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These Insurance Alerts are brought to you by Ces Soyring. Ces is the designated District Five Insurance Alert resource. She is well known as a teacher and consultant in the chiropractic profession. Her expertise in administrative and insurance issues is unsurpassed. She is an instructor at Texas Chiropractic College and has been a speaker at numerous State Association conventions, T.C.C Homecomings and T.C.A. conventions. Over the past twenty-five years, Ces has trained thousands of doctors and chiropractic assistants on how to correctly run an insurance program in their offices. If you want to stay current on insurance issues affecting your practice – then return frequently to this page to get the most up-to-date information available. _______________________________________________________________ July 12, 2010 Medicare Fee Rate Change & PECOS letters FEES On June 28th, Trailblazer’s posted the new fee schedules that include the 2.2% increase from the latest congressional action which passed June 24th. These ‘temporary’ increases in fees are for claims dated June 1st until Nov. 30th. Note that the fees posted are back-dated to June 1st. If you have been holding your claims in-house, as recommended, you may adjust the claims to reflect the current fees. PECOS Trailblazers also recently sent letters to chiropractors who are currently enrolled in Medicare but who do not have an established enrollment record in the Provider Enrollment, Chain and Ownership System (PECOS). All providers who have not updated their Medicare information (or applied before 2005) need to go online and follow the step by step information to revalidate their Medicare information.
Updating your information in PECOS is not just “recommended” it is essential. If you do not update, your Medicare number will be placed inactive and you will need to file for a new number (a whole new application). You may either update online using PECOS and then mailing in the 2-page certification, or you may fill-out an 855I paper application form. The online is definitely the best way to go since it is given higher priority to processing than the paper application form. This revalidation must be done within 60 days from receiving the letter; and you will not be notified again.
July 1, 2010 Increase in Medicare Fee Rate Last Friday, on June 25, 2010, President Obama signed the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010 which gives providers a 2.2% increase in MC rates. Unfortunately this is a temporary increase on claims from June 1 – November 30, 2010 only. However, the law does increase rates retroactive back to June 1st which means some claims may have already been processed incorrectly. CMS directed Medicare contractors (Trailblazers) to discontinue processing claims at the negative rates (-21%) which they had been ordered to do on June 18th and to now temporarily hold all claims again for services rendered on or after June 1, 2010, until the new 2.2 percent update rates are tested and loaded into the system. We expect that Trailblazers will begin processing claims at the new rates no later than July 1, 2010.
June 6, 2010 What’s Up (and down) with Medicare Fee Rates? What’s up with the Medicare fees changes? Back in January there was a proposed 21% decrease planned, but congressional action has frozen the rates 4 times in the past 6 months. While congress “froze” the rates, reimburse still changed slightly due to MC trying to recoup their “demo project” money. The last congressional freeze expired 05/31/10 and with no permanent action as of today, CMS has decided to hold claims for the first 10 days of June to see what will happen. But wait…there are fee changes! Why? Basically, because of the conversion factor rate (that went into effect 01/01/10, but didn’t get applied until the end of May!). The new fees listed on Trailblazer’s website as of 06/01/10 have some fees, for some locations going up, while others are going down and still others remain unchanged! For example: Dallas County (locality #11), in 2009 the fee for a participating provider for code 98940 was $24.72, then it ‘froze’ at $24.59 and remains, even with the conversion factor changes at $24.59; but for code 98942, the fee was $44.74 in 2009, froze at $44.57, and is now at $44.56; lost a penny! But for Tarrant County (locality #28), in 2009 the fee for a participating provider for code 98940 was $24.19, then it ‘froze’ at $24.03 and has now changed to $24.25 and for 98942 it was $43.86, froze at $43.62, and is now at $43.98; up on all 3 codes over 2009 fees! For non-par, non-assigned, limiting fees, changes are approximately the same in Dallas County, staying the same fee for 98940 and 98941 and losing a penny on the 98942. But for Tarrant County, fees went up on the 98940 from $26.25 to $26.50 and 98941 from $36.60 to $36.90 and 98942 from $47.66 to $48.05. Previously Processed Claims The question remains that if these conversion rates went into effect in January and did not get applied until May, what about all those claims that were already processed from January to May? CMS admits that they do not know what they are going to do about those claims, but they ask providers to NOT refile them. Chances are that the claims would simply deny as “duplicate” claims since they were already paid, even if they were paid incorrectly by a few pennies one way or the other. To be honest, these claims seem to be the least of Medicare’s worries. What still remains to be seen is “What will Congress do” about that 21% cut still hanging over our heads? If that does happen, you can bet that all those previous processed claims will be reprocessed –at the reduced fee schedule!
June 1, 2010 Medicare Filing Deadline New changes in claim form filing deadlines for Medicare (Trailblazers –Part B) claims. The Patient Protection and Affordable Care Act (PPACA), has amended the time period for filing Medicare claims. Under the new law, claims for services furnished on or after January 1, 2010, must be filed within one calendar year after the date of service. In addition, Section 6404 mandates that claims for services furnished before January 1, 2010, must be filed no later than December 31, 2010.
May 1, 2010 Medicare Fee Rate Changes Delayed Until May 31st What's happening with Medicare Fees? Well, as you know, originally CMS predicted a 21% cut and Trailblazer's posted those fees mid December showing a five to ten dollar price reduction. Then Congress passed an emergency bill that held the fees at “2009 prices” until March 1st …then April 1st …and now Congress has passed another ‘band-aid’ bill holding fees at the current fee schedule until May 31st.
You will note that the revised pricing, isn't "exactly" at 2009
prices. Most fees went down fifty cents to one dollar depending on the CPT
code and the locality. CPT code 98941 actually went UP, (less than ten
cents) in some localities, and went down in others.
Lastly, this is the beginning of the demo "payback” period (Remember when CMS agreed to pay chiropractors in 5 areas across the country for things like exams, x-rays and therapies to see if it was cost effective?) Well now, even though the report was favorable, CMS wants its money back. They have begun to recoup the costs they have associated with the Chiropractic Demonstration Project through a slight reduction to the CMT codes reimbursement. According to the Federal Register (Vol. 74, No. 226 / Wednesday, November 25, 2009 / Rules and Regulations) CMS has stated “..our plans to recoup $10 million each year through adjustments to chiropractic CPT codes for calendar years 2010 through 2014. In order to achieve the $10 million recoupment during such years, payment under the PFS for these codes will be reduced by approximately 2 percent.” Hence, the slight difference in fees: RVUs made some cost go up; and CMS are taking back from all what they gave to a few. None of this affects Medicare deductibles which went up to $155. for 2010, (based on approved amounts) for traditional Part B.
April 1, 2010 MEDICARE’S NEW MODIFIER As of April 5, there will be a new modifier (-GX) for Trailblazer’s Medicare. The new modifier has been created with the definition “Notice of Liability Issued, Voluntary Under Payer Policy” and is to be used to report when a voluntary ABN was issued for a service. Please note that the –GX modifier must be submitted with non-covered charges only. The –GA modifier is still used for mandatory use of the ABN, when the Advanced Beneficiary Notice is signed for covered services that may be denied (due to over LCD or maintenance care). Once an ABN is signed, you can no longer use the –AT modifier, it must be changed to a –GA.
March 1, 2010 FILING & PROMPT PAYMENT OF CLAIMS. According to TDI rule (Sec. 1301.102. SUBMISSION OF CLAIM) a physician or healthcare provider must submit a claim to an insurer not later than the 95th day after the date the physician or provider provides the medical care or health care services for which the claim is made. The healthcare provider may, as appropriate:
A physician or health care provider may not
submit a duplicate claim for payment before the 46th day after the date the
original claim was submitted
if claims were submitted as a paper claim, or within 30 days if filed
electronic.
February 1, 2010
Revalidation Cycle for Medicare
January 1, 2010 Electronic Health Records News The Certification Commission for Health Information Technology (CCHIT) announced that its electronic health record (EHR) technology certification program was updated to match recently released changes set by Health and Human Services (HHS). The new rule’s effective date is February 12, 2010. The Commission will begin to develop its ‘Site’ certification program and expects to launch it this summer after HHS announces the final rules. Site certification is designed to accommodate hospitals and health care providers who have EHR technology already implemented. So far, CCHIT has certified 11 programs for EHR, mostly for hospitals, EMR and ‘ePrescibing’ for medical doctors.
May 11, 2009 OIG Report Slams Chiropractic Documentation On May 6th the Office of Inspector General (OIG) released its most recent report on “Inappropriate Medicare Payments for Chiropractic Service.” The report was done to determine if chiropractic services were appropriate after 12 visits, if maintenance care was being paid for as active care and if the chiropractic profession had rectified its lack of proper documentation. Their findings concluded that Medicare inappropriately paid $178 million for chiropractic claims in 2006, representing 47% of claims. Citing that Medicare had paid over $157 million for maintenance care and that improper coding and documentation remained high on the error lists, the OIG recommended tighter reviews, a new modifier, implementing a cap on the number of visits to 12 per year and that CMS must take appropriate action on undocumented, unnecessary and miscoded claims. To download the complete 36 page report, go to: http://oig.hhs.gov
_______________________________________________________________ April 30, 2009 Reporting “Delay of Payment” notices to TDI on managed care claims Texas Department of Insurance (TDI) requires the following information if you are filing a complaint in regards to a delay in payment from an insurance carrier:
Evidence of how the claim was submitted: Certified mail return receipt, or Courier delivery confirmation Proof of your collection attempts prior to contacting TDI. Copies of correspondence sent to the carrier. Replies you received from the carrier.
_______________________________________________________________ April 20, 2009 Cigna Implementing Claim Check 8.5
New software being used at Cigna as of April 20th
,2009 means that all doctors will need to add documentation to any claim
that has modifiers -25 and/or -59 on any CPT code. The supporting
documentation must establish the reason for the modifiers. Doctors may go to
www.cignaforhcp.com and click on the
eServices tab at the top of the page.
_______________________________________________________________ April 2, 2009 Aetna Releases Latest Policy Bulletin on Medical Necessity Aetna Managed Care contracts may have limitations or exclusions to chiropractic benefits. However, even when the policy does have chiropractic coverage, Aetna has identified the following criteria to be met:
If no improvement is documented with the initial
two weeks, additional chiropractic treatment is not considered medically
necessary unless the chiropractic treatment is modified.
If no improvement is documented with 30 days
despite modification of chiropractic treatment, continued chiropractic
treatment is considered not medically necessary.
For the complete bulletin, go to
www.aetna.com
and search for clinical policy bulletin: chiropractic services.
_______________________________________________________________ April 1, 2009 R.A.C. Medicare Audits Recovery Audit Contractors are specialized Medicare audit companies. This idea originally began as a demonstration study that resulted in recovering more than $900 million from healthcare provider claims. These refunds went back into the Medicare Trust Fund. Last year Medicare made it official that it was going to begin awarding permanent contracts for these audits in many states. The firm that got the contract in Texas is Connolly Consulting Associates, Inc. of Wilton, Connecticut. This company is paid on a ‘contingency fee basis’ for each claim that it reviews. This means that the contractor has a financial incentive to identify errors on your claims. This audit process began in Texas on April 1, 2009. Connolly Consulting Associates, Inc. will be permitted by Medicare to do a retrospective audit of your seven previous years of Medicare claims if consistent and frequent errors are found in your Medicare claims. Medicare has estimated that on average doctors will owe Medicare in excess of $30,000 in audit payments, if they are audited.
_______________________________________________________________ March 15, 2009 Office of the Inspector General releases their 2009 plan The OIG has created an action list for audits of hospitals and doctors. This list includes chiropractors in two areas of Medicare. The OIG will be reviewing chiropractic claims identified as maintenance visits. The OIG will also evaluate procedures for identifying and resolving credit balance situations, which occur when payments from Medicare and other secondary insurers exceed the provider's charges or the allowed amount. The OIG intends to audit, evaluate and inspect a long list of sub-specialty groups, such as chiropractors in 2009.
_______________________________________________________________ March 1, 2009 Determining Your Medicare Profile An interoffice Medicare memo has indicated that there is a profile that Medicare uses to evaluate the CPT coding of chiropractic patient visits. A report of CPT codes that chiropractors file on their Medicare claims is being generated by Medicare from its databases. Over-utilization profiles are used by Medicare to red-flag a provider for a possible audit. According to Susan McClelland, A.C.A. Medicare guru, “The split should be somewhere in the neighborhood of 35-55-10. If your profile differs from this by more than two standard deviations, it can put up a red flag. Using just one of the Medicare codes is definitely a red flag. Here is what Susan meant. If your office saw 100 Medicare patients in 2008 and you filed 35 of those claims with CPT code 98940 (1 to 2 regions), 55 of them at 98941 (3 to 4 regions) and 10 of them with a 98942 (5 regions), you would fit the ‘standard profile of Medicare’. However, let’s say you billed everyone with just a 98940, then you would be red flagged by Medicare. Or if you billed 25 patients, instead of 10 using a 98942 code – again you could be red flagged by Medicare. Medicare can run a report of which CPT codes a chiropractor files on their claims and determine from that report the exact percentage of each code used. Of course, this is not to say that going over the ‘standard profile for Medicare’ is fraud or a false claim violation. What it does mean is that if you do not stay in the 35-55-10 range, you will raise a red flag for a possible Medicare audit.”
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