Section 1011 Provider Symposium

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Section 1011Provider Symposium

• December 5, 2007
• Dallas, Texas

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Symposium Topics
1. Program Information
2. Enrollment
3. Eligibility
4. Payment Processing
5. Compliance Reviews
6. Web Updates
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Section 1011 Provision

• Allows 250 million annually for Fiscal Years
  (FYs) 2005-2008.
• Allows annual state allotments based on the
  states relative percentage of undocumented
  aliens.
• Percentage determined by number of undocumented
  aliens who reside in each state divided by the
  total number of undocumented aliens in all
  states.
• (Data obtained from Census bureau).

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Section 1011 Provision

• Two-thirds of funds are divided among 50 states
  and the District of Columbia.
• One-third of funds is divided among six states
  with the largest number of undocumented alien
  apprehensions. (Dept. of Homeland Security data)
  

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Pro Rata Reduction
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Medicare Similarities

• Section 1011 is contracted by the Centers for
  Medicare Medicaid Services (CMS).
• Section 1011 is administered through TrailBlazer
  Health Enterprises, LLC.
• Section 1011 uses the Medicare payment
  methodology (formula) and a replicate of the
  Medicare Part A processing system.

TEXT
TEXT
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Medicare Differences

• Section 1011 is a quarterly reimbursement
  program, not an insurance plan.
• You submit payment requests instead of claims.
• Section 1011 is not a Medicare Carrier, Fiscal
  Intermediary (FI) or Medicare Administrative
  Contractor (MAC).
• Reimbursement based on the Section 1011 Final
  Implementation Notice. Program does not change.

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The TrailBlazer Connection
TrailBlazer
Medicare Carrier
Centers for Medicare Medicaid Services
MAC
Fiscal Intermediary
Section 1011
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Terminology

• Alien A non U.S. citizen.
• Undocumented alien is a person who enters the
  U.S. without legal permission or who fails to
  leave when permission has expired or Aliens who
  have been paroled into the U.S. at a U.S. port of
  entry.
• GPNet Gateway Production Network allows
  electronic connectivity to TrailBlazers
  processing system.

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Terminology

• Laser Visa Biometric, machine readable, border
  crossing identification card.
• Pro Rata Reduction Calculated reduction of
  total payments for a state if available funds are
  exceeded.

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Acronyms

• ACT Ask the Contractor Teleconference.
• CMS Centers for Medicare Medicaid
  Services.
• DRG Diagnosis Related Group.
  Payment methodology used in calculating
  1011 payments.
• DDE Direct Data Entry.

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Acronyms continued

• EDI Electronic Data Interchange.
• EFT Electronic Funds Transfer.
• EMC Electronic Media Claims.
• EMTALA Emergency Medical Treatment
  and Labor Act. (Section 1867 of
  the Social Security Act)
• ERA Electronic Remittance Advice.

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Acronyms continued

• HIPAA Health Insurance Portability and
  Accountability Act of 1996.
• NPI National Provider Identifier.
• PR Payment Request.
• PPD Provider Payment Determination Form.
• UARS Undocumented Alien Reimbursement
  System.
• UPIN Unique Physician Identification Number.

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Provider Enrollment
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Enrollment Requirements

• Medicare Participating Providers
• Provider Enrollment Application (CMS Form 10115).
  
• Authorization Agreement for Electronic Funds
  Transfer EFT (CMS Form 588).
• Must include voided check, pre-printed deposit
  slip or banking verification letter must be
  included with EFT.
• Electronic Remittance Advice (ERA) request
  form.

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Enrollment Requirements continued

• Non Medicare Participating Providers
• Section 1011 Provider Enrollment Application
  (CMS Form 10115 in hard copy)
• Form 855I - Physicians.
• Form 855B - Ambulance companies.
• Authorization Agreement for Electronic Funds
  Transfer EFT (CMS form 588).
• Voided check, pre-printed deposit slip or banking
  verification letter must be included with EFT.
• Electronic Remittance Advice (ERA) request
  form.

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Provider Enrollment Cycle
Fiscal Year 3, 4th Quarter
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Enrollment Application
Change
2. Applicants Legal Business Name
3. Doing business as (DBA)
4. Address (Include county)
7. Current Fiscal Intermediary / Carrier
6. State of Service
9. Applicants Medicare ID Number
10. Hospital election (Hospital only)
11. Physician Privileges (Physician only)
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Enrollment Application page 2
14. Type Name and title of authorized
representative.
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Hospital Roster
Attachment 1
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Physician Privileges Roster
Attachment 2
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EFT Authorization

National Provider ID (NPI)
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ERA Request Form
Existing ERA Receiver ID , if applicable
Provider Number(s)
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Enrollment Changes

• Changes may include
• Enrollment Form Data Changes.
• Roster Changes.
• Hospital Election Changes.

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Application Change Process

• When changing physical address, hospital
  election, physician privilege, etc., follow these
  steps
• Write change at the top.
• Make necessary changes in applicable sections.
• Include Attachment 1 if adding or removing
  physicians from your roster.
• Include Attachment 2 if adding or removing
  hospital facilities from your roster.

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Application Change Process

• Enrollment application form must be signed by the
  Authorized Representative.
• Enrollment application form must be mailed and
  not faxed.
• Indicate if the Authorized Representatives
  information has changed.

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Election Changes

• Hospitals choosing to change their election
  should
• Notify all practicing physicians of their intent
  to change.
• Submit a new Enrollment application with
  explanation of the change. (Application must have
  Authorized Officials Signature).
• When a hospital is no longer billing for a
  physician, the physician is withdrawn from the
  program.

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Election Changes

• When a hospital changes its election to bill for
  a physician and the physician is already enrolled
  in the program, the physicians PIN for that
  hospital will be terminated.
• Election changes must be made by July 1st of the
  same year.
• Election changes occur annually and are effective
  October 1st of each year.

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Enrollment Summary

• EFT Agreement and ERA requests are required in
  the enrollment process.
• Changes to the enrollment form must have change
  written at the top of the form and the form must
  be signed by the authorized representative.
• Section 1011 accepts the original signature of
  authorized official on enrollment and EFT forms.
  Photocopies will be returned.
• All incomplete documents are returned to you.

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Section 1011 Eligibility
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Section 1011 Eligibility

• Eligible services are EMTALA-related services
  (including medical screening) to the point of
  patient stabilization. (FPN notes usually two
  days).
• Eligible providers are hospitals, physicians and
  ambulance providers that meet the program
  requirements.
• Eligible aliens are undocumented aliens, paroled
  aliens and Mexican citizens permitted to enter
  the United States for not more than 30 days under
  laser visa authority.

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Eligible Services

• Health care services required by the
  application of section 1867 EMTALA of the
  Social Security Act
• and these services include related inpatient,
  outpatient and ambulance services as defined by
  the Secretary of Health and Human Services.

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Eligible Services continued

• Covered services for hospitals begin
  when EMTALA begins and continue until the
  point of stabilization.
• There is no EMTALA obligation after patient
  stabilization.
  
• Triage (screening) services are covered and
  billable to Section 1011.

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Eligible Providers

• Hospitals
• Medicare participating hospitals that meet the
  program requirements
• Indian Health Service (IHS) facilities.
• Providers of ambulance services
• State licensed providers of ambulance services
  for covered transports to a hospital ER or from
  one hospital to another.

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Eligible Providers continued

• Eligible physicians
• Doctors of medicine.
• Doctors of osteopathy.
• Under statutory restrictions,
  legislation allows if EMTALA
  related
• Doctors of podiatric medicine.
• Doctors of optometry.
• Doctors of dental surgery.
• Chiropractors.

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Ineligible for Section 1011

• Mid-level practitioners.
• Nurse practitioners.
• Physician assistants.
• Clinical nurse specialists.
• Certified Registered Nurse
  Anesthetists (CRNAs).

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Determining Eligibility

• Complete and sign the PPD (or other acceptable
  collection instrument).
• Section 1011 asks that you not ask if a patient
  is an undocumented alien.
• Follow normal screening procedures.
• Can your form be used to answer the PPD?
• If patient refuses (or is unable) to provide
  proof of eligibility, do not submit a payment
  request.
• Additional 10 percent reimbursement for
  outpatient payment requests.

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Determining Eligibility continued

• Some acceptable forms of ID
• Foreign voting card, drivers license or
  passport.
• Matricula Consular card (Mexican Govt).
• Border-crossing card (laser visa).
• Form I-94 stamped Parole or Parolee.
• Some unacceptable forms of ID
• Foreign student ID.
• Resident Alien card (green card) issued by U. S.
  Citizenship Naturalization Services.
  Patient is documented, unless green card
  has expired.

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Ineligible Patients

• US Citizens.
• Permanent Residents.
• Aliens with employment authorization.
• Individuals with valid non-immigrant visas
• Tourists.
• Students.
• Business travelers.

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Provider Payment Determination
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Eligibility Summary

• Eligible Section 1011 services must be
  EMTALArelated services to the point of
  stabilization.
• When completing the PPD form (CMS 10130A) to
  determine patient eligibility
• If you checked yes stop. Sign and date.
• If you checked no continue to the next
  question.
• If you choose an alternative collection document,
  it must capture the same data as the PPD to be
  acceptable.
• Section 1011 asks that you not inquire if a
  patient is an undocumented alien.

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UARS Undocumented Alien Reimbursement System
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UARS

• Undocumented Alien Reimbursement System, designed
  for processing and paying Section 1011 payment
  requests exclusively.
• Ensures all payment requests are submitted
  electronically in a HIPAA-compliant format.
• Replicate of the Fiscal Intermediary Shared
  System (FISS).

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UARS continued

• All provider types can access UARS and submit
  payment requests through Direct Data Entry (DDE).
• Hospitals also have the option to submit payment
  requests via Electronic Media Claims (EMC).
• Electronic PR submissions only
• Final Policy details that payment requests cannot
  be submitted hard copy.

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UARS Entry continued
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UARS Entry continued
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UARS Entry continued
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UARS Entry continued
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UARS Entry continued
51881
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UARS Entry continued
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UARS Entry continued
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UARS Availability

• UARS hours of availability
• Monday through Friday
• 7 a.m. 8 p.m. (CT)
• Weekends and holidays
• 7 a.m. 2 p.m. (CT)

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Billing Example

• If patient or third party payment is received
  prior to billing Section 1011, the payment is
  reported on the payment request in the value
  codes field and is subtracted from the Section
  1011 reimbursement.
• Example
• Hospital submits payment request for 1000.
• The Section 1011 reimbursement amount is 600.
• Patient pays 100.
• Section 1011 subtracts the 100 payment and
  reimburses the hospital 500.

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UARS Common Mistakes

• Billing mistakes
• Professional fees should not be submitted with
  type of bill (TOB) 111. Only hospitals can submit
  TOB 111.
• Duplicate charges which occur because the patient
  HIC is used on more than one payment request
  (system retains information from initial
  submission).
• Coding mistakes
• Many providers fail to include the ICD-9
  procedure code and procedure dates while billing
  operating room charges (revenue codes with 036X
  prefix) .

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UARS Common Mistakes continued

• Anesthesia billing mistakes
• Submit payment requests with the inappropriate
  modifier(s).
• Submit the anesthesia duration in minutes only.
  Time can be two or three digits and must be
  entered in the total covered (TOT COV) field.
• Example If the anesthesia duration is 2 hours,
  enter the duration as 120 instead of 002.

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UARS Corrections

• UARS does not allow online corrections or
  adjustments. If an error is discovered
• Identify the error via fax or e-mail and include
  the correction.
• E-mail correction to section.1011_at_trailblazerheal
  th.com.
• Subject Payment Request Correction Needed.
• Or, fax correction to (469) 372- 6143.
• Subject Payment Request Correction Needed.

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UARS Corrections continued

• Body of e-mail or fax must contain
• Section 1011 PIN.
• Patient Identification number.
• Patient control number.
• Medical record number.
• Payment request dollar amount.
• Date(s) of service.
• How the error should be corrected.
• Name, title and telephone number of billing
  contact person.

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Payer of Last Resort

• Section 1011 is payer of last resort
• You should seek payment from all available
  funding sources prior to billing Section 1011.
• This includes federal, state and third party
  payers
• Department of Homeland Security.
• Medicaid or State Childrens Health Insurance
  Program.
• Private insurers or Health Maintenance
  Organizations (HMOs).
• Patients.
• This process is consistent with the statute and
  it limits reimbursement to instances where no
  other reimbursement will likely be received.

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Overpayments

• Receipt of a payment from the patient or third
  party subsequent to Section 1011 payment.
• Assessed due to Medical Review and Compliance
  Review findings.
• Providers should notify Section 1011 that an
  overpayment has occurred.
• Withhold overpayments from the next quarterly
  Section 1011 payment.

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Overpayments

• If the balance is not a sufficient balance in
  the next quarterly payment (to repay the
  overpayment in full), TrailBlazer will notify you
  and allow 30 days to repay the overpayment
  without accrual of interest.

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Excluded Services

• Based on EMTALA regulations, certain revenue
  centers are not considered emergency services and
  are excluded from 1011 payment.
• Additionally, certain diagnosis codes, when used
  as the primary diagnosis, are excluded from the
  1011 program.

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Excluded Codes

• View the Revenue Center Exclusion List for
  excluded codes. The following revenue codes are
  always excluded from Section 1011 reimbursement
• 0960
• 0961
• 0962
• 0964
• 0969

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Professional Fees

• Professional fees are outpatient charges and are
  billed under the physicians Provider
  Identification Number (PIN) with bill type 131.
• Specific revenue codes apply only to physicians
  services for billing purposes. For the billing
  codes, see Revenue Codes for Physicians on the
  Section 1011 website under payment request
  processing.

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UARS Summary

• UARS is an electronic system
• Submit through DDE (all provider types) or EMC
  (facility charges only).
• Section 1011 does not accept hardcopy payment
  requests.
• Corrections may not be made online (you should
  fax or e-mail the corrections).
• Revenue code 036X must have procedure code(s) and
  procedure date(s).
• Bill type 111 is for Inpatient and 131 is for
  Outpatient.

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Compliance Reviews
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Compliance Reviews

• Why conduct Compliance Reviews?
• To ensure payments are made to providers for
  eligible services.
• To ensure hospital on-call payments to physicians
  are properly calculated.
• To ensure inappropriate, excessive or fraudulent
  payments are not made from state allotments.
• To ensure PR submissions are supported by
  clinical and non-clinical documentation.

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Basis for Reviews

• Included but not limited to
• Identified billing inconsistencies.
• High utilization rates or high denial rates.

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Compliance Review Process

• Two types of Compliance reviews
• In-house, performed in conjunction with Medical
  Review.
• On-site, more detailed reviews performed at the
  provider facility.

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In-House Compliance Review

• Payment requests selected for Medical Review and
  Compliance Review.
• You are required to furnish PPD form (or other
  acceptable collection instrument) and applicable
  supporting documents in a hardcopy format.
• PPD form (or other acceptable collection
  instrument) must be consistent with medical
  records and other supporting documents associated
  with the services rendered.

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On-Site Review

• You will be notified six to eight weeks prior to
  the scheduled review.
• Compliance auditors come to your site to review
• Patient eligibility documentation.
• Medical records.
• Social workers notes.
• Patient accounts receivable.

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On-Site Review

• Conduct an entrance conference to communicate
  review purpose.
• Review your policies and procedures to determine
  patient eligibility.
• Interview staff members associated with admitting
  patients and completing the Provider Payment
  Determination (PPD) form.

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On-Site Review

• Review business records to ensure collection
  efforts from all payment sources have been made.
• Review medical records to ensure patient
  information is complete and consistent.
• Communicate daily audit findings to provider.
• Conduct an exit conference to communicate audit
  findings and recommendations.

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On-Site Review Preparation

• If eligibility data is stored electronically, be
  prepared to provide a copy of the form(s) used to
  determine eligibility.
• Ensure availability of all records associated
  with the payment requests being reviewed.

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Compliance Review Summary

• Ensures integrity of the Section 1011 program.
• Ensures eligibility, accuracy and consistency of
  patients medical records.
• Ensures payments are not fraudulent or excessive.
  

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Medical Review
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Medical Review

• July 2, 2007 the Medical Compliance Review
  processes were streamlined.
• Providers now receive one letter.
• Payment requests selected for Medical Review are
  also reviewed for eligibility.
• Every payment request sent to TrailBlazer is
  subject to review by two Section 1011
  departments.
• The Medical Review department examines all billed
  services, while the Compliance Review department
  verifies patient eligibility.

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Medical Review

• New Process for Reducing Payment Requests
• When the number of days submitted in a payment
  request is reduced by Medical Review, this is
  referred to as a reduction to the point of
  stabilization.  
• Effective Monday, November 12, 2007, Medical
  Review implemented a new process for handling
  these reductions.

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Medical Review

• Providers will now receive a letter notifying
  them of the number of days approved and
  requesting the following documentation relating
  to those days
• A corrected hard copy bill in the form of a UB-04
  (CMS-1450) for the payment requests that were
  reviewed and reduced to the point of
  stabilization.
• An itemized bill showing charges for room and
  board only  and ancillary expenses associated
  with the days approved.
• A hard copy of the notification letter received
  to help expedite the match-up and processing of
  the corrected bill to the provider file.
• Providers will have 30 days to submit the
  corrected bill before the payment request is
  denied or funds are set up to be withheld.
  Medical Review decisions may be disputed within
  the allowable time frames.

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Dispute Resolution
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Dispute Resolution Process

• Most disputes received are the result of
  Compliance Review denials.
• Submit disputes no later than 45 days after
  payment date or any post-pay activity.
• Must submit PPD (and supporting documents) along
  with the completed dispute request form. If
  disputing a medical decision, all applicable
  documentation that supports the dispute should be
  submitted.
• Once dispute is received, a second review is
  conducted.
• Dispute decisions are final and may not be
  appealed.

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Web Navigation
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Web Navigation

• Lets navigate the following web links
• ListServ.
• Participating Section 1011 hospitals.
• Questions and Answer document.
• Program payments.

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• Thank you
• for attending!