Palmetto GBA announced earlier this week that they will begin performing service-specific medical review audits for oncology and ophthalmology specialties. The medical reviews will focus on the following:

 Outpatient Oncology Radiation Therapy Procedure Codes

Outpatient Ophthalmology Procedure Codes

Outpatient Hematology/Oncology Other Drugs Procedure Codes

The North Carolina Medical Society (NCMS) will continue to follow and provide updates regarding the medical reviews. The NCMS Fraud and Abuse webpage is also a helpful tool for those physicians involved in the audit or for those who would like to learn more.

This week, Health and Human Services (HHS) Secretary Kathleen Sebelius announced a proposed rule, the third in a series of simplification rules in the new health care law, that can potentially save health care professionals and health plans up to $4.6 billion over the next ten years by reducing and simplifying administrative processes. View the entire announcement here.

In order to reduce physicians’ administrative burdens, the rule recommends that health plans have a unique identifier with a standard format to automate billing processes and other transactions. The rule also delays the compliance date for ICD-10, which has been a concern for many physicians, from October 1, 2013 to October 1, 2014 for new codes used to classify diseases and health problems. This delay will give physicians and their practices more time to prepare and coordinate the transition. View the proposed rule ICD-10 fact sheet for more information.

The deadline for comments is 30 days after the rule is published in the Federal Register, which will tentatively occur on Tuesday, April 17, 2012.

The Division of Medical Assistance (DMA) announced last week that the North Carolina Medicaid Incentive Payment System (NC-MIPS) will be updated to assist health care professionals in applying for and receiving Electronic Health Record (EHR) incentive payments in 2012. The upgrade will go live on June 5, 2012 for Adopt/Implement/Upgrade (AIU) attestations and on June 27, 2012 for Meaningful Use (MU) attestations.

The purpose of the upgrade is to improve automation and the overall pace of the system. Attestations and 2012 AIU incentive payments will continue to be processed throughout the transition.  For those who have received a 2011 AIU incentive payment, the earliest to attest for a Year 2 Meaningful Use incentive payment will be in late June.

Physicians must register with the CMS and upon receiving a welcome letter from NC-MIPS can complete the attestation template in order to receive AIU incentive payments in 2012. Click here to access the NC-MIPS Provider Portal and to follow additional attestation instructions during the upgrade.

NCMS members with questions or needing assistance with Meaningful Use, contact Terri Gonzalez, NCMS Practice Technical Assistance Coordinator, at 800-722-1350 or tgonzalez@ncmedsoc.org.

CMS will be holding the following conference call and webinars for physicians:

Physician Quality Reporting System & eRx 2011 10-Month Feedback Report

Date and time: Tuesday, April 17, 2012; 1:30 pm – 3:00 pm
Topic: CMS Experts will provide an overview of the Electronic Prescribing 10-month Feedback Report.

Current Status of Medicare Implementation of HIPAA Version 5010 and D.0

Date and time: Wednesday, April 25, 2012; 2:00 pm – 3:30 pm
Topic: The call will address the current 5010/D.0 metrics, recommendations by Medicare and outstanding fixes impacting both Part A and B Version 5010 transition. A great tool to review before the conference call is CMS’ recently updated Version 5010 FAQs.  

Each call will include a question and answer session. Click here to register for both calls.

WEDI-CMS-Industry Collaboration & Problem Solving Webinar
Date and time: Thursday, April 19, 2012; 1:00 pm – 2:30 pm
Topic: The Workgroup for Electronic Data Interchange (WEDI), along with CMS and other industry partners, will provide an overview of the WEDI 5010 Issue Reporting System in an effort to identify issues with and to work toward appropriate solutions for the system. Click here for more information and to register.

‘Avoiding Medicare Fraud & Abuse: A Roadmap for Physicians’ Web-Based Training
This web-based training includes definitions, laws exclusions, civil monetary penalties, case examples and other resources to educate physicians on fraud and abuse. Click here to access the training course.

As reported in the past, the North Carolina Department of Health and Human Services (DHHS) has been working to manage cash flow within their approved budget while juggling a number of fines, penalties and lawsuits. This external pressure along with increased enrollment led to the announcement yesterday, April 4, 2012, at the North Carolina General Assembly (NCGA) that DHHS, and more specifically the Division of Medical Assistance (DMA), will likely run out of money at the end of this month to pay for services for Medicaid patients.

Governor Beverly Perdue’s Budget Director, Andy Willis, testified before the Joint Legislative Oversight Committee on Government Operations during a meeting dedicated to the Medicaid budget. Mr. Willis reported that money would run short at the end of this month but that DHHS had found $45 million within their state appropriation to continue to reimburse for services until the NCGA reconvenes on May 16. 

Senator Pete Brunstetter (R-Forsyth), one of the Appropriations Chairs for the North Carolina Senate said, “This is something that we are going to have to address quickly, in the first few days when we return in May.” 

The problem that he refers to is a limitation in the DHHS Budget that says the department must balance within its’ own budget. That provision essentially means that no money can be shifted from any other general funds (i.e., Transportation, the Rainy Day Fund) to balance Medicaid. The provision was included by budget writers in part because of a history of problems like this where overspending required the State Office of Budget Management to redirect additional general fund dollars to cover Medicaid overages.

Even with the various overages experienced this year, Medicaid is within three percent of the budgeted target for the roughly $12 billion program, of which the state funds about $3.4 billion. Many legislators agree that is a significant improvement over previous years. Lawmakers continue to look for ways to better predict these health care expenditures, which is difficult because of varying enrollment, fluctuating utilization and additional burdens steadily flowing down from the Federal Government due in part to the health reform law.

Your NCMS continues to work with legislators and other health care partners to identify savings opportunities without jeopardizing access to care for your Medicaid patients or payment reductions. While lawmakers still view rate cuts as a possible solution, Wednesday’s conversation revealed that this initial budget problem would be handled with money from other sources in the state budget. At the same time, we will be facing budget corrections for the remaining biennium budget year.

Watch the Bulletin and other action alerts for opportunities to communicate with your legislators about this issue in the coming month.

The American Medical Association (AMA) recently recognized the NCMS for its involvement in requesting the Centers for Medicare and Medicaid Services (CMS) delay obscure place-of-service coding requirements, set to take effect April 1, in an email alert sent to AMA members. The efforts of the AMA, the NCMS and other state and specialty medical societies, convinced CMS to delay the coding implementation until October 2012. Click here to view the email alert, which should be available shortly.

 Related NCMS Bulletin article:

NCMS Persuades CMS to Delay Obscure Place-of-Service Coding Requirements (3-30-12)

1. athenahealth’s webinar for Stage 2 Meaningful Use

If you successfully attested for Stage 1 of CMS’ Meaningful Use program and received your incentive payment, congratulations! Now, it gets tougher. NCMS Partner athenahealth invites members to participate in a free webinar providing insights and expertise on just-announced Stage 2 measures on Wednesday, April 25, 2012 at 3:15 PM Eastern Time.

During the webinar, athenahealth experts will review the proposed Stage 2 measures and discuss ways practices can take next steps toward another sizable incentive check.  Topics include:

• Details of Stage 2 measures and how to meet them
• Guidance on sending feedback to CMS and the Office of the National Coordinator for HIT
• Details on the EHR certification criteria
• athenahealth’s viewpoints on the Stage 2 delay and other policy implications

Register today to get ahead for Stage 2 Meaningful Use.

Can’t join the webinar but want to move forward? Put your NCMS membership to work by contacting Terri Gonzalez, Practice Technical Assistance Coordinator. Terri provides member practices with assistance on EHR selection, training, interface coordination and upgrades needed to meet Meaningful Use and Patient Centered Medical Home criteria.

2. PAI’s Medical Audit Webinar for Physicians

The Physician Advocacy Institute, Inc. (PAI) will be holding a “Medical Audits: What Physicians Need to Know” webinar on Tuesday, April 24, 2012, 10:00 am and Thursday, April 26, 2012, 2:00 pm. The webinar is based on the white paper recently released by PAI explaining the various types of audits and how to appeal adverse audit findings. Presenter Frank Cohen, MPA, MBB, the principal author of the white paper and expert in health care analytics, will provide information and tools about the different types of audits faced by physician practices, advise how to respond to record requests for medical audits as well as discuss a survey recently conducted regarding the experiences of physician practices that have received and responded to overpayment recovery requests.

To register for the April 24 webinar click here. To register for the April 26 webinar click here. For more information about PAI visit http://hmosettlements.com/ and refer to the PAI section. Questions can be directed to Mary Jo Malone, PAI EVP/CEO at maryjomalone@sbcglobal.net.

Visit the NCMS Fraud and Abuse webpage for additional information on medical audits.

This week the North Carolina Medical Society (NCMS) contacted the Centers for Medicare and Medicaid Services (CMS) urging delayed implementation of Transmittal 2407, Revised and Clarified Place of Service (POS) Coding Requirements, which was set to take effect on Monday, April 2, 2012.  The Transmittal contained new and relatively vague instructions for how all medical practices should describe the place of service on the CMS 1500 or its electronic equivalent when billing the professional component for diagnosis services.  The NCMS, after learning from the radiology community about the shift in policy and its implications, acted quickly to request a delay.

Review the letter from NCMS Executive Vice President, CEO Bob Seligson to CMS Administrator Marilyn Tavenner here.

We got their attention: on Thursday CMS acknowledged our concerns and agreed to delay implementation of this Transmittal until October 2012.  CMS has also pledged to consider the Society’s concerns and to make needed changes to the policy. CMS is planning to officially announce the delay on their “2012 Transmittals” site, located here.

The NCMS believes that the lack of general knowledge about the new POS rules and problems with implementing them at the practice level would cause massive disruption in the revenue cycle for practices across the state. We thank Administrator Tavenner and CMS for responding favorably to our concerns.

Note: Please share with members of your billing staff and vendors.

As indicated by the article above and the recent volume of communication with CMS by the NCMS and other organizations, there is tremendous activity underway at CMS resulting in simultaneous implementation of programs and requirements that may result in penalties to medical practices. In an effort to seek relief for physicians, this week the NCMS signed on to a letter to CMS generated by the American Medical Association (AMA) voicing concern. These programs include the value-based modifier, eRx penalties, PQRS and EHR incentive program, along with the transition to ICD-10, all of which have the potential to create extraordinary financial and administrative burdens and mass confusion for medical practices.

To view the letter click here, and watch upcoming issues of the Bulletin for information on CMS requirements and deadlines. Immediate CMS reminders include:

• Today, March 30, 2012, is the application deadline for the Medicare Shared Savings Program, which will begin Sunday, July 1, 2012. Click here for more information.
• Upon receiving notice that physicians were unsuccessful in attempts to contact the QualityNet Help Desk regarding Medicare e-prescribing (eRx) penalties and hardship exemptions, CMS has confirmed that the Help Desk is now able to receive these calls. Physicians are encouraged to call the Help Desk at 866-288-8912 or qnetsupport@sdps.org.

The Centers for Medicare and Medicaid Services’ QualityNet Help Desk is up and running to take calls from physicians on the Medicare e-prescribing penalty. 

There is no formal appeals or review process for the CMS e-prescribing penalty, but physicians are encouraged to contact the help desk with questions or concerns about their penalty and / or hardship exemption request. CMS is handling all requests and any questions or concerns on a case-by-case basis.   

The QualityNet Help Desk can be reached M-F; 7:00 am – 7:00 pm CMT at 866-288-8912 or via email at qnetsupport@sdps.org.

This week the Office of Inspector General of the U.S. Department of Health and Human Services (DHHS) released a report entitled “Early Assessment of Audit of Medicaid Integrity Contractors,” which found that 81% of the Centers for Medicare & Medicaid Services’ (CMS) pre-screened audits undertaken to fight waste, fraud and abuse in Medicaid were either unable or unlikely to identify overpayments during a recent six-month period.
 
The analysis found only 11% of assigned audits conducted from January 1 – June 30, 2010 by Medicaid Integrity Contractors (MIC) were completed with $6.9 million in overpayments identified, $6.2 million of which resulted from seven completed collaborative audits involving Audit MICs, Review MICs, States, and CMS. The remaining audits had not progressed enough to draw conclusions about likely outcomes.

Failure to find overpayments was blamed on the use of audit algorithms previously found ineffective, errors in the data, and the contractors who selected the providers to receive audits based on their likelihood to receive overpayments. The CMS spent $17.2 million on all such contractors in fiscal 2010. The report recommended the CMS increase its coordination with each state’s Medicaid officials.

The NCMS provides assistance and education to medical practices on how to prevent such audits.  Visit the NCMS Health Care Audit Resource Center for more information. PractEssentials, a NCMS Foundation initiative, provides consulting services designed to help your practice identify potential problems areas, evaluate options, and implement solutions. On April 25, PractEssentials will conduct a one-hour webinar on recovery audits. For assistance from PractEssentials or for more information, contact Franklin Walker, Director of Programs, at (800) 722-1350 ext 141.

The Centers for Medicare and Medicaid Services (CMS) Office of E-Health Standards and Services (OESS) announced yesterday that the extension for implementing Version 5010 transaction standards, which was set to end April 1, 2012, will be extended for an additional three months, until June 30, 2012.

During this extension, OESS will not initiate action against providers who are not compliant with the updated HIPAA versions standards. Obviously, the extension allows everyone, including physicians, additional time to complete testing and meet the new standards. During this period, the NCMS encourages physicians who experience problems with 5010 compliance to contact the NCMS Member Resource Center. Further, we encourage physicians to report to OESS any payer or business partner who are not 5010 compliant, using the online complaint form.

The NCMS urges its members to work towards meeting the compliance standards for Version 5010. The NCMS offers Version 5010 & ICD-10 resources on our website and CMS also offers Version 5010 resources, such as basic and testing readiness fact sheets, frequently asked questions and resources to help you transition smoothly to 5010.

Questions can be directed to the NCMS Member Resource Center at 800-722-1350 or kfreeman@ncmedsoc.org.

North Carolina Medicaid’s Adult Safety with Antipsychotic Prescribing (ASAP) Initiative begins Tuesday, March 20, 2012, with a prior authorization policy called “Off Label Antipsychotic Safety Monitoring” for recipients 18 and older.  The first phase of the program will include Medicaid eligible adults receiving atypical (second generation) antipsychotic agents prescribed for an indication that is not approved by the federal Food and Drug Administration (FDA).  Here is the process for obtaining prior authorization:

1. Off label uses such as insomnia, anxiety, and primary treatment of depression will require a fax (866-246-8507) or phone-based (866-246-8505) prior authorization request to be submitted to ACS, a Xerox company who administers medication-related prior authorizations for NC Medicaid.
2. The presence of psychiatric diagnoses such as schizophrenia, bipolar disorder, Tourette’s syndrome, and adjunctive treatment of depression warrant exemption from prior authorization. To authorize an exemption for these specific indications, the prescriber must write in his or her own handwriting “meets PA criteria” on the face of each new or renewal antipsychotic prescription or in the comment block on e-prescriptions. 

For complete information, please refer to the Medicaid website at http://www.ncmedicaidpbm.com/  and the Resources page of http://www.documentforsafety.com/. These sites will be live by the program start date.

Centers for Medicare and Medicaid Services (CMS) will be holding the following provider calls:

Physician Quality Reporting System and Electronic Prescribing (eRx) Incentive Program provider call will be held on Tuesday, March 20, 2012, 1:30 pm – 3:00 pm. The US Department of Health and Human Services (HHS) Million Hearts Initiative will also be discussed. Click here to register. Registration closes March 20, 2012 at 12:00 pm.

Medicare and Medicaid EHR Incentive Program Basics provider call will be held on Thursday, March 29, 2012, 3:00 pm – 4:30 pm. The call will provide an overview for program eligibility, how to get started and how to report meaningful use as well as provide other resources to help physicians and their staff who are participating in the incentive program. This is the last year for providers to receive maximum Medicare incentive payments. Registration should be available shortly.

The US House of Representatives Energy and Commerce Committee passed HR 452, the “Medicare Decisions Accountability Act” by voice vote on Tuesday, March 6, 2012. HR 452 will repeal the Independent Payment Advisory Board (IPAB), which was created by the Patient Protection and Affordable Care Act (PPACA) to recommend Medicare cuts for physicians, hospitals and other health care providers. HR 452 is sponsored by Rep. Phil Roe, (R-TN).

The IPAB Repeal Coalition, along with its 42 partners, sent a letter to members of the Committee asking them to  repeal the implementation of IPAB. Read the letter here.

The House Ways and Means Committee Subcommittee and Health also held a hearing on HR 452 on March 6. The committee was expected to vote on the bill yesterday.

For other current Medicare news and updates refer to the NCMS Medicare Resource Center.