“This is an important member benefit that will help physicians to prepare for the challenges they face from the business side of their practices,” NCMS EVP, CEO Robert W. Seligson said. “Understanding the types of audits and how to respond to them helps practices to better identify and correct errors in billing and coding, as well revealing when auditors might err in their findings.” Mr. Seligson serves as president of the PAI.

This white paper is available on the NCMS Fraud and Abuse webpage, where you will find other helpful resources covering Medicare and Medicaid audits. The principle author of the paper is Mr. Frank Cohen, a renowned expert in health care analytics and data mining, and a consultant to physicians and medical associations nationwide.

The NCMS is a signatory member of the PAI, which was formed in 2006 as a result of class action settlements with major national health insurers. Even though most of the settlement agreements have expired, the PAI continues to develop projects and tools that guarantee the viability of physician practices and the ability of physicians to deliver quality patient care. Read more about PAI at http://www.hmosettlements.com/.

Q: What can I do if a clearinghouse, billing company, or third-party payor is not prepared for 5010, or is not following other federally-mandated standards for electronic transactions under HIPAA?

A: The North Carolina Medical Society recommends that you first contact the appropriate trading partner and/or third-party payor to learn more about the problem you are experiencing with your claims. It is important to ask a lot of questions and to gather as much information as possible about the issues you are having.

If the problem does not get resolved, you can file a complaint through the federal Office of E-Health Standards and Services (OESS), which enforces HIPAA’s Administrative Simplification provisions.  To file a complaint, access OESS’s online Administrative Simplification Enforcement Tool. The first time you file a complaint, you will need to create an account. Once you have done so, click on “New Complaint.”  The tool will then lead you through a series of prompts, asking for information about the entity that you are complaining about.

Taking such action will incentivize our vendor and payor partners to work to make industry-wide transitions like 5010 and ICD-10 much smoother.  The NCMS also offers Version 5010 and ICD-10 Resources that will help you with these transitions. Please contact the NCMS Member Resource Center at (919) 833-3836 with any questions or concerns regarding the transition.

The North Carolina Division of Medical Assistance (DMA) has issued a response to the recent announcement from the federal Office of E-Health Standards and Services that it will observe a 90-day grace period for compliance with 5010. (See 5010 Deadline Just Around the Corner, Bulletin, 12-9-2011) 

DMA will continue to process claims filed in 4010 and  5010 formats ONLY until March 31, 2012.  Providers who continue to submit 4010 claims after January 1, 2012 will be required to submit a transition plan documenting their plan to reach 5010 compliance by March 31, 2012. The transition plan must document the steps that have been completed, the remaining steps that need to be completed, the Medicaid provider numbers impacted and contact information, including email address and phone number. 

For questions or assistance regarding this information, please contact Hewlett Packard Enterprise Services (HPES), ECS at 800-688-6696 or 919-851-8888; press option 1.  Click here to read the official notice from DMA.

Physician Assistants, Please Continue to Hold your Medicaid Enrollment Applications

After receiving inquiries about Medicaid enrollment for physician assistants (PAs), the NCMS would like to remind all PAs and their medical practices to hold their Medicaid enrollment applications until the Centers for Medicare and Medicaid Services (CMS) approves the State Plan Amendment and the Division of Medical Assistance (DMA) clarifies details around billing, rates, and other applicable requirements for these practitioners. The North Carolina Medical Society will continue to provide updates on this issue as we receive them.

Please contact the NCMS Member Resource Center at (919) 833-3836 or kfreeman@ncmedsoc.org with any questions or concerns.

See related articles:

Physician Assistant Medicaid Enrollment Update (Bulletin, November 4, 2011)

Physician Assistants, Hold Your Medicaid Enrollment Applications! (Bulletin, October 7, 2011)

Reminder: Important EHR Incentive Program Deadlines Are Approaching

The NCMS would like to remind its members of the following deadlines approaching for the Medicare Electronic Health Record (EHR) Incentive Program:

• Providers have until Wednesday, February 29, 2012, to register and attest to meeting meaningful use in order to receive payment for calendar year (CY) 2011 through the Centers for Medicare and Medicaid Services (CMS) EHR Incentive Program Registration and Attestation System.
• Providers also have until Wednesday, February 29, 2012, to submit any pending Medicare Part B claims from CY 2011. Please notice: CMS allows 60 days after December 31, 2011, for all pending claims to be processed.

More Important Information:

• Medicare EHR incentive payments to providers are based on 75 percent of the Part B allowed charges for covered professional services furnished by the EP during the entire payment year.
• If providers do not meet the $24, 000 threshold in Part B allowed charges by the end of CY 2011, CMS expects to issue an incentive payment for providers in April 2012 for 75 percent of their Part B charges from 2011. Please contact the Division of Medicaid Assistance (DMA) at (866) 844-1113 for more details about payments.

Questions regarding the CMS EHR Incentive Program can be directed to Terri Gonzalez, Practice Technical Assistance Coordinator, at 919-833-3836 or tgonzalez@ncmedsoc.org.

CMS Offers Program to Assist Physician ID Theft Victims

The Centers for Medicare and Medicaid Services (CMS) has developed the provider victim validation/remediation initiative for physicians whose identification has been stolen and used to defraud federal health programs. Physicians can seek resolution from Medicare program safeguard and zone program integrity contractors, which operate according to region and state and can investigate instances of identity theft after being notified by a potential victim. The AMA lists information about the contractors at www.ama-assn.org/resources/doc/washington/identity-theft-victim-program-letter-oct2011.pdf. The Medicare program integrity contractor serving North Carolina is AdvanceMed.

Physicians who believe they are victims of identity theft but have not yet suffered any financial liability should contact Palmetto GBA, the Medicare administrative contractor (MAC) for North Carolina, or the federal Health and Human Services (HHS) Office of Inspector General hotline at 800-HHS-TIPS (800-447-8477).

Sign Up Today for ICD-10 Training

The North Carolina Health Information Management Association (NCHIMA) has partnered with North Carolina Area Health Education Centers (NC AHEC) to provide North Carolina physicians with ICD-10 training. The following Continuing Education class, “ICD-10-CM Training & Implementation Issues (Phase II) for the Provider Office” will be taught at:

Click here to sign up for any of the ICD-10 sessions. Questions or concerns regarding ICD-10 can be directed to Franklin Walker (fwalker@ncmedsoc.org), NCMSF Director of Programs and Practice Management, or Terri Gonzalez (tgonzalez@ncmedsoc.org), NCMSF Practice Technical Assistance Coordinator, at (919) 833-3836.

The North Carolina Medical Society can assist its members in the transition to 5010 and ICD-10. Click here for additional resources on the NCMS website regarding ICD-10.

As part of the Center for Medicare and Medicaid Services’ (CMS) revalidation efforts, all suppliers and providers who are not currently receiving EFT payments are required to submit the CMS-588 EFT form with the Provider Enrollment Revalidation application, or at the time any change is being made to the provider enrollment record by the provider or supplier, or delegated official.

For more information about provider enrollment revalidation, click here.

The NCMS is a strong proponent of federal initiatives to alleviate the administrative burden placed on physician practices. HHS Secretary Kathleen Sebelius said, as a result of the rule, health care professionals will spend less time filling out paperwork and more time focusing on delivering the best care for patients.

Physicians spend about 12 cents of every dollar they receive from patients to cover the costs of filling out forms and performing other administrative tasks, according to a May 2010 study in the journal Health Affairs. Researchers found that simplifying these systems could save four hours a week of a physician’s professional time and five hours of support staff time.

The new EFT rule is the second in a series of regulations required by the Patient Protection and Affordable Care Act. The first—Adoption of Operating Rules for Eligibility for a Health Plan and Health Care Claim Status—was adopted last June and set standards for how physicians and other health care providers use electronic systems to determine a patient’s eligibility for health coverage and check on the status of a claim.

HHS is working on further administrative simplification rules that will include a standard unique identifier for health plans, a standard for claims attachments, and requirements that health plans certify compliance with all HIPAA standards and operating rules.

Click here to view the HHS News Release on streamlining electronic funds transfers in health care.

This special edition of the Bulletin focuses on the accomplishments achieved on your behalf in the managed care arena by the NCMS and the Physicians Advocacy Institute, a national organization in which the NCMS is actively involved.

Reimbursement issues are the number one frustration among physicians according to our member surveys. As we look back on 2011, the NCMS built a strong track record ensuring that health plans used fair business practices in their dealings with physicians. You’ll see from other stories appearing in this final Bulletin of 2011 that the NCMS devoted significant resources to these efforts.

I also want to highlight our work this year in the public sector. The NCMS was able to minimize the impact of the state’s revenue shortfall on the state Medicaid budget. We also worked successfully to resolve many issues between Palmetto GBA and the physicians and physician assistants who treat Medicare patients.

The NCMS Bulletin routinely reports on these successes throughout the year, and more information can be accessed at our website at http://www.ncmedsoc.org/. Rest assured that in the year ahead the NCMS will continue to work on issues that affect your practice, the delivery of health care in North Carolina, and most importantly, the relationship you have with your patients.

On behalf of the staff and Board of Directors, I wish you a joyful and happy holiday season.

                                                                                     Robert W. Seligson, MBA, MA

                                                                                    EVP, CEO

                                                                                    President, Physicians Advocacy Institute

NCMS Managed Care Activity in 2011

Throughout 2011 the NCMS remained actively engaged with the health plans. We successfully addressed and resolved a variety of managed care issues. We reported these efforts in the Bulletin to keep you informed about how our work would affect your practices. Here is a sampling, of what the NCMS has accomplished:

DOI Sides with Medicine, Blocks Controversial BCBSNC Radiology Policy (12-9-11)

UHC Deploying a Revised Treatment Cost Estimator for Members in 2012 (12-2-11)

IPG Inks Agreement with BCBSNC to Provide Implantable Device Management (12-2-11)

“Heal the Claims Process” and PractEssentials: Resources to Help Cut Practice Costs (11-11-11)

Joint Complaint Filed Over BCBSNC Radiology Services Reimbursement Policy (10-28-11)

PAI Compliance Committee Convenes in Chicago (9-9-11)

Meeting with NCMS Prompts UnitedHealth Group to Revisit Many Details of Premium Designation Program (6-17-11)

Thomas/Love Settlement Agreement Expires; BCBSNC to Permanently Adopt Many Key Settlement Practices (6-3-11)

Blue Cross Blue Shield Launches “Let’s Talk Cost” (4-15-11)

UHC Extends Premium Designation Program Deadlines; Physicians Should Check Designations (3-25-11)

Delay Prompts UnitedHealthcare to Extend Deadline in Premium Designation Program (3-4-11)

Humana: HEDIS Reviews on Humana Medicare Advantage Members Begin in March (2-18-11)

State Health Plan to Seek Reimbursements from Ineligible Members, Not Physicians (1-21-11)

UHC Notifying MDS about Physician Profiling/Tiering Program; Doctors Have Limited Time to Seek Reconsideration of Information (1-14-11)

PAI: Physicians Reap More Than $2 Billon in Benefits from Settlement Successes

The NCMS has been actively involved with the Physicians Advocacy Institute (PAI) since it was formed in 2006 as a result of Multi-District Litigation (MDL) class action settlements against major national for-profit insurers. PAI has worked to guarantee compliance with the settlements and to develop projects and tolls that help guarantee the viability of physicians’ medical practices and the ability of physicians to deliver quality patient care.

Here is a summary of Physician Advocacy Institute activity on behalf of physicians:

Physicians have received more than $2 billion dollars in benefits from the settlement agreements reached with Aetna, CIGNA, Health Net, Humana, Anthem/Wellpoint, and many Blue Cross Blue Shield plans as a result of class action lawsuits brought against these insurers by the NCMS and 18 other state and county medical organizations and physician representatives.

For most physicians, the greatest benefit came from the business changes these insurers were required to implement under the settlement agreements, such as:

• Paying claims promptly;
• Separately recognizing and paying for modifiers 25 and 59;
• Notifying physicians 90 days in advance of any material adverse changes; and
• Limiting the time frame in which insurers could seek recovery of alleged overpayments.

      (Source: Physicians Advocacy Institute)

At the time the settlements were approved by the federal court (US District Court, Miami), the business changes were estimated to be $2 billion to physicians. Because Aetna, CIGNA, Health Net and Humana have committed to retain many of the business changes after the termination of their settlement agreements, this value will only continue to increase over time.

 Compliance Disputes Benefit Physicians

 Hundreds of physicians and several signatory medical societies, including the NCMS, have filed compliance disputes to ensure that insurers hold to their agreements. Since the inception of the compliance process in 2004, compliance disputes have benefited physicians by at least $22 million. The compliance process is overseen by PAI, which was founded in part to enforce the settlement agreements. PAI’s Board is comprised of the CEOs of many of the state and county medical associations which filed the initial lawsuits, including the NCMS. NCMS Executive Vice President, CEO Robert W. Seligson, MBA, MA, has served as an officer of the PAI since its inception, and currently serves as President.

NCMS Intervention in compliance disputes benefited physicians

• An insurer sought recovery of $437,358.12 in alleged overpayments from a North Carolina family physician relating to claims over a four year period in violation of §7.22.  After NCMS filed a compliance dispute on his behalf, the insurer agreed to cease any efforts to collect alleged overpayments beyond the 18 months allowed by its settlement agreement, saving the practice at least $200,000.
• An insurer paid a North Carolina emergency physicians’ practice $125,000 after it filed a compliance dispute alleging that the insurer’s EOB’s sent to patients did not accurately reflect patients’ responsibility for payment, in violation of §7.21.
• An insurer withdrew a contract addendum which did not comply with its settlement agreement and issued a new addendum consistent with the settlement agreement after NCMS filed a compliance dispute showing that the original addendum did not provide physicians with sufficient advance notice of material adverse changes and fee schedule reductions in violation of the settlement agreement.
• After a compliance dispute alleging that an insurer was not paying for the add-on codes for myocardial infusion and CAD mammography in violation of §7.20, North Carolina physicians submitting claims for reprocessing received $363,000.

PAI Claims Data Warehouse Evaluates What Happens to Physicians’ Claims

PAI has developed a business intelligence tool called MDEdge, which is used to analyze 837 claims data from all third party payors and 835 remittance forms from insurers indicating what has been paid. The tool can determine if payments to physicians are correct and if the insurers have applied code edits or made other inappropriate “adjustments” to the physician’s reimbursement. Physicians can learn more about this tool by contacting National Healthcare Exchange Services (NHXS) at: info@mdedge.org or calling 888-466-1472. Click here to access an FAQ about MDEdge.

Click here to read more about how the NCMS has worked for you in addressing managed care payor issues.

For resources and more information about managed care, click here.

The DOI agreed that before implementing such a change to reimbursement, a health insurer must first offer affected physicians and facilities a contract amendment and an opportunity to negotiate new terms.

The dispute was one of the first to involve the application of a new fair contracting law.  That law passed in 2009, and involved a collaborative legislative effort from the NCMS, the NC Medical Group Managers, and a few key state specialty societies. The goal was to end the harmful insurance industry practice of undermining the explicit, negotiated terms of managed care contracts with ever-changing health plan policies and procedures.

In a persuasive Letter of Support to Insurance Commissioner Wayne Goodwin, fifteen medical specialty societies, the NC Academy of Physician Assistants, and the Medical Group Managers underscored the precedential effect that the decision would have, and echoed the request for relief from DOI.

The request for regulatory involvement only came after BCBSNC repeatedly refused to withdraw the policy and follow the proper process at our request.  Given the DOI’s decision, the NCMS is hopeful that health insurers will commit to working cooperatively with the medical community to address our future concerns.

View the NCDOI’s letter to BCBSNC.

See related articles:

Joint Complaint Filed Over BCBSNC Radiology Services Reimbursement Policy (Bulletin, October 28, 2011)

UPDATE: BCBSNC’s Radiology Services Reimbursement Policy Revised and Reposted (Bulletin, October 7, 2011)

In a letter being sent to physicians in the UHC network, CEO Jeff Alter says improvements are designed to allow members to compare treatment-specific costs by provider, location and facility type. This will include medical professional and facility costs, and the typical services that make up a treatment episode. Members can view estimates for 110 services, including selected procedures for common ambulatory and outpatient services, such as radiology and lab, office visits, consultations, preventative services and outpatient procedures. Estimates will be ranked by the top 25 percent, the middle 50 percent, or bottom 25 percent of costs for a member’s geographic area. By the third quarter of 2012, claim-based estimates will be replaced by data based on the physician, hospital or other provider’s allowed fee schedule or contracted rate amount.

An FAQ is available from UHC providing additional information about the new Health Care Cost Estimator.

Click here to read the letter UHC is sending to physicians and practice managers.

Opportunities to participate in the new reimbursement model using IPG will be made available through new contracts with BCBSNC, the state’s largest health care insurer.

The NCMS will be following this development and would like to hear from physicians about any concerns or problems they may have with the IPG-BCBSNC reimbursement model. Please contact the NCMS Member Resource Center at kfreeman@ncmedsoc.org or call 800-722-1350.

To learn more about IPG and its services, go to: http://www.ipgsurgical.com/.

Click here to access information about BCBSNC guidelines and policies concerning implantable devices.

To access tools and resources to help you make the most of electronic health care transactions, please visit http://ama-assn.org/go/htc.

AMA is also seeking testimonials from physician practices that have successfully implemented electronic health care transactions. Email the AMA Practice Management Center, or contact the NCMS Member Resource Center at 919-833-3836, or email Member Resource Coordinator Kristin Freeman at kfreeman@ncmedsoc.org, for more information or to submit your testimony.

Practice management support is also available through the NCMS Foundation’s PractEssentials program. Please contact the Foundation’s Programs and Practice Management Director Franklin Walker (fwalker@ncmedsoc.org) or Practice Technical Assistance Coordinator Terri Gonzalez (tgonzalez@ncmedsoc.org) at 919-833-3836.

The complaint follows recent conversations between the parties that failed to resolve concerns over how the policy is being implemented. The three provider organizations argue that to change reimbursement rates, BCBSNC must follow the formal contract amendment process set out in the law.

Stay tuned for updates on this story.

To read the Complaint, click here.

To view supporting documents:

Click here to see June 2011 BCBSNC CMP Radiology Services Reimbursement Guidelines “Notification”

Click here to see October 2011 BCBSNC CMP Radiology Services Reimbursement Guidelines “Notification”

See related article:

UPDATE: BCBSNC’s Radiology Services Reimbursement Policy Revised and Reposted, Bulletin, 10-7-11

NCMS quickly informed BCBSNC of our concerns that a unilateral policy change that modified radiology reimbursement rates could not be implemented without first informing the affected medical practices and following the contract amendment process outlined in state law. BCBSNC has explained the Policy primarily as an effort to get in line with its commercial competitors, many of which have already implemented similar policies inspired by Medicare’s highly-controversial multiple procedure payment reduction policy.

In a meeting late last week between the NC Medical Society, NC Radiological Society, and the NC Hospital Association, representatives from BCBSNC disclosed that the Radiology Services Reimbursement Policy would be revised and reissued with another 60-day notice period. That occurred on September 30, with the new effective date set for December 1, 2011. Read BCBNSC’s statement on the change and the revised policy here. 

While we count the delayed implementation as significant progress, the NCMS still takes the position that the revised policy is not being implemented in compliance with state law.  Therefore, in the weeks leading up to December 1, we will be continuing our conversations with BCBSNC, working to persuade them to withdraw the policy, and moving to ensure that BCBSNC complies with our state’s fair contracting laws.

Those who are interested can participate once an Electronic Data Interchange (EDI) Enrollment Agreement is on file with Palmetto GBA. Physicians who are already submitting claims electronically do not have to submit a new agreement. However, those physicians who are unsure if they have submitted the agreement should fill out the form anyway and a verification email will be sent noting whether or not an agreement needs to be or was previously signed.

For registration, only one Provider Administrator per EDI Enrollment Agreement per PTAN performs the process. The Provider Administrator then gives permission to additional users related to that PTAN. Providers interested in registering for OPS need their NPI, Provider Number, Tax ID Number and the amount of the last Medicare payment received.

Members who have questions or who are having difficulty registering can view Palmetto GBA’s User Manual or contact the Palmetto GBA Technology Support Center (TSC) at (866) 749-4301.

The workshops will feature:

• Key changes between 4010 and 5010 transactions
• HIPAA 5010 transactional standards (and its benefits)
• Incentive payments for electronic medical records (EMR)
• Questions about 5010, with a sneak peak at ICD-10

Download a HIPAA 5010 and ICD-10 Workshop Registration Form, which must be faxed (414-208-2978) or emailed (Carolinasprteam@uhc.com) by September 28, 2011.

Workshop Schedule:

Tuesday, October 4

8:00 am, Marriott Executive Park, Charlotte

3:00 pm, Hilton Asheville Biltmore Park, Asheville

Wednesday, October 5

8:00 am, Embassy Suites, Winston-Salem

12:00 pm, Downtown Marriott, Greensboro

Thursday, October 6

8:00 am, The Courtyard by Marriott, Burlington

12:00 pm, Marriott Crabtree Valley, Raleigh

Friday, October 7

8:00 am, Hilton Wilmington Riverside, Wilmington

Commissioner Goodwin says NC DOI requested the adjustment after consulting with insurers, agents and brokers, consumer advocates and DOI technical experts; however, no physicians were consulted in the process.

According to a statement released by NC DOI, North Carolina requested that the 80 percent MLR requirement be adjusted to 72 percent in 2011, 74 percent in 2012, and 76 percent in 2013. Comprehensive health insurers issuing policies to individuals in the state would have to meet the 80 percent MLR stand in 2014.

Click here to read the MLR adjustment request and view accompanying exhibits. These exhibits include the MLR for each insurer selling coverage in North Carolina.

See related article:

Focus on Health System Reform – The Medical Loss Ratio, 6-4-10, NCMS Bulletin

PAI was formed as a result of the managed care lawsuits that several medical associations filed against the nation’s biggest health plans. North Carolina Medical Society Executive Vice-President and CEO Bob Seligson serves as PAI’s President. PAI formed the Compliance Committee to monitor the health plans and to ensure that they were complied with the provisions of the Settlement Agreements.

When? Thursday July 21, 2011; 1:30-3pm ET

Target Audience – Physicians, physician assistants, nurse practitioners, clinical nurse specialists, health educators, registered dietitians, nutrition professionals, medical billers and coders and other interested health care professionals.

In order to receive the call-in information, you must register for the call. Registration will close at 1:30pm on Wednesday, July 20, 2011 or when available space has been filled; no exceptions will be made, so please register early.

For more details, including instructions on registering for the call, please visit http://www.eventsvc.com/palmettogba/072111

NCMS presented those complaints to UnitedHealth Group and Premium Designation Program executives.  In response, UHG agreed to reconsider many aspects of the Program in order to make it more user-friendly, accurate, and fair for physicians.  Some of those commitments include:

• Ensure that initial notification letters are sent timely and that physicians and practices have ample time to file for reconsideration/appeal.
• Create a state-specific letter that clarifies what, if any, laws or regulations apply to the PDP.
• Clarify the letter sent to the practice to identify the physicians who did and did not receive designation, and how the practice manager may receive delegation to access the reports.
• Refrain from posting a physician’s new rating until any pending appeal has been resolved.  Instead, United may leave the physician’s previous rating posted or post a message stating “Rating under appeal.”
• Faster resolution of administrative errors such as incorrect physicians assigned to the practice, incorrect patients assigned to a physician, incorrect group name, etc.
• Improved reconsideration worksheets that allow for some reasonable amount of physician notes and documents to be submitted regarding a particular episode.

NCMS is pleased that United was willing to receive physician feedback about the PDP, but also to use the feedback to improve future iterations of the program. Urging managed care companies to improve the fairness and accuracy of their physician profiling programs continues to be one of the Medical Society’s main areas of focus.