This edition of the Wesgram contains information about changes with several payors, as well as new programs being offered.  There are also a number of upcoming events and meetings that you and your staff may wish to attend.  If you have any questions, please feel free to contact Barbara Good (Barbara@wvsma.org).

Make sure you check out the WVSMA’s new website, www.wvsma.org to learn the most up to date information on what is happening in West Virginia healthcare.  Please note that our email addresses have also changed.   
 

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The WVSMA recently held a very successful 2012 CMOM (Certified Medical Office Manager) course in Huntington, WV!  In partnership with the Practice Management Institute, the WVSMA offered the four-day Certified Medical Office Manager class to office managers from all over the state. 

CMOM class attendees of the four day class, which was held at St Mary’s Medical Center in Huntington, praised the course for both the curriculum content and the knowledge gained from fellow participants.  PMI instructor Rhonda Granja received strong accolades from the class for her enthusiastic teaching style.

Attendees learned how to initiate policies and protocols so as to improve, protect and stabilize the financial security of the medical practice.  They also studied managed care, OIG, and HIPAA compliance, practice administration and personnel management.  

Participants must now wait for the results of their certification exam.  In the meantime, their newly found knowledge is already affecting their medical practices in a positive manner. 

The WVSMA congratulates the class participants and wishes them continued success.   We also thank the physicians who realize the value of a knowledgeable and certified office manager.  

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(information supplied by BrickStreet)

Healthcare Solutions, the parent company of Cypress Care and Procura Management, has announced a strategic all-product contract with BrickStreet Insurance, a leading provider of workers’ compensation coverage. Beginning on June 1, 2012, Healthcare Solutions will become BrickStreet’s primary supplier for PPO and bill review services, pharmacy benefit management and certain specialty health care services, and a preferred supplier for case management and other specialty health care services.

Through this contract, BrickStreet Insurance, writer of workers’ compensation coverage in West Virginia, Virginia, Kentucky, Illinois and Pennsylvania, will have access to a proven network of providers with specialization in workers’ compensation.

“We are pleased to have the opportunity to work with BrickStreet to provide a comprehensive suite of services to their claimants,” said David A. George, CEO of Healthcare Solutions. “We look forward to demonstrating to all stakeholders that Healthcare Solutions provides access to high quality clinical care for injured workers through the company’s product and service solutions.”

Under the new program, Healthcare Solutions will provide BrickStreet customers with pharmacy benefit management, durable medical equipment, home health care and transportation services through the Cypress Care service offering, and bill review and case management services through the Procura service offering.  PPO network access will be provided via the Procura/OneNet network. Across all services, Healthcare Solutions will coordinate medical care for injured workers while helping to ensure a seamless transition for providers to the program.   

“Healthcare Solutions’ proven track record of dedicated customer service and market-leading products and technology will enhance our ability to produce positive outcomes for injured workers,” said Fred Boothe, Vice President of Insurance Services with BrickStreet. “Healthcare Solutions’ ability to facilitate the medical care of an injured worker in a holistic and cost-effective manner aligns well with our mission of surrounding our customers with superior solutions and service.”

For more information, please contact BrickStreet at 1-866-45BRICK (452-7425).

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West Virginia is expanding its managed care program in late 2012.  Two major changes are planned for this population.
Medicaid beneficiaries currently enrolled in the MCO (Managed Care Organization) program will begin receiving pharmacy services through their current MCOs on October 1, 2012.

Also, SSI beneficiaries, who are currently enrolled in fee-for-service Medicaid, will begin enrolling in MCOs on December 1, 2012.  Enrollment will be phased in by county and excludes those enrolled in both Medicare and Medicaid. 

Members who are SSI-eligible at the time of enrollment will be allowed a 90-day exemption to complete an ongoing course of treatment with a current provider if he or she is not in any of the MCO networks. Non-network providers will be paid at the prevailing Medicaid rates during this 90-day period.

According to West Virginia Medicaid, MCOs will develop a process for working with the member and current non-network providers to identify a new provider and ensure that an appropriate transition plan is developed, including the exchange of patient records.

MCOs will be conducting outreach with individual providers so physicians should expect to hear from individual MCOs in your area. 
The MCOs will share information related to policies and procedures regarding prior authorization and other operations.

If you have any additional questions on the planned MCO program expansion, please contact: Brandy Pierce, Director of Managed Care, at 304-558-1700.

If you would like to schedule an on-site outreach and education training provided by the State’s enrollment broker, Automated Health Systems, please call 304-345-0436 or 1-800-449-8466.

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Immediate Offset Requests: Fax Numbers

Requesting an immediate offset is easy! Just write ‘Immediate Offset’ on the demand letter and fax it to the appropriate fax number below. There are advantages to requesting an immediate offset, which include:

• Avoiding the possibility of checks crossing in the mail and subsequent duplicate collection
• Saving costs associated with check fees and postage
• Avoiding chance of interest accrual due to late receipt

The completion of a form is not required. However, Palmetto GBA asks that you follow the step-by-step instructions outlined below.
To request an immediate offset, fax your request to immediate offset at the appropriate fax number below:

Immediate Offset Fax Numbers:
J11 Part A: (803) 462-2574
J11 Part B: (803) 462-2575

To ensure your request is handled appropriately, all requests must include:

   • A copy of the first page of the overpayment demand letter you received, as well as the detail pages showing the Account     Receivable/Invoice Number
   • Indicate immediate offset on the fax cover sheet
   • A copy of the spreadsheet identifying the claims included in the overpayment (if one was received)
   • The printed contact name and signature of the person requesting the immediate offset should also be included on the fax cover sheet
   • The contact person should be authorized to make the financial decision to request an immediate offset from future Medicare funds due to your office
   • Please include the authorized person’s telephone number should there be questions that require follow-up

Providers can choose to indicate permanent immediate offset on the fax cover, along with the contact name, signature and telephone number mentioned above, if they would like to authorize recoupment of all existing and any future overpayments through claim payment offset. If this option is made, a formal demand letter will continue to be mailed to the provider for future overpayments, but an additional offset request will not be required for future overpayments.

Please keep in mind that immediate offset requests can only be honored if there are pending payments in the Medicare claims processing system from which to offset. If there is an insufficient amount of pending payments to satisfy the overpayment, interest may accrue.

The above fax numbers are only for immediate offsets. Any other financial concerns should be sent in writing to Palmetto GBA.

All Medicare Provider and Supplier Payments to be Made by Electronic Funds Transfer

Existing regulations require that at the time of enrollment, enrollment change request, or revalidation, providers and suppliers that expect to receive payment from Medicare for services provided must also agree to receive Medicare payments through electronic funds transfer (EFT). Section 1104 of the Affordable Care Act further expands Section 1862(a) of the Social Security Act by mandating federal payments to providers and suppliers only by electronic means.

As part of 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, supplier or delegated official. For more information about provider enrollment revalidation, review the MLN Matters® Special Edition Article #SE1126.

2013 & 2014 eRx Payment Adjustment

Please note that payment adjustments under the eRx Incentive Program run until 2014. For information on how to avoid the 2013 and 2014 eRx payment adjustments, please visit the Electronic Prescribing Incentive Program Web page and review MLN Matters Article #SE1206. 

Screening for Depression in Adults

Effective October 14, 2011, Medicare began to cover annual screening for adults for depression in a primary care setting (as defined by CMS), if there are staff-assisted depression care supports in place to assure accurate diagnosis, effective treatment, and follow-up. Beneficiary coinsurance and deductibles do not apply for annual depression screening billed using the new preventive service code. Full details are can be found in MLN Matters Article 7637.

Medicare's Provider Enrollment Revalidation Process

Over the coming months and years, new and existing providers enrolled with Medicare prior to March 25, 2011, must revalidate their enrollment information, but only after receiving notification from Palmetto GBA. You will be able to submit your application via paper (CMS-855 form) or the preferred method for revalidation is electronically through the Internet-based PECOS (Provider Enrollment, Chain and Ownership System).

Providers may not revalidate prior to receiving a revalidation request from Palmetto GBA.

ASC X12 ANSI 5010 – Are You Ready?

The compliance date for upgrading to Version 5010 standards for electronic health transactions was January 1, 2012; CMS enforcement discretion is in place until June 30, 2012.

CMS' Office of E-Health Standards and Services (OESS) announced a three (3) months extension of enforcement discretion, through June 30, 2012, for any covered entity that is required to comply with the updated transactions standards adopted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA): ASC X12 Version 5010 and NCPDP Versions D.0 and 3.0.

If you haven't completed your Version 5010 upgrade, a fact sheet is available on the website, www.cms.gov. 

Telephone Reopening Tips

Telephone reopenings are available to quickly correct minor clerical errors over the phone. But the resolution of complex issues, such as denials based on local or national coverage determinations or denials on codes that require manual pricing, cannot be conducted over the phone. A redetermination request or a written reopening request may be needed in those instances.

If your claim is too complex to be handled over the telephone, the telephone reopening representative will advise you that a telephone reopening cannot be conducted

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CMS Doubles Window for Enrollment Submissions to 60 Days

Physicians can now submit an enrollment application up to 60 days before a provider’s start date, per CMS.  Previously, physicians had to wait until 30 days prior to the start date to submit the appropriate CMS-855 via paper or on Internet-based Provider Enrollment Chain Ownership System (PECOS).

Note: This change is for new enrollments only and doesn’t impact the existing 60-day window that you have to revalidate a provider, once you receive a revalidation notice in the mail.
                                             
Being able to submit 60 days in advance gives you twice as much time to respond to any problems with the application, such as missing supporting documents or submitted data that doesn’t match IRS and other federal databases that CMS uses for validation.

Deadline Approaches to Submit ICD-10 Comments

The deadline is rapidly approaching to submit comments regarding the new compliance date for ICD-10 Coding.

The proposed rule to delay the compliance date for ICD-10 from October 1, 2013 to October 1, 2014 is posted to the Federal Register. There is only one week left in the 30-day comment period. This comment period allows you to provide very important feedback to HHS about this proposed compliance date change, which will affect many aspects of your organization.

When proposing the delay to ICD-10, HHS took into consideration feedback that some provider groups have concerns about their ability to meet the October 1, 2013 ICD-10 compliance date, based in part on implementation issues they have experienced meeting HHS’ compliance deadline for Version 5010 standards.

All HIPAA-covered entities must transition to ICD-10 in order to assure that there is a smooth transition between provider organizations and trading partners, which will help to avoid rejected claims and provider payment delays. By delaying the compliance date for ICD-10, as proposed in this rule, providers and other covered entities will have more time to prepare and fully test their systems to ensure a smooth and coordinated transition among all industry segments.

All comments are due to HHS no later than 5:00 pm ET on May 17, 2012, and can be submitted in the following ways:

• Electronically by following the ‘‘Submit a comment’’ instructions on the Regulations.gov website

• By regular mail sent to:

Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS–0040–P
P.O. Box 8013
Baltimore, MD 21244–8013

Keep Up to Date on Version 5010 and ICD-10!

Please visit the ICD-10 website for the latest news and resources to help you prepare!

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(information supplied by UnitedHealthcare)

Reminder: Changes to Advance and Admission Notification Requirements went into effect April 1, 2012

UnitedHealthcare uses a variety of processes within the plan’s medical management model to evaluate appropriateness of care when making benefit determinations. To further align these processes with prevailing industry practice and to promote optimal patient outcomes, they have made some important changes to our advance notification requirements.

Physicians:

Effective April 1, 2012, UnitedHealthCare will begin expanding the application of medical necessity criteria for members who are on the plan’s new coverage documents (Certificates of Coverage and Summary Plan Descriptions) and enrolled in benefit plans to which the advance notification requirements described in the 2012 UnitedHealthcare Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide (2012 UnitedHealthcare Administrative Guide) currently apply.

The following six service categories may require a medical necessity review (prior authorization), depending on a member’s benefit design, effective April 1, 2012:

    Capsule Endoscopy*
    Cochlear Implants*
    Hyperbaric Oxygen Treatment
    Joint Replacement
    Outpatient Spine surgeries**
    Sleep Apnea procedures and surgeries

* Capsule Endoscopy and Cochlear Implants, were revised with an effective date of May 1, 2012 as stated in the March 2012 Network Bulletin.

** Inpatient Spine Surgeries is currently on the Advanced Notification List

April 2012 edition of the Medical Policy Bulletin now available

The April 2012 edition of the Medical Policy Bulletin is now available.  The monthly publication published on the first calendar day of every month provides an update on new and/or revised Medical Policies, Drug Policies and CDGs, in their entirety, along with an overview or summary of changes.

To review the April edition, please visit www.UnitedHealthcareOnline

 

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The WVSMA is pleased to announce that it has entered into a collaborative arrangement with TriCare to ensure that our military members and their families will be taken care of by our physicians and their staffs. 

In order to participate with TriCare, physicians need only agree to accept assignment (Medicare reimbursement).  They do not need to sign a contract in order to participate in most TriCare plans.  Reimbursement is quick (generally within 8 days if billed electronically) and accurate.  Physicians and staff can be proud that they are caring for the ones who serve our great country. 

Another benefit of participating with TriCare is the addition of a special ombudsman for physicians and patients.  West Virginia’s Adjutant General has appointed Toney Colagrosso as Health Benefit Advisor for TriCare.   Toney is available to physicians and patients to ensure that patients receive prompt treatment and care while physicians receive prompt reimbursement for their services.  Toney is approachable and reachable to help your practice. 

For more information on how your practice can serve our military members and their families, feel free to contact Toney Colagrosso (toney.colagrosso@us.army.mil) or via phone (304) 552-2938.  You may also contact Barbara Good (Barbara@wvsma.com). 

Let’s ensure that our military members are taken care of in the best possible way.  Please advise your staff that your practice participates with TriCare!
 

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(information supplied by HealthSmart)

Wells Fargo Third Party Administrator, Inc. recently merged into HealthSmart Benefit Solutions, Inc. (“HealthSmart”).   As a result of the transaction, Healthsmart now owns the SelectNet Plus, Inc. network.  

SelectNet Plus, Inc. has advised providers of the opportunity to participate in a new network---a proprietary, fully integrated provide network called HealthSmart ACCEL.   The ACCEL network is administered solely by HealthSmart and its affiliated companies. 

For more information regarding HealthSmart or the new ACCEL network, you may contact Valorie Raines at 1-800-647-0878.  

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West Virginia will be well represented at the PMI Conference in San Antonio in June.  If you are interested in attending this excellent conference, please let Barbara Good know.  There is an additional 15% discount for our group.  

This year, both PMI and AAPC CEUs will be offered this year at PMI's National Conference in San Antonio. 

PMI has received prior approval of AAPC for up to 18 continuing education units (6 CEUs for attendance at the Advanced Coding & Auditing Boot Camp, June 13, plus 6 CEUs per day for the Conference on June 14 and 15).

Practice Management Institute also grants up to 6 CEUs per day for attendance for PMI Certified Professionals (CMC, CMIS, CMOM, CMCO).  You may also choose to attend one of the two pre-conference sessions on June 13 for 6 CEUs for PMI certified professionals. CMC and CMIS certified professionals should attend the Advanced Coding & Auditing Boot Camp for full credit.

Don't miss this unique opportunity to learn, earn CEUs, network and enjoy San Antonio with Practice Management Institute
 

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The Huntington OMA will meet on Wednesday, May 16th, at St. Mary’s Medical Center.  The program will be a special PMI (Practice Management Webinar), Mastering Medical Decision Making, presented by Jeffrey Restuccio. This in-depth, 90-minute webinar will cover the fundamentals of Evaluation and Management coding and documentation.  It will also provide an in-depth analysis of the Medical Decision Making (MDM) Process and its impact on the level of E & M service. 

This program will offer 1.5 CEUs for attendees.   For additional information and to register for the meeting, please contact Stacie Spotloe, State OMA VP of Public Relations and Huntington Chapter VP, (304) 525-9100, or via email (staciespotcmom@yahoo.com). 

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The Health Plan is sponsoring a Provider Seminar free of charge for physicians, office managers, receptionists, pre-auth staff, coders and billers. This seminar will take place on Wednesday, May 23, 2012 at Flatwoods Days Inn Hotel & Conference Center located at 2000 Sutton Lane, Sutton, WV. Registration begins at 9:30am and the seminar is scheduled from 10:00am to 3:30pm. Lunch will be provided.

The Health Plan is excited to have Michael Harmon, Compliance Specialist with the WV Mutual Insurance Company conduct a presentation on Compliance. 2012 Correct Coding Initiatives is also on the agenda. This presentation will focus on Level of Service Determination, Fraud, Waste and Abuse, Common Coding Errors and Denial Management.

CEUs will be available for both PMI certified professionals and AAPC certifications. Quality Improvement Initiatives, Preauthorization and Medical Management, Government Programs Expansion and Billing Procedures are also topics that will be discussed. Register online now. Contact Roxanne Loughery at 1.800.598.3911 for further information.

You can also download the registration form and mail or fax the completed form to:

Roxanne Loughery
The Health Plan
1137 Van Voorhis Road, Suite 44
Morgantown, WV 26505
FAX: 1.304.598.3914

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Walking Miracles.Org, a new 501c3 non profit that provides cancer survivor support services in WV, is having a founding donors dinner on Thursday, May 24, at Berry Hills Country Club from 6:30 – 9:30 PM.  The event will begin with a “Meet and Greet” from 6:30-7:00 PM.
 
Ticket prices are $125 for a single and $200 for a couple and tables are $1000 at 8 people per table. Special guests are Sugar Ray Leonard, Landau Murphy Jr., and singer Ryan Hamner.
 
Additional information about this special event may be obtained by contacting Janice Bowen at (304 345-6846 or via email JFBOWEN@SUDDENLINK.NET.  
 
For more information about Walking Miracles, see their website www.walkingmiracles.org.  

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• • Welcome to the May 2012 Wesgram Online!
• • WVSMA Completes Successful CMOM Course!
• • Healthcare Solutions Announces All-Product Contract With BrickStreet Insurance
• • West Virginia Medicaid Managed Care to Expand Enrollment
• • Palmetto GBA News
• • Medicare News
• • UnitedHealthcare News
• • WVSMA and TriCare Join Forces!
• • Wells Fargo TPA Merger
• • Practice Management Conference (PMI) Update
• • Huntington OMA Meeting
• • The Health Plan of the Upper Ohio Valley
• • Walking Miracles Founding Donors Dinner