From the President
From the Statehouse
From the Third Party Payer Consultant
From the Legal Counsel
Asset
Protection
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From the President...Gregory L.
Borah, MD, FACS
IMPORTANT MEDICARE
and NJ OUT-OF-NETWORK ADVOCACY
A
Medicare meltdown now seems certain, as the U.S. Senate failed
to repeal the Medicare physician payment formula that will cause
a drastic 21 percent payment cut to physicians who care for
Medicare patients. On March 1, the cut went into effect, forcing
many physicians to limit the number of Medicare patients they
see in order to keep their practice doors open.
A
new 2010 survey of neurosurgeons found that about 60 percent of
doctors are already reducing the number of Medicare patients in
their practices, and cuts will force an additional nearly 40
percent more to decrease the number of new Medicare patients
they see. More than 18 percent of neurosurgeons no longer take
new Medicare patients. Doubtlessly, specialists (including
Plastic Surgeons) will be forced to follow their lead.
In
the 'good old days' we could cost shift and take a loss on
Medicare patients as a public service and still make up for the
losses keeping our practices afloat with insured patients. This
strategy, born of our altruistic inclinations, just set the bar
of reimbursements low and subsequently the health care insurers
took advantage of us and tied their rates to Medicare. These
for-profit insurers were not bound by a sense of obligation to
hold down profits made from seniors, because they were
'businessmen' and a maximum profit was the only goal. In fact
they always argue it is their fiduciary duty to maximize profits
by any means possible!
Doubtlessly, the U.S. Senate will come up with some temporary
'fix' again and this charade of concern for Medicare
beneficiaries will continue until the next time. If the medical
profession had any imagination they would band together to
establish 'not-for-profit' insurance companies or collectives to
offer better reimbursements to doctors and better coverage to
patients - but I won't bet on it in my practice lifetime. At
this point only a total melt-down of the flawed medical
insurance system will likely result in the push for meaningful
change. The next year or two will likely be pivotal in this
process.
At
the New Jersey state level, the NJ PlastyPac is engaging in a
meaningful dialogue with the new Republican state administration
and legislation. Important changes are a foot in New Jersey with
proposed 'out-of-network' benefit caps to surgeons. We need to
be at the legislative table the issues are debated, but this
takes money - and lots of it! The NJSPS Board has personally
committed to contributing to the PAC, but it is vitally
important that every member of the NJ Society's donate to the
PAC today. This investment in your practice future will be
repaid many times over in your ability to continue to bill
out-of-network.
Please make a $1,000 contribution to the NJ PlastyPAC on-line or
by fax, so we can represent you in this critically important
fight in Trenton!
From the Statehouse....Beverly
J. Lynch
The Senate Health, Human Services and Senior Citizens Committee
debated and released a new measure (S-377, sponsored by
Committee Chairwoman Senator Loretta Weinberg, D-Teaneck), that
makes various changes to the membership and duties of the State
Board of Medical Examiners (BME).
Specifically, the bill:
-
Provides that
the three public members of the BME include one person who
represents a senior citizen advocacy group, one who
represents a child advocacy group, and one who represents a
Statewide consumer advocacy group.
-
Specifies that
at least one of the 12 physician members of the BME shall be
a pediatrician.
-
Specifies that
a member of the BME is eligible for reappointment for one
additional term of office, but no member shall serve more
than two consecutive terms of office.
-
To ensure that
the BME takes timely disciplinary action to protect the
public, when appropriate, the bill provides that:
o the Medical Practitioner Review Panel of the BME is
required to investigate notices or complaints it receives
from health care facilities and health maintenance
organizations regarding a licensee in order to make a
recommendation to the BME, and to make its recommendation
within 90 days after receipt of the complaint, rather than
to investigate "promptly," as the law currently provides.
If the review panel requires additional time due to
extenuating circumstances, it shall so notify the board,
indicating the reason and the amount of additional time
required to make its recommendation, and transmit a copy of
the notice to the Attorney General and the complainant.
o within 60 days upon receipt of notification from a
physician of any action taken against the physician's
medical license by any other state licensing board or any
action affecting the physician's privileges to practice
medicine by any out-of-State hospital, health care facility,
health maintenance organization or other employer, the BME
shall investigate the information received and obtain any
additional information that may be necessary in order to
make a determination whether to initiate disciplinary action
against the physician.
Some in the physician community argued that specifying the
representation of three public members and a pediatrician would
restrain the work of the Board. The bill can now be considered
by the full Senate, at the discretion of the Senate President..
From the Third Party Payer
Consultant....James McNally, CPC
Ordering/Referring
Physician PECOS Mandate Delayed
As reported previously, effective April 5, 2010, Medicare
Administrative Contractors (MACs) were slated to begin denying
claims for ordering/referring physician claims where the name
and NPI number of the physician listed in box 17 and 17a were
not in the Provider Enrollment Chain and Ownership Supply
(PECOS) system or the claims system of the MAC.
CMS is extending this deadline to enroll in the PECOS system
until January 3, 2011.
CMS indicates that it will send a reminder to all physicians to
enroll in the new PECOS system if they enrolled in Medicare more
than six years ago. To read more, go to:
http://www.cms.hhs.gov/MedicareProviderSupEnroll/06_MedicareOrderingandReferring.asp#TopOfPage
As more information becomes available, we will keep you
apprised.
For additional guidance on this issue, read the article below or
contact us through the Third Party Insurance Help Program.
Ordering/Referring
Physician File Now Available
CMS has made available a file that contains the National
Provider Identifier (NPI) and the name (last name, first name)
of all physicians and non physician practitioners who are of a
type/specialty that is eligible to order and refer in the
Medicare program and who have current enrollment records in
Medicare (i.e., they have enrollment records in PECOS that
contain an NPI).
This file is downloadable from the Medicare provider/supplier
enrollment Web site at:
www.cms.hhs.gov/MedicareProviderSupEnroll
Click on “Ordering/Referring File” on the left-hand side.
(Please note that this Adobe file contains approximately 800,000
records. Due to the large size of this Adobe file, Medicare
suggests you right click and select “Save as” before attempting
to open this file).
A new file will be made available periodically that will replace
the posted file; at any given time, only one file (the most
recent) will be available. The file can be viewed online. In
addition, it can be downloaded by users with technical expertise
and further sorted or manipulated. It can also be used to search
for a particular physician or non physician practitioner by NPI
or by name.
Please note the following: (1) Records are in alphabetical order
based on the surname of the physician or non physician
practitioner. (2) Name suffixes (e.g., Jr.), if they exist, are
not displayed. (3) There are no “duplicates” in the file. Many
physicians or non physician practitioners share the same first
and last name; their corresponding NPIs are the assurance of
uniqueness. (4) Deceased physicians and non physician
practitioners are not included in the file. (5) If a user is
unsure of a physician or non physician practitioner’s NPI, he or
she can look it up in the NPI Registry at:
https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do
Keep in mind that the record in the NPI Registry is not the
Medicare PECOS enrollment record.
Attention: Medicare Paper
Claims Submitters
Currently, paper claims that are received where the health
insurance claim number (HICN) and the beneficiary name do not
match, are returned to the provider with a development letter
advising the provider to correct the problem and submit as a new
claim.
The Centers for Medicare and Medicaid Services (CMS) is now
directing contractors to follow the current electronic rejection
process with all claims, electronic and paper.
These paper claims will now be rejected and returned to the
provider with a rejection letter specifying the reason the
claims were returned. The effective date of this change was
tentatively scheduled for February 26, 2010.
Medicare Claims Not Crossing
Over to the Supplemental Insurer
The Centers for Medicare & Medicaid (CMS) is informing all
physicians, and suppliers to an issue that occurred starting on
or about January 1, 2010, and would have negatively impacted
their patients’ crossover claims.
Due to a system issue with the Common Working File (CWF), some
claims are not crossing over to the supplemental insurance
carrier for benefits.
CMS, along with the CWF System Maintainer are working towards a
system solution.
Therefore, CMS' recommendation to all providers, physicians, and
suppliers is as follows:
-
Examine your
Electronic Remittance Advice (ERA) or standard paper
remittance advice from this time period to determine if your
patients' claims are identified as having been crossed over
to your patients' supplemental insurers. Remittance Remark
Code MA 18 will indicate your claim has crossed over to the
supplemental insurer.
-
If you
determine these claims were not crossed over, you are within
your rights to submit claims to your patients' insurers for
supplemental payment using methodologies acceptable to those
entities.
CMS Issues Instructions for
Processing Claims Containing Anti-Markup Services
Medicare Contractors have been provided with instructions for
processing claims for diagnostic services that are subject to
the ‘anti-markup payment limitation' and that are billed with
missing or incomplete information in Item 20 of the form
CMS-1500 or its electronic equivalent.
To
read more, go to the link below.
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6670.pdf
For guidance on this issue, contact us through the Third Party
Insurance Help Program.
EBCBS Releases Physician
Office Administrative “Roadmap”
A
number of inquiries have been received from the membership with
regard to Empire Blue Cross Blue Shield’s Professional Relations
representatives. The calls run the gamut but most complaints or
issues concern the identification and/or availability of these
representatives to answer questions from the Network physicians.
As
a result, a contact was made with senior staff at EBCBS who have
provided the following access information so a practice can
identify who their representative or Network Management
Consultant is and how to contact them.
EBCBS has posted the “Physician Office Administrative Roadmap”
document on their web site under “Self Service & Support”. Aside
from other critical and important information, they instruct the
panel physicians to complete the following steps to find out
contact information on their Network Management Consultant.
Please call 1 800 992 BLUE (2583) and select the following
Prompts in order after listening to the recorded message.
-
Option 1 –
Medical Providers
-
Option 4 –
Updates and Other Information
-
Option 1 –
Participation and Credentialing Information - Enter your Zip
Code
The name and telephone number of your contact at EBCBS should
come up and you should save this information.
The document itself can be accessed at:
http://www.empireblue.com/provider/noapplication/f4/s8/t4/pw_b141799.pdf?refer=ehpprovider
If
your office experiences any problems with this methodology,
please contact us through the Third Party Insurance Help
Program. That way we can alert EBCBS to any issues that may
prevent you from identifying and contacting your Network
Management Consultant.
Another MSP Problem Surfaces with
Regard to Part B Claims
The Centers for Medicare & Medicaid Services (CMS) has
identified yet another problem where claims were not
automatically crossing over to supplemental payers even though
the provider remittance advice indicated otherwise. This
problem began January 5, 2010.
Your action is required where a remittance advice with an issue
date between January 5, 2010, and February 12, 2010, has two or
more service lines for a beneficiary where both of the following
apply:
-
One service
line is 100 percent reimbursable (i.e., the approved amount
and amount to be paid are equal,) AND
-
One service
line where part of or the entire Medicare approved amount is
applied to the Part B deductible and/or carries co-insurance
amounts.
They were not able to forward these beneficiary claims to
supplemental payers even though the remittance advice may
indicate otherwise. Providers will need to identify these
claims by reviewing their remittance advice with an issue date
between January 5, 2010, and February 12, 2010, that contain the
criteria noted above.
Once identified, providers will need to take action to balance
bill the beneficiary’s supplemental payer. As of February 12,
2010, this system problem was fixed and all claims are crossing
over to supplemental payers as indicated on the provider
remittance advice.
CMS has already notified supplemental payers of these issues and
regrets any inconvenience you may experience related to this
Medicare claim supplemental payer crossover problem.
Aetna To Cut Assistant at Surgery
Payment Rate
Effective May 1, 2010, Aetna will change their payment rate for
physicians assisting at surgery.
As
of this date, the rate will change from 20 percent of the
negotiated rate or recognized charge based on Aetna
reimbursement policies to 16 percent of the negotiated rate or
recognized charge.
They will reimburse multiple eligible assistant surgery codes as
follows:
-
16 percent for
the primary procedure
-
8 percent for
the second eligible procedure
-
4 percent for
each additional eligible procedure
Horizon BCBS Hit with Modifier 25 &
59 Compliance Dispute
Horizon Blue Cross Blue Shield of New Jersey (HBCBSNJ) has
released a February 2010 memo detailing changes to their
modifier payment policy. Two commonly used modifiers, 25 and 59,
had changes that have negatively impacted their reimbursement
levels.
As
a result, the Medical Society of New Jersey (MSNJ) has filed a
compliance dispute against Horizon alleging multiple violations
of the national class-action settlement agreement concerning
these modifiers.
The Horizon BCBSNJ memo announced that this change will become
effective on May 17, 2010, and will recognize services submitted
with a variety of modifiers as “nonstandard” and “not performed”
or pay for the services at significantly discounted amounts.
The class action settlement dictated that Horizon was supposed
to post on its web site the limited number of finite code
combinations not appropriately reported together for separate
payment of modifiers 25 and 59.
Horizon has not posted this list but, instead, has announced
this across-the-board policy of recognizing modifiers 25 and 59
appended procedures as “nonstandard.” They are also conducting
chart and claim audit review of some physicians’ services
submitted with a modifier 25 asserting over-utilization, without
first having provided notice of the limited number of finite
code combinations not appropriately reported together for
separate payment of modifier 25. The compliance dispute filed by
MSNJ requests that the carrier cease these audits until it has
first complied with the settlement agreement’s notice
requirement by posting the limited list. MSNJ will be posting
the full text of the compliance dispute on their web site
shortly.
In
the meantime, if you believe that you have an additional
violation, please contact MSNJ via
e-mail at info@msnj.org.
Put “Horizon Compliance Dispute” in the subject line or call
Melinda Martinson, MSNJ, Senior Manager, Physician Practice
Advocacy, at (609) 896 1766, ext. 276.
For your information and review, the full HBCBSNJ policies on
the modifiers in controversy are located at the link below.
Modifier 25
https://services5.horizon-bcbsnj.com/eprise/main/horizon/tsnj/tsweb/uploadimages/upload/Modifier_25.pdf
Modifier 59
https://services5.horizon-bcbsnj.com/eprise/main/horizon/tsnj/tsweb/uploadimages/upload/Modifier_59.pdf
For guidance on this issue, contact us through the Third Party
Insurance Help Program.
Legal Report...Kern
Augustine Conroy & Schoppmann, P.C.
KACS Monthly Report Submission - 2/26/10
Surgical Practices Should "Self-Register"
Signed into law last year, SB787 allows practices with a one-OR
surgical suite meeting the law's definition of "surgical
practice" to continue these services, but only if they register
with the Department of Health & Senior Services (DOHSS) by March
20, 2010. As yet, no regulations or registration process exist.
As a result, DOHSS has decided to accept from surgical practices
a written submission that includes the information required by
the statute: name and address of the surgical practice; name of
the chief administrator or designated agent of the practice;
names and addresses of all owners of the practice; the scope of
services provided at the practice; proof of certification by CMS
or an accrediting body recognized by CMS; and, on an annual
basis, the number of patients served by payment source
(including the number of Medicaid-eligible and medically
indigent persons), the number of new patients accepted, and the
number of physicians, PAs and APNs providing services at the
practice. Submissions should be mailed to: John Calabria,
Director, Office of Certificate of Need & Healthcare Facility
Licensure, NJ Dept of Health & Senior Services, P.O. Box 358,
Trenton, NJ 08625-0358.
New Data Breach Rule and New HIPAA in Effect
As of February 22nd, the new federal Data Breach
Notification Rule will be enforced. That means any breach of
patient information that occurs from now on must be analyzed
under the Data Breach Notification rule. Unless
the data is exempt, or the breach is excepted from the new law,
a practice must notify all individuals affected by the data
breach. Depending on the circumstances of the breach, the
practice may also need to notify the media of the breach.
Notification to the U.S. Department of Health & Human
Services could be required, as well, and, at the least, the
breach must be reported to HHS as part of the practice's annual
reporting obligation, which requires a practice to report to HHS
by March 1, 2010, all breaches that have occurred since
September 23, 2009. In addition, some of the new patient rights
under HIPAA and new requirements for how practices use and
disclose a patient's protected health information took effect in
February. While there is some speculation regarding delayed
enforcement of new business associate requirements and
modification of business associate agreements, no definitive
guidance had been issued by the regulators as of the effective
date.
Rule Activity Aimed at Improved Security for NJ
Prescription Blank Forms
The NJ Division of Consumer Affairs (Division) has adopted
amendments to the rules governing NJ Prescription Blanks (NJPB),
requiring NJPBs to be consecutively numbered and to contain the
prescriber or healthcare facility National Provider Identifier,
if one has been obtained. The Division also is soliciting
comments regarding possible amendments to its rules governing
the printing of NJPBs, citing several recent incidents of
fraudulently produced NJPBs that highlight the need for
increased security in order to combat prescription drug
diversion in the State. In one case, the base stock used to
produce NJPBs was diverted from a Division-approved printer
vendor by individuals who used the base stock to produce
counterfeit prescription blanks. In another instance,
individuals were able to duplicate NJPB base stock for use in
producing counterfeit blanks. The Division is considering
requiring all approved printer vendors to purchase base stock
from a single paper source supplier. The Division is also
considering requiring all security features to be incorporated
in the NJPB base stock by the single paper source supplier or
added by the Division's approved printer vendors during the
printing process. The Division is also considering requiring all
approved printer vendors to be physically located in New Jersey
in order to facilitate enforcement activities by helping to
ensure Division access to printer vendor facilities. The recent
incidents involving the diversion of NJBP base stock from
approved printer vendors demonstrates that increased inspection
activities are necessary to combat fraud and promote public
safety. Comments on this pre-proposal should be sent by April
17, 2010 to: David Szuchman, Director, Division of Consumer
Affairs, Post Office Box 45027, Newark, New Jersey 07101.
Government Initiatives Target Healthcare Fraud
The President's 2011 Budget includes "historic support for
anti-fraud efforts" and the Justice Department has announced
wide ranging efforts to combat healthcare fraud. Governor
Christie's Banking & Insurance Transition Subcommittee finds
NJ's Office of Insurance Fraud Prosecutor to be ineffective and
underutilized because it has failed to produce a volume of
prosecutions commensurate with its funding and recommends
changes to beef up prosecutions. Given the Governor's impressive
record as a former US Attorney, he will likely adopt a
stepped-up, aggressive policy against insurance fraud, a
substantial revenue generator for the state. Effective
enforcement of alleged abuses in NJ's $9 billion Medicaid
program could yield hundreds of millions of dollars in savings,
fines and penalties. In fact, Medicaid False Claims Act
prosecutions are cited as generating "tens of millions of
dollars" while utilizing relatively few resources. Physicians
should expect the "elimination of fraud, waste and abuse" to be
a state and federal mantra for the foreseeable future. If you
find yourself the focus of a fraud investigation, contact Kern
Augustine's Daniel Giaquinto, at 908-704-8585.
Records Retention - Longer Than You Might Think
Physicians need a record retention policy that ensures
compliance with law, as well as providing the documentation to
defend against audits, malpractice actions and agency
investigations. Under NJ law, medical records should be retained
for seven years from the date of the most recent entry. Records
of minors should be retained to age 18, plus two years, or seven
years from the last record entry, whichever is greater. Under
the federal False Claims Act, the government can look back up to
ten years to investigate an alleged violation of the Act, so
Medicare and Medicaid records should be maintained for ten
years. Medicare Advantage providers must, at a minimum, make the
records of Medicare Advantage patients available to CMS for ten
years following the end of the contract term or following the
completion of an audit, whichever is later, and even longer if
the government decides the retention period should be extended.
Asset Protection: Most Common
Planning Mistakes and Oversights...Dave Vargo, CFP, CMFC
Very often I find that money earmarked for education is either
held in a Uniform Gift to Minors Account (UGMA) or owned
outright in the Doctor's name. Unfortunately, both of these
types of ownership offer very little (if any) protection from
potential creditors. I think that the most efficient vehicle for
education savings is a 529 plan.
For my clients that live in New Jersey I recommend using New
Jersey's 529 plan. Not all 529 plans are created equal. Although
there are a few states that offer creditor protection for the
assets held in their plans, they only afford this protection to
residents of their state. So if you own Alaska's 529 plan
(sponsored by John Hancock) the assets only receive creditor
protection if you are a resident of Alaska. New Jersey offers
creditor protection for New Jersey residents.
529 plans also offer favorable tax treatment. Earnings grow tax
deferred and earnings are free from federal tax when withdrawn
for qualified higher education expenses. Qualified expenses
include tuition, fees, required books, supplies and equipment,
and room and board if the child is enrolled at least half-time.
Originally the tax benefits were scheduled to "sunset" in 2010.
The Pension Protection Act of 2006 has made the current tax
treatment permanent. Because both the creditor protection and
the favorable tax treatment are hard to replicate, New Jersey's
529 plan is a very viable alternative for education funding.
If
you have any questions please feel free to contact me at (877)
972-7900 or
dvargo@varbeco.com.
David J. Vargo, CFP®, CMFC
President, Varbeco Wealth Management,LLC
Announcement: New discounts available to NJSPS members
Your NJSPS membership now entitles you to discounts from several
premier Disability and Long Term Care insurance providers. Both
Union Central and the Standard are offering discounts on not
only their individual disability insurance but also Business
Overhead Expense (BOE) and Disability Buy-Out policies.
Participating Long Term Care insurance providers include
Guardian, Prudential, and John Hancock.
For more information please contact Varbeco Wealth Management at
(877) 972-7900 or
dvargo@varbeco.com.
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