Medicare Administrative
Contractors Post Updated Fees to Reflect Revisions to Certain
Codes
Medicare Advantage Fraud,
Waste, and Abuse (FWA) Training no longer Mandatory
United Healthcare UCR
Settlement Documents are on the Way
Reminder on PQRI Feedback Reports
CMS Releases Guidance on Signature
Requirements
Horizon BCBS Revises Modifier 25 & 59
Policy
CMS Issues Conflicting
Deadlines on PECOS Enrollment
Medicare Administrative
Contractors Post Updated Fees to Reflect Revisions to
Certain Codes
Medicare has revised the payment files for the 2010 Medicare
Physician Fee Schedule Database (MPFSDB) based on retroactive
provisions under the Patient Protection and Affordable Care Act
(Pub.L.111-148) (the Affordable Care Act).
The most recent files have been posted to their website on May
19, 2010.
The revised fees are effective May 19, 2010 for claims with
dates of service on or after January 1, 2010 and should be used
until such time as the controversy over the 21.2% reduction is
resolved.
PHYSICIANS MUST KEEP IN MIND THAT THESE FEES ARE REVISED TO
REFLECT CHANGES IN RELATIVE VALUES AND A SLIGHT CHANGE TO THE
CONVERSION FACTOR ONLY.
THE 21.2% REDUCTION IN THE CONVERSION FACTOR WITH SUBSEQUENT
REDUCTIONS IN FEES MAY STILL TAKE EFFECT ON JUNE 1, 2010 UNLESS
CONGRESS ACTS TO HALT THESE CUTS!
To download these files, go to Highmark Medicare Services:
https://www.highmarkmedicareservices.com/partb/reimbursement/feedb-2010.html#nj
Medicare Advantage Fraud,
Waste, and Abuse (FWA) Training no longer Mandatory
As reported previously and expected, the Center for Medicare and
Medicaid Services (CMS) has published a rule about Medicare
Advantage and Part D plans requiring that physicians take a
formal course on an annual basis in Fraud, Waste and Abuse (FWA)
training.
The rule explains that physicians and suppliers, by virtue of
their being enrolled in the Medicare program do not need to
obtain fraud, waste and abuse-compliance training from Medicare
Advantage plans.
For guidance on this issue, contact us through the Third Party
Insurance Help Program.
United Healthcare UCR
Settlement Documents are on the Way
A record breaking settlement has been reached in organized
medicine’s action against United Healthcare (UHC) and their use
of artificially low payments via their UCR fee schedules in the
payment for out of network services to physicians.
More than $350 million is available to compensate physicians and
their patients for 15 years of artificially low payments for
these out-of-network services.
The deadline for filing a claim to share in the settlement fund
is October 5, 2010. The settlement claims administrator began
mailing the settlement notice and claim forms to physicians on
April 16, 2010.
Physicians should be on the lookout for a plain white mailer
with “United Healthcare” written on the bottom and with the
return address referencing the Settlement Claims Administrator:
United Healthcare Class Action Litigation c/o Berdon Claims
Administration LLC, P.O. Box 15000, Jericho, NY 11853-1001.
In order to assist you in this effort, the American Medical
Association (AMA) is providing a new on-line resource that will
help affected physicians with step-by-step guide to and help in
determining eligibility, assembling documentation and filing a
claim under the terms of the settlement.
Go to the link here and read more about what needs to be done in
regard to this record-breaking settlement reached in the AMA’s
legal victory against UnitedHealth Group—the nation's largest
health insurer and parent company of UHC.
http://www.ama-assn.org/ama/pub/advocacy/current-topics-advocacy/private-sector-advocacy/health-insurer-settlements/unitedhealth-ucr-settlement.shtml
AMA physician members can also get personal assistance with
filing a claim by going to the AMA Practice Management Center at
the link here or by calling (800) 621-8335.
http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/practice-management-center.shtml
For guidance on this issue, contact us through the Third Party
Insurance Help Program.
Reminder on PQRI Feedback
Reports
For questions with regard to the PQRI program, you may contact
Quality Net at:
(866) 288-8912
E-mail:
qnetsupport@sdps.org
Web Site:
https://www.qualitynet.org/portal/server.pt
Individual EPs can call their respective carrier or A/B MAC
Provider Contact Center to request 2007 Re-Run and 2008 PQRI
feedback reports that will contain data based on their
individual NPI. This means that EPs who are part of a group
practice can get their individual feedback reports as well.
When requesting feedback reports, EPs will be asked to provide
an e-mail address. EPs can then expect to receive the e-mailed
feedback report within 30 days of the request. If no report is
available, the provider will receive an e-mail notification.
EPs Requesting Reports Based on Taxpayer Identification
Number (TIN) for Group Practice Information
EPs who request feedback reports based on TIN or group practice
information will still be required to access their PQRI feedback
reports via the PQRI Portal after first registering in IACS. An
IACS user identification and password is required to access the
PQRI Portal. The PQRI Portal may be found at
http://www.qualitynet.org/pqri on the Internet.
CMS Releases Guidance on Signature
Requirements
The Centers for
Medicare & Medicaid Services (CMS) has issued Change Request
(CR) 6698 to clarify for physicians how Medicare claims review
contractors review claims and medical documentation submitted by
providers.
CR 6698 outlines
the new rules for signatures and adds language for
E-Prescribing. See the rest of this article for complete
details. These revised/new signature requirements are applicable
for reviews conducted on or after the implementation date of
April 16, 2010.
To read more, go
to the link here.
http://www.cms.gov/MLNMattersArticles/downloads/MM6698.pdf
For guidance on
this issue, contact us through the Third Party Insurance Help
Program.
Horizon BCBS Revises Modifier 25 & 59
Policy
As reported
previously, Horizon Blue Cross Blue Shield of New Jersey (HBCBSNJ)
had released a February 2010 memo detailing changes to their
modifier payment policy. Two commonly used modifiers, 25 and 59,
had changes that had negatively impacted their reimbursement
levels.
As a result, the
Medical Society of New Jersey (MSNJ) had filed a compliance
dispute against Horizon alleging multiple violations of the
national class-action settlement agreement concerning these
modifiers.
Subsequent to this
action and after “significant feedback” from panel physicians,
HBCBSNJ has revised their policy to better reflect the
appropriate use of these modifiers.
For your
information and review, the full HBCBSNJ policies on the
modifiers in controversy are located at the links below.
Modifier 25 -
Modifier 25 will allow an E&M service at 100% of the applicable
Horizon BCBSNJ fee schedule when performed with a separate and
distinct non-E&M procedure/service on the same date of service.
The other service will also be considered at 100%. The 50%
reduction will only apply to non preventive E&M and preventive
E&M services on the same day. To read more, go to:
https://services5.horizon-bcbsnj.com/eprise/main/horizon/tsnj/tsweb/uploadimages/upload/Modifier_25.pdf
Modifier 59 –
Horizon will no longer automatically reduce the second service
prior to multiple surgery pricing if it meets the definition of
modifier 59. Multiple surgery pricing reductions/rules will
still apply as they have in the past. To read more, go to:
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.
CMS Issues Conflicting
Deadlines on PECOS Enrollment
In February, CMS
announced a new deadline of January 3, 2011 for the
implementation of phase 2 of the enrollment requirements for
getting ordering, referring providers into the PECOS system.
According to the
Federal Register published May 5, 2010, the date has been moved
up to July 6, 2010. The change is in interim status, with
a 30 day comment rule, so we will not know for certain that July
6 is the new effective date until early June.
As more
information becomes available, we will keep you apprised.
Claims with an
ordering/referring physician name and NPI number require that
the ordering/referring physician be enrolled in the Provider
Enrollment, Chain and Ownership System (PECOS). Without this,
claims will be denied.
To determine if
you are already in the system, review the file found at:
http://www.cms.hhs.gov/MedicareProviderSupEnroll/06_MedicareOrderingandReferring.asp
If you are on this
list, no action is necessary.
If you are not on
this list, you will need to set up a record in the PECOS system.
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