Date: 2014-09-18

Seniors and people with disabilities will have continued access to a wide range of Medicare health and drug plans in 2015; CMS reports $12 billion in prescription drug savings
Today, the Centers for Medicare & Medicaid Services (CMS) announced that more people with Medicare will have access to higher quality Medicare Advantage (MA) plans, and for the fifth straight year, enrollment is projected to increase to a new all-time high, while premiums remain affordable.
The average MA premium submitted by health plans for 2015 would increase by $2.94 next year, to $33.90 per month. However, CMS estimates the actual 2015 MA average premium will increase by only $1.30, as more beneficiaries elect to enroll in lower cost plans. The vast majority of MA enrollees will face little or no premium increase for next year with 61 percent of beneficiaries not seeing any premium increase at all.
“Since the Affordable Care Act was enacted, enrollment in Medicare Advantage plans is now at an all-time high, and premiums have fallen,” said CMS Administrator Marilyn Tavenner. “Seniors and people with disabilities are benefiting from a transparent and competitive marketplace for Medicare health and drug plans.”
More MA plans will offer supplemental benefits that traditional Medicare beneficiaries value, such as dental and vision benefits. Access to the MA program remains strong, with 99 percent of beneficiaries having access to a plan. Between 2010 when the Affordable Care Act was enacted and 2015, enrollment in MA plans is expected to increase 42 percent and premiums will have decreased by 6 percent.

MA quality continues to improve as approximately 40 percent of MA contracts will receive four or more stars for 2015, an increase of around 6 percent from 2014. About 60 percent of MA enrollees are currently enrolled in plans with four or more stars for 2015, an increase of approximately 31 percent compared to the percentage in four or five star plans based on 2012 ratings. CMS calculates star ratings from 1 to 5 (with 5 being the best) based on quality and performance for Medicare health and drug plans to help beneficiaries, their families, and caregivers compare plans.
Earlier this year, CMS announced that the average estimated basic Medicare prescription drug plan premium in 2014 is projected to be $32 per month. Because of the Affordable Care Act, people with Medicare are seeing reduced costs through both savings on covered brand-name and generic drugs and having access to certain preventive services at no cost sharing. Since the passage of the Affordable Care Act, more than 8.3 million people with Medicare have saved over $12 billion on prescription drugs through July 2014, an average of $1,443 per beneficiary. The Affordable Care Act closes the “donut hole” over time. In addition, in 2014 through July, an estimated 18.6 million people with traditional Medicare took advantage of at least one preventive service with no cost sharing, and more than 2.6 million took advantage of the Annual Wellness Visit.
The Annual Open Enrollment period for Medicare health and drug plans begin on October 15, and ends December 7. Each year, plan costs and covered benefits can change. Medicare beneficiaries should look at their Medicare coverage choices and decide what options best meet their needs. Beneficiaries who need assistance can visitwww.medicare.gov, call 1-800-MEDICARE, or contact their State health Insurance Assistance Program (SHIP).
For more information on Medicare Open Enrollment and to compare benefits and prices of 2015 Medicare health and drug plans, please visit: http://www.cms.gov/Center/Special-Topic/Open-Enrollment-Center.html.
For state-by-state information on discounts in the donut hole, please visit: http://downloads.cms.gov/files/Summary-Chart_2010-July-2014.pdf.
For state-by-state information on utilization of preventive services at no cost sharing to beneficiaries in Medicare, please visit: http://downloads.cms.gov/files/State-Level-Preventive-Services_YTD-2014_July-2014.pdf.

source: http://cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2014-Press-releases-items/2014-09-18.html?DLPage=1&DLSort=0&DLSortDir=descending

The medical provider community is becoming more aware of the health plan claims procedures contained in the Employee Retirement Income Security Act (ERISA). The federal ERISA claims regulations provide many advantages to physicians when they pursue payment on their patient’s claims covered under private; i.e., non-government, group-sponsored plans. These advantages include the right to prompt claim decisions, the right to full and complete explanations on all EOBs, and the right to obtain e-mails, data, and documents from group health insurers or administrators when claim determinations are “adverse” (a complete or partial claim denial).
According to a little-known provision in the Affordable Care Act, these ERISA processes — designed to promote speed, fairness, and transparency — are now also required to be incorporated into every government employee group health plan. Beginning in about 2011, the healthcare reform law required that these ERISA procedures be added to government-sponsored plans, such as those covering the employees of cities, school districts, states, and even the federal government.
This article outlines the main benefits of these regulations and explains how physicians can use them to address the vague and frustrating claim denials often seen in EOBs. With some education and perseverance, using these tools can improve a physician’s bottom line.
First, we should be clear that these regulations apply to all group health plans. Many physicians have been under the impression that the rules only apply to self-insured plans and not to plans that are funded by a group insurance policy. Let’s debunk that myth here: ERISA applies to all group plans, whether insured or not; and now, through the Affordable Care Act, ERISA’s regulations apply to all government employer-sponsored plans as well.
Second, as a threshold matter, physicians must recognize that not only do the patients have legal rights here, but so does the physician. As ERISA beneficiaries, the physicians can pursue the same pathways as their patients can, under the patient’s health plan. Simple language — often already contained in a physician’s intake paperwork — and certain wording in the patient’s health plan can create beneficiary rights in the physician.
While the insurance industry and most claim administrators have vigorously fought this concept, there is solid legal authority supporting a physician’s rights here. Thus, once the physician is legally deemed a beneficiary, he or she can hold the insurer or claim administrator’s feet to the fire when it comes to pursuing payment on claims.
The ERISA health plan claims regulations have, for example, the following advantages:
• Insurers and claims administrators must respond to all health plan claims within 30 days;
• The burden is on insurers and claim administrators to justify a claim denial based upon an alleged lack of medical necessity or if it is allegedly experimental of investigational, with scientific or clinical evidence; and
• If a claim is denied, the insurer or administrator must provide internal documents to a requesting physician, such as their internal emails and memos.
The first important concept is the timing rule: An insurer or administrator must respond to a filed claim within 30 days. And if the response is a request for medical records, there is only a one-time request allowed per claim, and only a 15-day extension of the requirement to render a timely claim decision. If these deadlines are blown, the physician should demand payment in full, regardless of the type of services rendered. Legal counsel can pursue payment in full, using other methods, if a written demand by the physician is unsuccessful.
The next significant rule is that an insurer or claim administrator must explain the scientific or clinical basis for any decision that alleges a lack of medical necessity or that a service rendered was experimental or investigational. Insurance companies try to shift the burden to the physician, but the law places the burden in reverse: If a claim is denied on these grounds, the insurer or administrator needs to step up to the plate — with proof. And the insurer or administrator cannot transmit numerous and untimely requests for records as to medical necessity, after the 30-day deadline.
And finally, when a claim decision is adverse, the physician should demand all of the insurer’s internal medical documentation, e-mails, or other documents that allegedly support the insurance company or claim administrator’s decision. The regulations have contained these rights for 12 years, but physicians have not become aware of them, nor pressed for these materials on denied claims. Using this tool can often result in the receipt of a check, on a disputed claim, representing payment in full.
Be assured that these rules are a tool kit that will serve physicians well in their quest for payment and fair treatment on all claims filed under both public and private group health plans.

By: Richard Quadrino

– Source: http://www.physicianspractice.com/medical-billing-collections/healthcare-reform-erisa-claims-and-government-health-plans#sthash.wrp7DTL6.dpuf

Recovery Audit Contractors (RACs) may be about to take a break while CMS awards new contracts, but don’t rest on your laurels. CMS has handed out yet another auditor contract for a single auditor, known as a Supplemental Medical Review Contractor (SMRC) to do nationwide claims reviews for issues identified as being at risk for high dollar errors.

For Part B providers, the biggest target the new auditor, Strategic Health Solutions of Omaha, Neb., has identified is E/M claims billed with 99214 and 99215. Among the other targets are claims for hyperbaric oxygen therapy services, transformainal epidural injections (64479-64484), MRI of the lumbar spine (72148, 72149 and 72158) and some PET services (78451-78452, 78469 and 78494).

A full list of the open items for auditing by Strategic Health Services is available at http://www.strategichs.com/current-smrc-projects/.

The good news is, the SMRC will post its targets at the link above, which will all be referred by CMS based on issues identified by the OIG Work Plan and the Comprehensive Error Rate Testing (CERT) program, among other areas. In addition, this auditor is not being paid under a contingency fee arrangement, such as the RACs.

That may be where the good news stops. Strategic Health has posted copies of samples of the Additional Documentation Requests (ADRs) on its web site so you can see the type of letter the company will send. You get 30 days to respond, but unlike some auditors, Strategic Health Solutions will not reimburse you for the cost of copying and sending the documentation sought, as the company makes clear that this is part of the cost of doing business with Medicare.

It’s also not as easy to send the documentation. Strategic Health Solutions will accept it via esMD, the electronic submission of medical documentation tool available at www.cms.gov/esmd. You can also fax the documentation to a fax number in the letter. It can be mailed to the contractor either on paper copies or an encrypted CD in paper format. When you use the CD option, the password must be mailed separately.

Author: Scott Kraft

– Source: http://codapedia.com/article_688_Yet-another-new-auditor-looking-at-Part-B-claims.cfm#sthash.auAcPLd9.dpuf

After years of unchallenged recitation, the coding community has virtually canonized the phrase “not documented—not done” into coding scripture. But there are good reasons to question whether the now-famous epigram reflects an actual rule or whether it has simply taken on a life of its own like other “urban myths.”

In a 2008 article that retains relevance to coders today, Michael D. Miscoe, CPC, CHCC, noted that thorough documentation has become the de facto requirement to support claims for reimbursement by government and private payors. But an objective investigation into Medicare rules and their supporting statutes won’t support the common belief that “not documented—not done” is a legitimate rule, he argued in theJournal of Medical Practice Management.

By a strict interpretation of Medicare rules, lacking documentation does not render a medical service noncompensable. The Social Security Act itself mandates no payment “unless there has been furnished such information as may be necessary in order to determine the amounts due” (42 U.S.C. §139(e). A “clean” claim with the proper ICD-9 and HCPCS codes and appropriate fees fulfills this requirement.

Recent case law further supports this conclusion: The federal court ruled against the U.S. in a False Claims Act (U.S. ex rel Sikkenga v. Regence Blue Cross Blue Shield of Utah) case and reasserted that the Medicare statute only imposes an information requirement and “not a particular content requirement.”

Not So Fast!

A wary practice manager may want to hide this information from certain providers within his or her organization. Many group practices include physicians who reluctantly scrawl the briefest of “notes” for office encounters—sometimes inadequate for recording and communicating what happened during the visit. They sometimes hide behind a cavalier attitude summed up with, “ . . . I know what I did!”

Just because a strict interpretation of the law may extract some of the teeth from “not documented—not done,” that doesn’t reduce the need for good, accurate, and thorough documentation. Quality patient care includes maintaining a record that allows anyone with a legitimate reason to pick up the chart to understand the patient’s history of diagnosis and treatment.

Average physicians see thousands of patients each year. Regardless of claims to the contrary, a documentation-averse provider seldom possesses memory skills capable of recalling unwritten details years later.

Although the OIG’s own audit manual names documentation as only one of four types of “evidence” to determine whether a particular service was performed and properly reimbursed, why put auditors, your practice, and yourself through substantial anguish to prove your case? Doesn’t it make much more sense to document well?

Author: Codapedia Staff

– Source: http://codapedia.com/article_673_Not-Documented-Not-Done-Medicare-Myth-or-Rule.cfm#sthash.isMEL6dZ.dpuf

Effective for dates of service beginning Jan. 1, 2015, CMS will require four new modifiers for Medicare claims, to be appended in lieu of 59 distinct procedural service under defined circumstances.

CMS describes the new modifiers, announced in CMS Transmittal 1422, Change Request 8863,as “subsets of distinct procedural services (-59 modifier),” to include:
• XE – Separate Encounter. Used to describe services that are separate because they take place during separate encounters.
• XS – Separate Structure. Used to describe services that are separate because they are performed on different anatomic organs, structures or sites.;
• XP – Separate Practitioner. Used to describe services that are distinct because they are performed by different practitioners.
• XU – Unusual Non-overlapping Service. Used to describe services that are distinct because they do not overlap the usual components of the main service.
Modifier 59 may be used to override National Correct Coding Initiative (NCCI) edits, or otherwise to gain separate reimbursement by indicating that a code represents a service that is separate and distinct from another service with which it is usually bundled. For example, excision of skin lesions include simple repair at the same location; however, if a repair occurs at a separate location from the lesion excision, you may report it separately by appending modifier 59 to the CPT code describing the repair.
Endemic, ongoing misuse and abuse of modifier 59 is well documented. A 2005 report by the Office of Inspector General (OIG), “Use of Modifier 59 to Bypass Medicare’s National Correct Coding Initiative Edits,” found that 40 percent of modifier 59 claims failed to meet CMS program requirements, resulting in an estimated $59 million in incorrect payments in 2003. More recently, 2013 CERT Report data projected a one-year error of $770 Million in incorrect modifier 59 payments. As a result, modifier 59 is a frequent target of payer audits, and it has appeared on the OIG’s annual work plan, every year for a decade.
“The primary issue associated with the -59 modifier,” according to CMS, “is that it is defined for use in a wide variety of circumstances.” In other words, the broad, “catch-all” applicability of the modifier — it is often called the “modifier of last resort”— invites misuse and abuse. The intent of the four, newly-introduced modifiers, collectively referred to as -X{EPSU} modifiers, is to require providers to specify the circumstances that call for separate reimbursement of the reported services, which generally would not be reported together. For instance, returning to the example above of the lesion excision and separate repair at a different location, you would append modifier XS to the repair code to indicate “separate structure.”
Per CR8863, “CMS will not stop recognizing the -59 modifier but notes that CPT instructions state that the -59 modifier should not be used when a more descriptive modifier is available. CMS … may selectively require a more specific – X{EPSU} modifier for billing certain codes at high risk for incorrect billing. For example, a particular NCCI PTP code pair may be identified as payable only with the -XE separate encounter modifier but not the -59 or other -X{EPSU} modifiers.”
More information about the new modifiers is sure to come, but CMS is already encouraging their use. CR8863 states, “Contractors are not prohibited from requiring the use of selective modifiers in lieu of the general -59 modifier when necessitated by local program integrity and compliance needs.” Not only should you prepare to use the -X{EPSU} by Jan. 1, you might also expect even greater scrutiny of future modifier 59 claims

By: G. John Verhovshek, MA, CPC

– Source: http://www.physicianspractice.com/medical-billing-collections/medicare-moves-replace-modifier-59#sthash.NFa6csrv.dpuf