014.  Below are some of the key highlights of the rule. 

• Absent Congressional action, the sustainable growth rate (SGR) payment adjustment for 2014 is 23.7 percent.  When combined with two budget neutrality adjustments (unrelated to SGR), the net decrease to the conversion factor for 2014 payments under the MPFS will be 20.1 percent.

• After strong opposition from the AMA and many specialty societies, CMS is not finalizing its plan to cap non-facility practice expenses for over 200 physician services at the lower rates for ambulatory surgical centers or hospital outpatient departments.  The caps were below crucial supply costs for some procedures.

• The rate of CMS acceptance of RUC recommendations for 2014 is 76 percent.  RUC recommendations adopted by CMS for psychotherapy services will improve Medicare payment for mental health services by psychiatrists and non-physician practitioners.  CMS did not accept many of the RUC recommendations for upper gastrointestinal (GI) endoscopy procedures and immunohistochemistry.  $435 million will be redistributed within the MPFS for 2014. 

Read the full summary.

MSNJ will host a lame duck update via conference call on Monday, December 16th at 6:30 P.M.  This will be an informal forum during which MSNJ President Ruth Schulze, MD, will be available to hear any concerns or priorities for the house of medicine as we finish this legislative session and enter the next one.

 

Call in information:

866-740-1260

Code: 8961209

MSNJ Joins Medical Associations Supporting Injunction against UHC in Connecticut 

This week MSNJ joined a number of counties in Connecticut, state and specialty societies, and the Physician Advocacy Institute in an amicus brief supporting a preliminary injunction order obtained against UHC in the matter of Fairfield County Medical Association v. United Healthcare of New England. UHC sought to overturn the injunction, through a motion to stay, but was unsuccessful. The matter is now on appeal to the 2d Circuit Court of Appeals where the amici, including MSNJ, will join in another brief to support the injunction on December 23. We argue that the associations and their physician members suffer irreparable harm in the form reputational damage, patient confusion, and damage to long-standing physician-patient relationships.

 

The underlying litigation was filed by two county medical societies in the Connecticut Federal District Court and takes the position that UHC's termination of physicians from its Medicare Advantage network violated the physicians' contracts. In Connecticut, like New Jersey, UHC terminated the physicians' participation in the Medicare Advantage plans under the contract amendment clause instead of the "no cause" provision that allows termination of the contract on 90-day notice in advance of the contract's anniversary date. The complaint alleges that physicians bargained for all of the plans covered in their contracts and that UHC may not remove a plan under the amendment clause and take the position that it is without cause.

 

The injunction obtained in the litigation only applies to the physicians in the two counties bringing the action. It preserves the status quo-stops the terminations-- and permits the physicians to continue to vindicate their contractual rights. It gives these physicians time to individually file for arbitration under the contract's arbitration clause. The contract specifically excludes class arbitration.

 

MSNJ and others in organized medicine will continue to support the injunction obtained in Connecticut. MSNJ is evaluating all options, including intervention in the pending litigation. Any physician who was unsuccessful in appealing their termination from the UHC Medicare Advantage plan and intends to arbitrate is urged to contact MSNJ as soon as possible. Any physician who did not receive notice of their termination and plans to arbitrate is urged to contact MSNJ as soon as possible. Write to info@msnj.org and put: "UHC Medicare Advantage Termination" in the subject line.

Horizon Managed Care Recoupment

Many MSNJ members have reported receipt of accounts receivable notices relating to a large overpayment recovery effort by Horizon. It is our understanding, based on member reports, that this effort is associated with managed care claims that were mistakenly paid at the traditional fee schedule. We are concerned that our members have not received advanced notice of the recoupment effort, other than EOB's that list an accounts receivable report. We asked Horizon to provide additional information regarding the effort, supply physicians with formal notice of the recoupment (including appeal rights), and delay automatic recovery until the 45 day appeal period ends or the appeals process is exhausted (whichever is later). Physicians who will face financial hardship due to the recoupment should contact their network specialists to discuss the matter.  We will update members through e-News and our website. In the meantime, members are encouraged to review our guidance document and FAQ on recoupment. Members with additional questions or concerns may contact us at info@msnj.org. Please put "Horizon Managed Care Recoupment" in the subject line. 

Candidates for Open Positions
We are accepting applications for interested candidates for positions on the Board of Trustees, Judicial Councilor, AMA Delegates and various positions. Please review the Offices to be Filled by Election Report and read a brief synopsis of the committees and its expectations.

If you are interested in running for a positions or have questions about specific vacancies, please feel to contact your county executive or Sue Hoisington at 609-896-1766 X 207.

The deadline to submit a request is Wednesday, January 13, 2014.

New Data on Medicare Part D Prescription Drug Donut Hole Savings

CMS has released new data on Medicare prescription drug plan coverage. The Affordable Care Act has saved seniors and people with disabilities $8.9 billion to date on their prescription drugs. In New Jersey, 156,868 seniors and people with disabilities saved $165,019,270, or an average of $1,052 per beneficiary, from January 2013 through October 2013. Read the press release.

National Influenza Vaccination Week

In recognition of National Influenza Vaccination Week, the NJ Department of Health reminds everyone 6 months of age and older to receive a flu shot this season. Health professionals are asked to remind their patients of the importance of the vaccine, especially for those at a higher risk - young children, pregnant women, the elderly and those with chronic medical conditions. To find a nearby flu clinic, please visit the Find a Flu Shot Locator on the NJ Department of Health website. For more information about NIVW and flu, please visit the CDC NIVW web page. 

2013 WEDI Report Released

The annual Workgroup for Electronic Data Interchange (WEDI) report was released this week. It recommends ten changes to Health Information Technology regarding patient engagement, innovative encounter models, data harmonization & exchange, and payment models. Read the 2013 report.

Brach Eichler LLC, in conjunction with New Jersey Monthly, will host a free seminar on "The Private Practice of Medicine in an Obamacare World: Strategic Approaches" on Thursday, March 6, 2014 from 12:00 P.M. to 1:30 P.M. at the offices of Brach Eichler LLC, 101 Eisenhower Parkway, 2nd Floor, Roseland, NJ 07068. Learn how the Health Insurance Exchange impacts your practice. Lunch will be served. RSVP to Lauren Lynch by February 24, 2014 by e-mail or by phone at 973-364-8389.

Pediatric Respite Care

The full Assembly and Senate Health Committee have approved A3558, which would provide for licensure of pediatric respite care facilities.  The facilities will provide end-of-life care for children up to age 21 with limited life expectancies or complex, life-limiting illnesses and support for their families, and employ interdisciplinary teams to assist in providing curative treatment when possible, palliative care, and supportive services to meet the physical, emotional, spiritual, social, and economic needs of children and their families during illness, as well as during dying and bereavement if no cure is attained. The Senate will likely pass the bill this month, after which it will head to the Governor's desk.

 

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.  This bill is a lame duck priority for policy makers, so MSNJ, along with NJ AFP and COTH are working quickly on improvement to make sure the program is attractive.

 

Medicaid Fraud Prevention

The Assembly and Senate Health Committees have 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 is analyzing the creation such a program at this time.

 

Drug Adherence Efforts

The full Assembly and Senate Budget Committee have passed A1214, which requires the State Health Benefits Commission and the State Health Benefits Plan Design Committee to establish a three-year pilot program to provide benefits coverage to select employees with chronic health conditions using a value-based benefit design under the State Health Benefits Program (SHBP).  The value-based benefit design will target the following chronic health conditions: diabetes, high cholesterol, hypertension, and asthma. The coverage design will utilize explicit financial incentives to increase the employee's interaction with appropriate health care providers, and encourage use of those health benefits that specifically relate to the employee's chronic health condition.  The value-based benefit design pilot program will assign a participating employee to a pharmacist, who, in collaboration with the employee's primary treating physician, will be responsible for coordinating medication therapy management services within the scope of the pharmacist's license to practice pharmacy in the State of New Jersey.

 

The following financial incentives directly related to the diagnosis, care, mitigation, or treatment of the condition for which the employee is participating in the program will be provided:

(1) all tuition costs for any education class attended by the employee which provides medical condition self-management, recommended to the employee by the primary treating physician or assigned pharmacist;

(2) all costs for private visits with the employee's assigned pharmacist;

(3) all costs for a medical device or supply deemed medically necessary by the primary treating physician or assigned pharmacist;

(4) all costs for laboratory testing; and

(5) waiver of all co-payments for any prescription drug.

This bill is based on the well-known Ashville Project.  The bill will most likely be approved by the Senate and head to the Governor's desk in lame duck.

 

Pertussis Vaccine

The full Assembly and Senate Health and Budget Committees have approved A3978, which mandates that the Department of Health (DOH) prepare and make available informational literature on the pertussis vaccine for adults, including, but not limited to, information on the risks of pertussis, the morbidity and mortality rates among infants suffering from pertussis, the availability and efficacy of the Tdap booster vaccine, and the benefits of inoculating pregnant women, a new mother, and other adult family members, with the booster vaccine, prior to an infant's birth or the mother's discharge from a hospital or birthing facility, to prevent the transmission of pertussis to the infant.  DOH would require each hospital and birthing facility in the State to provide new mothers, including adoptive mothers, with the informational literature which would be distributed to the mother and any other family member, including adoptive family members, present at the infant's birth, by staff designated by the hospital or birthing facility, prior to the mother's discharge, as part of the hospital or birthing facility's discharge procedures. The bill will likely head to the Governor's desk in lame duck.

 

Congressional Forum

MSNJ participated in a forum held by Congressman Bill Pascrell on federal health matters, including SGR reform. MSNJ is working hard to urge our federal representatives to pass SGR reform. Please see MSNJ's website for more information.

 

NJ DHS Budget Forum

MSNJ testified during the annual DHS budget forum, which allows stakeholders to discuss priorities and requests for the upcoming State fiscal year budget (FY2015).  MSNJ testimony centered on the Medicaid program; we are working with the State and other partners on improved funding and program reforms in order to incent more physicians to participate.  MSNJ testimony can be found on our website.

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. 

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 

MSNJ will host a series of webinars on Medical Chart Audits:

• Horizon BCBSNJ - Physician Outlier Programs - December 18 from 12:00 P.M. to 1:00 P.M. Register online.

Deadline for Meaningful Use Delayed 1 Year

CMS has proposed a new timeline for the implementation of meaningful use for the Medicare and Medicaid EHR Incentive Programs. This revised timeline proposes that Stage 2 be extended through 2016 and Stage 3 to begin in 2017 for those providers who have completed at least two years in Stage 2. The delay is intended to allow CMS and the ONC to focus on helping providers meet Stage 2's demands for patient engagement, interoperability and information exchange. The proposed rules for Stage 3 requirements are expected to be released in the fall of 2014. Read more.

Medicare Update on Services Furnished to Incarcerated Beneficiaries

When denying claims for services furnished to incarcerated Medicare beneficiaries, MACs are instructed to use an updated Claim Adjustment Reason Code (CARC), Remittance Advice Remark Code (RARC), and Group code. MACs will begin using the following revised beneficiary liability and messages:

• CARC: 258 - Claim/service is not covered when patient is in custody or incarcerated. Appropriate Federal, State or Local authority may cover this claim/service.
• RARC: N103 - "Medicare records indicate this patient was a prisoner or in custody of a Federal, State, or local authority when the service was rendered. This payer does not cover items and services furnished to an individual while he or she is in custody under a penal statute or rule, unless under State or local law, the individual is personally liable for the cost of his or her health care while in custody and the State or local government pursues the collection of such debt in the same way and with the same vigor as the collection of its other debts."
• Group Code: OA - Will use this code to assign proper liability when denying claims for services furnished to beneficiaries while they are in Federal, State, or local custody so that the provider or supplier should seek repayment for the cost of its services provided from the authority that was in custody of the beneficiary on the date of service. Read more.

Providers who were impacted by the incorrect incarcerated beneficiary claim denials have been receiving refunds through Novitas' financial system (HIGLAS) without the associated remittance. Remittance advices will not be issued for these reprocessed claims. A spreadsheet is expected to be provided later this month with information needed to reconcile the accounts. Read CMS' FAQ. 

New Influenza Virus Vaccine Code

As taken from CR 8473, Medicare will pay for vaccine CPT code 90673 (Influenza virus vaccine, trivalent, derived from recombinant DNA (RIV3), hemagglutnin (HA) protein only, preservative and antibiotic free, for intramuscular use). This iseffective for claims with dates of service on or after January 1, 2014. All physicians, non-physicians practitioners and suppliers who administer the influenza virus vaccination must take assignment on the claim for the vaccine. Your Medicare contractor will add influenza virus vaccine CPT code 90673 to existing influenza virus vaccine edits and accept it for claims with dates of service on or after January 1, 2014. 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.

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.

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.

View December's Coding Tip of the Month on the Use of Z Codes

 

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.

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.

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.