A Message From Your MAC

Transcription

1 A Message From Your MAC Presented for Iowa HFMA/AAHAM 6 th Annual Payer Panel November 15, 2017 wpsgha.litmos.com

2 Disclaimer This program was designed for informational purposes only. The current Medicare regulations will always prevail. The provider alone is responsible for correct submission of claims. The official Medicare Program provisions change frequently and are contained in the relevant laws, regulations and rulings and can be found on the Centers for Medicare & Medicaid Services (CMS) website at Recording is not allowed; this includes audio, video, or photographic capture of educational material by any electronic or digital means, either original or copied/shared. 2

3 Today s Agenda New for You in Medicare Targeted Probe & Educate Office of Inspector General Report Hospital Billing Issues Annual Wellness Visit & Advance Care Planning New Medicare Cards Appeals Updates 3

4 Today s Agenda Exciting WPS GHA Portal Enhancements Transactional Side Portal Self Service Denial Tool Public Side of Portal Code Look-up MFA The Learning Center 4

5 News you can use New for You in Medicare 5

6 Biggest change to claims review in 20 years Targeted Probe & Educate (TPE) 6

7 TPE CR Medical review process used by all MACs is changing Biggest change to claims review in 20 years Based on favorable results of targeted probe and educate review pilots, TPE is being expanded Decrease in the number of claim errors 7

8 TPE Process Replace current reviews with up to three rounds of pre-payment review MACs: Will select topics Can target providers Request a limited sample Have option to refer 8

9 If High Denials Continue MAC refers to CMS for action that may include: Extrapolation Referral to ZPIC, UPIC, RAC 100% pre-pay review 9

10 New Medical Review Process 10

11 Office of the Inspector General (OIG) OIG Reports Two Significant Issues 11

12 Two Hospital Billing Issues SE Report highlights two hospital billing issues Improper use of modifier 59 Incorrect procedure coding for mechanical ventilation 12

13 Improper Use of Modifier 59 Issue Right Heart Catherization (RHC) w/ heart biopsies using modifier 59 Not appropriate if the basis for use is The narrative description of two codes is different, or To describe a different procedure or surgery if both codes are part of a code pair edit Check NCCI Practitioner PTP edit files 13

14 Mechanical Ventilation Issue MS-DRGs 207 and 870 require > 96 hrs. of mechanical ventilation 63 of 200 claims reviewed, did not comply $1,488,165 in overpayments Hospitals confirmed Improper count of hours, and Clerical errors 14

15 An optional element of the Annual Wellness Visit Advance Care Planning (ACP) 15

16 CPT ACP 1 st 30 Minutes Payment conditionally packaged under OPPS Assigned status indicator (SI) Q1 ACP furnished with another OPPS service Payment is packaged ACP is only service furnished Separately payable 16

17 CPT ACP 2 nd 30 Minutes CPT code is an add-on code Assigned status indicator N Payment is unconditionally packaged 17

18 ACP Service with AWV CMS is including Voluntary ACP as an optional element of the AWV ACP services furnished on same day as AWV, by same provider are considered a preventive service Report CPT code in addition to either G0438 or G

19 Deductible & Coinsurance for ACP w/ AWV Waived when billed on the same day as AWV Limited to once per year AWV is limited to once per year Deductible and coinsurance will apply to ACP If the AWV is denied for exceeding limit 19

20 Formerly Called the SSNRI (Social Security Number Removal Initiative) New Medicare Cards 20

21 Background Health Insurance Claim Number (HICN) contains SSN of primary beneficiary Prefix or suffix gives additional details New rules mandated by MACRA Decrease risk of identity theft Increase safety of Program funds Unique numbers and redesigned cards Deceased, active and new beneficiaries 21

22 Medicare Beneficiary Identifier Where: C Numeric 1 thru 9 A Alphabetic Character (A...Z); Excluding (S, L, O, I, B, Z) N Numeric 0 thru 9 AN Either A or N ***NOTE: Alphabetic characters are Upper Case ONLY Position 1 numeric values 1 thru 9 Position 2 alphabetic values A thru Z (minus S, L, O, I, B, Z) Position 3 alpha-numeric values 0 thru 9 and A thru Z (minus S, L, O, I, B, Z) Position 4 numeric values 0 thru 9 Position 5 alphabetic values A thru Z (minus S, L, O, I, B, Z) Position 6 alpha-numeric values 0 thru 9 and A thru Z (minus S, L, O, I, B, Z) Position 7 numeric values 0 thru 9 Position 8 alphabetic values A thru Z (minus S, L, O, I, B, Z) Position 9 alphabetic values A thru Z (minus S, L, O, I, B, Z) Position 10 numeric values 0 thru 9 Position 11 numeric values 0 thru 9 22

23 Transition Timeline Systems ready by 4/1/18 HICN or MBI used until 12/31/19 23

24 During Transition Message on eligibility response when new card sent Remittance Advice (RA) will include MBI if HICN was used Beginning 10/1/18 Limited use of HICN after transition period Appeals, adjustments, etc. 24

25 CMS New Medicare Card Web Page Access at 25

26 Things you need to know Appeal Updates 26

27 27

28 Backlog of ALJ Appeals December 2016 court order Clear backlog in 4 years HHS appealed December 2016 order Impossible to comply with 4 year timeline August 11, 2017 sent back to lower court HHS must demonstrate claim of impossibility 28

29 The 60 Day Requirement Increase in Duplicate Appeal Requests 29

30 Duplicate Appeal Requests Occurs when more than one request is received For the same provider Same patient Same date of service Same issue Regulations allow 60 days to render a decision 30

31 Staying on top of it all More Updates 31

32 CAH 96 Hour Rule Physician must certify reasonable expectation of discharge 96 hours Reduce burdens on providers CMS directed review contractors to make 96 hour rule a low priority for medical record review CAHs should not receive request for medical records related to the 96 hour certification requirement October 1,

33 Present on Admission (POA) SE POA information should only be reported on inpatient claims POA is being reported on claims for services that are exclusively incurred in the outpatient hospital setting 33

34 Qualified Medicare Beneficiary (QMB) SE 1128 Providers may not bill beneficiaries enrolled in the QMB Program for Medicare cost-sharing 34

35 WPS GHA Portal Enhancements 35

36 Portal Constantly Changing Web portal consists of two sides Public Side Transactional Side Your opinion counts! Please continue to periodically complete the ForeSee Website Satisfaction Survey 36

37 Find the information you need Provider Self Service Denial Tool 37

38 Claim Denial Self-Service Tool Enhancing the WPS GHA Portal Experience! Instant Information Claim denial help any time of day Reduce phone calls Increase provider convenience 38

39 Claim Denial Self-Service Tool Compact claim summary screen Gray section: claim information Blue section: remit information Blue More Info button 39

40 More Info Button Every line of claim has access to line specific information 40

41 Enhanced Information Information available Provider name & NPI Pay codes, if present ANSI codes & narrative from RA Close window to view next line item

42 Enhanced Information Related Claim

43 Action Script Explanation of claim denial Suggestions for correcting errors Potential claim actions File new claim Submit a clerical error reopening

44 Special Functions LCDs 44

45 Special Functions Eligibility 45

46 Special Functions Other Insurer Info 46

47 Code Lookup

48 Code Lookup

49 Code Lookup

50 Code Lookup Part A Reason Codes

51 Code Lookup 51

52 Code Lookup Exact Match 52

53 Code Lookup Partial Match 53

54 WPS GHA Portal User Manual Choose link at the bottom of each portal page to access the WPS GHA Portal User Manual 54

55 Keeping your information safe Multi Factor Authentication (MFA) 55

56 Multi-Factor Authentication (MFA) Required by CMS Passcode sent via phone or will be valid for up to four hours 56

57 Important Go Live Dates Initial Implementation March 31, 2017 MFA use is optional 3 pieces of authentication needed starting with date of opt-in Mandatory Conversion Starting July 17, 2017 Mandatory conversion began weekly according to the last name of the user 57

58 Conversion Schedule Date First letter of last name Date First letter of last name 07/17/2017 A-Ba 07/24/2017 Bb-Bo 07/31/2017 Bp-Ca 08/07/2017 Cb-Cz 08/14/2017 D 08/21/2017 E-F 08/28/2017 G 09/04/2017 H-Hl 09/11/2017 Hm-J 09/18/2017 K 09/25/2017 L 10/02/2017 Ma-Me 10/09/2017 Mf-N 10/16/2017 O-P 58

59 Conversion Schedule Date First letter of last name 10/23/2017 Q-R 10/30/2017 Sa-Si 11/06/2017 Sj-Sz 11/13/2017 T-V 11/20/2017 Wa-Wi 11/27/2017 Wj-Z 11/30/2017 Any other users not included in above schedule 59

60 Login/Register for MFA On WPS GHA Portal, click on the Login/Register box 60

61 WPS GHA Learning Center (LC) Located at Create/Manage Profile View Dashboard (Home) News Calendar Recent achievements

62 LC Features View Live Events Register On-Demand Courses Includes Questions and Answers developed by Provider Outreach and Education (POE) Training Questions Specific to LC events (LC issues/logistics/etc.) Link to WPS GHA Portal 62

63 Questions? 63

64 Follow-up Survey Your Opinion Counts! Please take five minutes to complete survey to provide feedback on your education experience 64

65 Thank you!