Title: MANAGING MEDICARE
1MANAGING MEDICARE
Hawaii Medical Association July 29, 2008
2WE WILL DISCUSS
- Palmetto Transition (A B)
- Coverage Local National
- Documentation Principles
- How to Respond to Requests for Records
- PQRI Physician Quality Reporting Initiative
- QA
3PALMETTO GBA
- Who is Palmetto?
- One of largest Medicare contractors
- Division of BCBS of South Carolina
- Offices in 5 states
Headquartered in Columbia, South Carolina,
Palmetto GBA is a wholly owned subsidiary of
BlueCross BlueShield of South Carolina. With over
2,700 employees in 14 states, Palmetto GBA spans
the nation with customers in 45 states, two U.S.
territories and the District of Columbia
www.palmettogba.com/J1
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5CUTOVER DATES
6WHATS A DOCTOR TO DO ?
- Browse and bookmark the J1 Web site,
http//www.palmettogba.com/j1 -
- Review the Timeline at http//www.palmettogba.com/
j1 to keep updated with the important dates
involving the implementation of the J1 MAC.
7WHATS A DOCTOR TO DO ?
- Register to receive the J1 MAC Implementation
E-mail updates at - http//www.palmettogba.com/palmetto/j1.nsf/
Person?OpenForm?opencat . -
- Visit and review the J1 FAQs page at
- http//www.palmettogba.com/Palmetto/J1.nsf/docsCat
/Frequently20Asked20Questions?opendocument?open
cat for answers to common questions
8WHATS A DOCTOR TO DO ?
- For questions not addressed in a posted FAQ,
please feel free to submit that question for
consideration by e-mailing your concern to
j1mac_at_palmettogba.com - Review Events at http//www.palmettogba.com/j1
to check the schedule for all upcoming training
seminars, Web casts, and teleconferences
9SPECIFIC ACTIONS REQUIRED
- EFT (Electronic Funds Transfer)
- EDI (Electronic Data Interchange)
- Early Boarding
- Claims and Appeals
- LCDs (Local Coverage Determination)
- Medical Review
- Provider Enrollment
- Other
10Electronic Funds Transmission
- Need to fill out form CMS 588
- www.cms.hhs.gov/cmsforms/downloads/ CMS588.pdf
- Fill out form and send along with
- Current bank information voided check
- Palmetto GBA FinanceJ1 EFT
P.O. Box 100277 - Columbia, SC 29202-3277 - Due Dates California Part B Aug. 15, 2008
- Help (866) 749-4301 or for e-mail
EFT.Admin_at_PalmettoGBA.com
Aug. 15, 2008
11Electronic Data Interchange
- Fill out J-1 EDI Enrollment form
- All current EDI submitters
- Separate form for new submitters or options
- J-1 EDI Enrollment form from Palmetto Website
- Software, manuals assistance also on Palmetto
Website - For Help
- 1-866-749-4301 for EDI Assistance
- medicare.edi_at_PalmettoGBA.com.
12EARLY BOARDING
- Extended period to test your connectivity
communication with Palmetto EDI - Early Boarding Schedule Send your forms in now
and can test before transition occurs. - EDI transition and to-do listserve are on the
Palmetto Website
13CLAIMS AND APPEALS
- Palmetto will get all claims appeals from
former contractor after cutover - Send all info to current contractor until you
hear otherwise - Palmetto will handle all claims not completed by
former contractor - If small provider can still use paper claims
- Mutual of Omaha claims will not transition until
CMS gives date - Possible dates are in 2010
- See Q and A section on Website
14Local Coverage Determinations
- Palmetto will merge A B LCDs from former
contractors - Least restrictive LCDs will be used
- Input from CAC representatives involved
- New LCDs posted on the website with connections
to CMS Medicare Data Base - CAC (Carrier Advisory Committee) structure will
continue in each state - After cutover, reconsideration always possible.
15PROVIDER ENROLLMENT
- No need to document current enrollment unless
asked - Information from current contractor will be
passed to Palmetto - Be certain you have a correct NPI
16NATIONAL COVERAGE DECISIONS
- National NCDs come from CMS
- Based on scientific studies data collected
- Presented often at MCAC-open meetings
- Notice and comment welcome
- Reconsiderations always possible
- NCDs cover entire country
- May specify services always covered
- May specify services never covered
- Published in CMS Coverage Manual
- May change as science changes, new studies
emerge, or as laws change.
- Reconsiderations always possible
17LOCAL COVERAGE DECISIONS
- Local LCDs from 1 or more states/areas
- Written by local CMDs about situations that are
data based need control or instruction - Presented at state CACs open to medical and
specialty societies representatives - Notice and comment welcome
- Reconsiderations always possible
- LCDs cover a Medicare Jurisdiction
- Usually give codes conditions for payment
- May state frequency of service and diagnoses
Always published locally and nationally
- Reconsiderations always possible
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22HOW YOU COPE WITH LCDS
- Know what is covered and which diagnoses and CPT
codes to use- theyre written - Know the frequencies or time frames that will be
paid - Document any unusual cases or exceptions you may
need - If you believe Medicare will not pay
- Have patient sign an ABN (Advanced Beneficiary
Notice) - ABN is downloadable from CMS
www.cms.hhs.gov/bni
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24DOCUMENTATION
- DOCUMENTATION SHOULD PAINT A PICTURE OF
- HOW PATIENT IS DOING / WHAT IS NEW DURING HIGHER
CODE VISIT - NEED FOR UNUSUAL / ATYPICAL DRUGS, LABS OR
UNUSUAL DIAGNOSTIC TESTS - NEED FOR FREQUENT VISITS OR HIGHER EM VISITS
- ANY SPECIAL PROBLEMS WITH THAT INDIVIDUAL
PATIENT - INCLUDE OBSERVATIONS AND SUPPORTIVE DATA AS
NEEDED - DOCUMENTATION NEED NOT BE EXTENSIVE
25DOC TRY TO PAINT A PICTURE
26DOCUMENTATION POINTS
- Templates/forms are fine, but must be
individualized for each patient visit - Patient name, date, time, and ID of who
documented chart - Computerized notes are okay if individualized,
but medical necessity still rules on review - Note time when service is time related-e.g.
therapy crit. care - If poorly legible, send typed or printed copy
with original
27DEALING WITH DENIALS
- Know correct codes for what you do
- Check national or local coverage policies
- Send all data requested in a timely manner and to
the correct address - If necessary, speak to the group asking for
recordsget name of someone - Ask assistance from HMA or your specialty
society---they can help. - Review your documentation
- Appeal if you think you have grounds
Review your documentation Appeal if you think you
have grounds
28DEALING WITH MISTAKES
- Physicians their offices do sometimes make
mistakes - If challenged, check your coding and billing
processes - Check your CPT, ICD-9, and with your colleagues
or with expert coders - Acknowledge mistakes if you correct problems
many reviews will stop there - Be decent with reviewers they are doing their
jobs - Humbleness never hurt any review situation
29DEALING WITH MISTAKES
- Make sure coders and billing personnel understand
the services you actually did - For special types of practice be able to
demonstrate it - Medicare cannot by law tell you how to practice
but it can refuse to reimburse - Know your rights and appeals process-with many
levels - You have the right to get out of Medicare /
Medicaid
30RESPONDING TO MEDICAL REVIEW
- WHO CAN ASK FOR RECORDS / DOWNCODE OR DENY
PAYMENT - MEDICARE A/B ADMIN. CONTRACTORS
- MEDICAL INTEGRITY (FRAUD) CONTRACTOR
- CERT CONTRACTOR
- RAC CONTRACTOR
- BUNDLING AND MEDICAL UNLIKELY EDITS
- PRIVATE INSURANCE COMPANIES (FOR MEDICARE
ADVANTAGE)
31MAC (A/B) CONTRACTOR REVIEW
- Must be written strategy submitted to CMS
- Based on accumulated claim data
- Statistically different from peers in
other states, areas, jurisdictions - Follow Progressive Corrective Action
- 20-40 CHARTS REQUESTED
- DENIAL CALCULATED
- Based on published NCD, LCD or reviewed
medical necessity - Review by clinicians (often MD specialists
in the field) - Several levels of appeals available
- Contact at Palmetto GBA always available
32WHO GETS REVIEWED
- DATA OUTLIERS
- UNUSUAL FREQUENCY
- UNUSUAL LEVEL OR PLACE OF SERVICE
- POOR DOCUMENTATION IN PROBE REVIEW
- PATIENT COMPLAINTS
- REPEAT FALLOUTS WARNINGS
- POSSIBILITY OF FRAUD
33PREPARE FOR REVIEWS DO
- 1. GET PERSONALLY INVOLVED
- 2. COPY ALL OFFICE, FACILITY OR OTHER RECORDS
REQUESTED - --PROGRESS/THERAPY NOTES (CURRENT AND
EARLIER IF HELPFUL TO EXPLAIN) - --NURSING NOTES, CLINICAL OBSERVATIONS,
AND ANY CONSULT NOTES IF HELPFUL
- --LAB DIAGNOSTIC TESTS IF RELATED TO
SERVICE - --CHANGE IN DX, MEDS, OR IN THE CURRENT
CONDITION - 3. WHEN IN DOUBT SEND MORE RATHER THAN LESS TO
SUPPORT MEDICAL NECESSITY OF SERVICE
34PREPARE FOR REVIEWS DO
- 4. CHECK FOR CORRECT DATES NAMES
---CORRECT PATIENT DATES
---CORRECT PHYSICIAN
- 5. SUBMIT TIMELY AND TO CORRECT ADDRESS REQUESTED
ON LETTER - 6. KEEP RECORD OF INDIVIDUAL ASKING FOR YOUR
RECORDS AND WHY THEY ARE ASKING - 7. CHECK FOR LEGIBILITY CAN RETYPE NOTES IF
ALSO SEND ORIGINAL - 8. CALL IF ANY QUESTIONS THE LOCAL CONTRACTORS
PROBABLY HAVE ANSWERS
35PREPARE FOR REVIEW DO NOT
- 1. HAND OFF TO OTHERS AND LEAVE
- 2. IGNORE REQUESTS FOR INFORMATION REVIEWERS
WILL NOT GO AWAY - 3. CREATE NEW ( STILL WET) PROGRESS NOTES OR
DOCUMENTATION THAT CLEARLY DID NOT EXIST BEFORE
---CAN SEND CORRECTIONS
---CLARIFICATIONS WITH ORIGINALS - 4. DELAY BEYOND DATES STATED
- 5. CALL MEDICAL DIRECTOR AND SWEAR
36PREPARE FOR REVIEW DO NOT
- YOU HAVE VARIOUS LEGAL AND APPEAL RIGHTS---TO BE
DISCUSSED - MOST AUDITS EDUCATIONAL, NOT PUNITIVE, AND CAN BE
RESOLVED
37PROBLEMS YOU CANT RESOLVE?
- CALL CONTACT PERSON AT PALMETTO GBA ASK FOR AN
IN PERSON OR TELEPHONE MEETING - YOU SHOW YOU CARE ABOUT THE SITUATION
- THE CONTACT OR VISIT ALONE MAY TEACH YOU HOW TO
SOLVE THE PROBLEM - CALL HMA STAFF OR 3RD PARTY RELATIONS COMMITTEE
OF YOUR SPECIALTY ASSOCIATION - MEDICARE CONTRACTORS CARE ABOUT GOOD RELATIONS
WITH ORGANIZED ASSOCIATIONS - REMEMBER, HMA STAFF CAN ALWAYS CALL US AT
PALMETTO TO HELP EXPLAIN THE REGS AND SOLVE THE
PROBLEMS WE ARE HERE TO HELP
38CERT AND MEDICAL INTEGRITY CONTRACTORS
- CERT Contractors (Document Review)
- Ask for only a single chart or case
- Purpose to review the reviewers
- If denied money must be returned
- Appeals possible if you disagree
- MIP Contractors (Medical Integrity)
- CalBisc and TrustSolutions in Calif.
- Potential fraud or abuse cases
- Respond promptly, get all info, may be
misunderstanding with patient
39RECOVERY AUDIT CONTRACTOR
- Contractor PRG Schulz of Atlanta, Ga.
- Reviews old claims (up to 4 years from date of
claims) - Demonstration Project in 3 states
- Paid 20-25 of what it brings in
- Will be nationwide in in next few years but
rules not final - Looks at medical necessity and
incorrect coding for over and
underpayment - Can appeal denials several levels
40PHYSICIAN QUALITY REPORTING INITIATIVE
Medicare Payment For Reporting Data
Continues in 2008 with up to 1.5 bonus
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43ELIGIBLE PROFESSIONALS
- MEDICARE PHYSICIANS
- MD, DO, DPM, Optometrists, Oral Surgeons,
Dentists, Chiropractors - PRACTITIONERS
- PA. NP, Clinical Nurse Specialist, CRNA,
Certified Nurse Midwife, Clinical Social Worker,
Clinical Psychologist, Registered Dietician,
Nutrition Professional - THERAPISTS
- PT, OT, SLP
442008 PQR1
- The 2008 PQRI measures list and the descriptions
of those measures are available in the
"Downloads" section below. - Final specifications for the 119 2008 PQRI
measures are listed on the CMS website
45ENROLLMENT
- Eligible professionals need not enroll or file an
intent to participate for the PQRI. Eligible
professionals can participate by reporting the
appropriate quality measure data on claims. - In order to satisfactorily meet requirements of
the program receive the bonus, certain
reporting thresholds must be met. When no more
than three quality measures are applicable to
services provided by an eligible professional,
each such measure must be reported in at least
80 of the cases in which the measure is
reportable. When four or more measures are
applicable to the services provided by an
eligible professional, the 80 threshold must be
met on at least three of the measures reported.
46ENROLLMENT
- Eligible professionals should select and report
measures applicable to their practice. - Reporting for the 2008 PQRI began with claims for
dates of service as of January 1, 2008.
Physicians should become familiar with the 2008
PQRI measures and coding for the measures. Mid
year reporting was July, 1, 2008 - TRHCA section 101 specifies that, for 2008, CMS
must use the taxpayer identification number (TIN)
as the billing unit, so any
bonus incentive payments
earned will be paid to the
holder of the TIN.
47PAYMENT FOR PARTICIPATION
- Eligible professionals who participate in the
2008 PQRI program will have access to a CMS
analysis of their reported data. - Those who successfully report quality measure
data on claims for services between Jan. 1 or
July 1 and Dec. 31. 2008, will be eligible for a
single consolidated incentive payment in mid
2009. - The bonus, is the equivalent of 1.5 of total
allowed charges for covered physician fee
schedule services provided from Jan 1 through
December 31, 2008.
48MORE HELP
WWW.AMA-ASSN.ORG/
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