Kearney &Associates,Inc. 1 How to Be in the New · • They have a computer programming issue end dating the LOCD. It ... • Then Click on Provider Basic Information • The Look

5/15/2017

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Revenue Cycle: How to Be Successful in the New Payment EnvironmentJULIE KEARNEY

MAY 23, 2017

Kearney & Associates, Inc.

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Believe

• Times are difficult to collect money

• Believe your staff and give them support

• Some issues it will take higher people to help

• Change is rapid and fast


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Many lines of Insurance

• Where are the contracts you signed with Payers?

• Do you have the payers set up correctly?

• Are you obtaining authorizations when necessary?

• Contract with all the plans


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Plan Contract

• Levels‐0191, 0192, 0193, 0194 vs 0120, 0110

• Medicare Advantage

• Mange Medicaid plus Medicaid therapy at Medicaid Fee Screen

• Authorizations


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LOCD Issues with Claims Denying‐B7

• They have a computer programming issue end dating the LOCD. It is suppose to be

fixed in March. Going forward it should fix but the State needs to manually fix the

past. These are the B7 Issues.

• LOCD List‐ If what you send in does not get on this list below it is a problem that

happened.

• http://www.michigan.gov/documents/mdhhs/LOCD_Status_Inquiry_538023_7.pdf


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NPI & CHAMPS ID


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LOCD Search


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LOCD Transition

• In June some time they will change the end date of the LOCD to 12/31/2999

• You will have to watch your LOCD to make sure they do not get wiped out or

they are given a wrong end date.


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Medicaid Coinsurance ACO & Bundle

• Medicaid is currently reviewing there policy.

• At this time the claims are denying.


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New Medicaid Timely Filing Rule 01/01/2017

• Effective January 1, 2017, claims must be filed no later than one calendar year from the date of service (DOS). For Institutional invoices, this will be calculated using the Claim Header “To/Through” date of service reported; for professional and dental invoices, this will be calculated using the Claim Line “From” date of service.

• In addition, claims for services furnished prior to January 1, 2017 must be submitted no later than December 31, 2017. Claims exceeding the new timely filing limits (over 1 year from the DOS) will be denied unless the claim meets exception(s) as listed below.


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New Timely Filing Rule

• Acceptable exceptions to the timely filing limits for claims submission include the following:

• Department administrative error has occurred

• Medicaid beneficiary eligibility/authorization was established retroactively

• Judicial action/mandate: A court or Michigan Administrative Hearing System (MAHS) administrative law judge ordered payment of the claim

• Medicare processing was delayed

• Provider returning overpayment

• Primary insurance taking back payment after timely filing billing limitation has passed

• Retroactive provider enrollment is not considered an exception to timely filing.


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Medicaid Timely Filing Rule• For claims meeting either of the first two exceptions, providers must contact the local MDHHS office to initiate the following exception process:

• The MDHHS caseworker completes and submits the Request for Exception to the Twelve‐Month Billing Limitation for Medical Services form (MSA‐1038).

• The provider must access the MSA‐1038 status tool at www.mihealth.org or contact the caseworker to determine approval or denial of the request.

• Once approved the provider prepares the claims related to the exception including “MSA‐1038 on file” in the comment section of the claim.

• The provider submits the claims to MDHHS through the normal submission process.

• Claims meeting all other exceptions are to be submitted as usual through the Community Health Automated Medicaid Processing System (CHAMPS) with appropriate remarks/notes justifying the exception request, such as:

• Court order

• Medicare documentation

• Claims previously billed under a different provider National Provider Identifier (NPI) number

• Claims previously billed under a different beneficiary ID number

• Claims previously billed using a different “statement covers period” for nursing facilities and inpatient hospitals

• Copy of insurance letter or Explanation of Benefits (EOB) showing date money was taken back from paid claim


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General

• [email protected] This email fixes the LOC that drop off or do not get fixed. It is best to

get your DHS Case Worker to fix it.

• [email protected] General Issues or Questions

• [email protected] This group fixed any MI Health Link Issues

• MSA‐MHL‐[email protected] This group fixes or looks at issues with MI Health

issues of disenrollment or something is broke


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DHS Pilot Regions

• There is a phone number ‐ 877‐522‐8050 ; fax number‐ (517) 324‐9919; email address ‐MDHHS‐LTC‐Central‐[email protected]; and physical address 2651 Coolidge, Suite 100 East Lansing, MI 48933 – MSA‐2565 forms can be sent to these numbers/email/mailing address.

• Facilities can send new LTC applications to the email, fax, or mailing address listed above.

• If the case exists in the local office, they can send the form to the local office staff who is to then transfer to the central staff. If they are unsure of who to send it to, they can call or email the central staff and they will assist them.

• Counties Involved Shiawassee, St Clair, Clinton and possible Eaton


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State Updates

• Mozell who does the dis‐enrollments for Manage Medicaid and Healthy

Michigan is still 6 months behind. She has a new phone number is 517‐241‐1156

and fax is the same at 517‐241‐5713 Email is also the same.

• [email protected] there is where you would get your 02 dropping off fixed

they are about 1 month behind.

• Provider Support is catching up about a month behind.


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Accepting and Refunding Monies to a Potentially Eligible Medicaid Beneficiary or Eligible Medicaid

Beneficiary

• It has been noted that some residents whose Medicaid eligibility is pending are paying

facilities for their care and not informing the local case worker of this payment. Once the

resident becomes Medicaid‐eligible the facility refunds the resident and bills Medicaid for

the months paid by the resident. This practice violates Medicaid policy and presents risks

for the resident. Providers should follow the guidance in this letter and inform families of

their responsibilities and risks.


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Medicaid Claims for Non Enrolled Providers

• Claims for Non‐Enrolled Providers if Physicians do not enroll or not active if the physician name is used on your claims will deny.

• Effective Date: March 1, 2017

• Medicaid, Healthy Michigan Plan, MIChild, Children’s Special Health Care Services, Maternity Outpatient Medical Services

• All Providers

• The purpose of this bulletin is to further align Medicaid policy with Sections 6401 and 6501 of the Affordable Care Act (ACA), and bulletins MSA 12‐55 and MSA 13‐17 regarding provider screening and enrollment requirements. Federal provider screening regulations require that all providers who participate in Medicaid complete the appropriate screening steps. Claims submitted by fee‐for‐service providers who have not fully completed provider enrollment with Michigan Medicaid will deny and/or not appear on a remittance advice. Provider enrollment must be completed in the Community Health Automated Medicaid Processing System (CHAMPS).

• MSA+17‐04.pdf


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Physician License

• Medicaid

• Providers should be verifying with Medicaid the physician license and make sure it is active. The State has the link below on the LARA website that you can look up the physician to see if license is active. In CHAMPS it does not give all of the detail this

site below does with date range. Remember, if the physician is not active with Medicaid the Nursing Home will not be paid.

• https://w2.lara.state.mi.us/VAL/License/Search

• Then Click on the right the Permanent ID and it will take you to another Link that will show the license issue date and the expiration date.

• Medicare (Check Current and Pending License for Physician and Non Physician)

• Pending physicians‐ https://data.cms.gov/Medicare/Pending‐Initial‐L‐and‐Ts‐Physicians/ip7y‐ztn9

• Pending Non Physicians‐ https://data.cms.gov/Medicare/Pending‐Initial‐L‐and‐Ts‐Non‐Physicians/n86y‐dqck

• Current Physicians Licensed with Medicare‐ https://data.cms.gov/Medicare/Order‐and‐Referring/qcn7‐gc3g


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Physician Look Up

• NPI

• We need to make sure taxonomy and address are correct for the medical professional you have physician, NP or PA.

• https://npiregistry.cms.hhs.gov/registry/provider‐search

• http://www.michigan.gov/lara/0,4601,7‐154‐72600_72603_27529‐43008‐‐,00.html Health License Disciplinary Action Reports

• OIG Exclusion List‐https://exclusions.oig.hhs.gov


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Medicaid Billing IssuePCC


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837 Claims Medicaid PCC

• DTP*573*D8*20130109~

• LX*1~

• SV2*0120**7665.00*DA*21~

• DTP*472*D8*20170201~

• LX*2~

• SV2*0120**1825.00*DA*5~

• DTP*472*D8*20170224~


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837 Claims Cont..

• SV2*0119**10220.00*DA*28~

• DTP*472*D8*20170201~


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Rejection Codes

• Reason/Remark codes are 96/N35


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Medicaid Provider Enrollment Agreement

• Login in to http://milogintp.michigan.gov

• Click on CHAMPS

• Pick Provider Enrollment Access

• Click Go

• Then Click on Manage Provider Information


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Medicaid Provider Enrollment

• Then Click on Provider Basic Information

• The Look and see what your dates are the following will be in this section.


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Milliman Care Guidelines, LLC, A Milliman Company https://www.mcg.com


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Evicore Portal/Diagnosis/AuthorizationeviCore healthcare is excited to announce that effective 12/12/2016, you will be able to access the Post-Acute Care provider web portal.

To access the portal, visit www.evicore.com.* If you are not registered on the eviCore.com provider portal, you will need to complete the brief user registration process. Once registered, you will have 24/7 access to view Post-Acute Care case information for Blue Cross® Blue Shield® of Michigan Med Plus BlueSM Members. The portal offers several features for providers:•View real-time status of Precerts and Post-Acute Care authorizations

•Access case details such as the authorization number and expiration date, requesting provider, servicing provider, and dischargedate

•View announcements and important notifications from eviCore

•Review up to five cases simultaneouslyeviCore will be hosting webinar training sessions to review the registration process and provide an overview of the Post-Acute Care portal. Each webinar session will be followed by a question-and-answer period if time permits. We encourage you to attend one of these informative sessions to ensure you have a successful experience with the portal.


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Evicore

• Evicore has created a survey for the SNFs to provide information to EviCore about their facility and the services they offer. In order for us to have the most updated information about the facility, we encourage providers to follow this link to complete the survey at their earliest convenience: https://www.surveygizmo.com/s3/2805274/eviCore‐PAC‐Survey. We are always looking at ways to best match the members needs with the facilities available to meet their specific post‐acute care needs. I would highly recommend doing the survey. They are making efforts to improve their process and we have to let them know the issues.

• Remember also they have the following email to send issues to and please use it [email protected] mailbox

• They also have an email for the provider relations team [email protected]


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Evicore & Med Plus Blue Part B Auth

• Well there has been a great deal of confusion from Med Plus Blue and Evicore

regarding Part B Authorizations for SNF. It is not required currently and the

claim will pay without an authorization. We have had Med Plus Blue staff say it

is required and Evicore staff have said it is required also. I have been working

with Evicore and Blue Cross to stop the total confusion and back and forth. Blue

Cross posted on Web Denis 02/17/2017 this information. In the next couple of

month’s, Blue Cross will also put it in the Record. Again, no authorization is

required for SNF for Med Plus Blue B. It may happen in the future but not now.


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Evicore & Med Plus Blue

• Web‐DENIS Alert

• Category: Medicare Advantage, post‐acute care providers

• Title: Post‐acute care provider responsibilities for delivery of requiredNotice of Medicare Non‐Coverage

• Start date: May 2, 2017 End date: Tbd

• All post‐acute care facility providers*, whether contracted with Blue Cross Blue Shield of Michigan or not, must:

• ∙ Let Medicare Plus Blue℠ PPO members know about their rights to appeal a decision that terminates post‐acute care services.

• ∙Deliver the Notice of Medicare Non‐Coverage to the member no later than two‐days prior to service termination.

• Member rights Upon receipt of a Notice of Medicare Non‐Coverage, members or their authorized representatives have the right to an expedited appeal to a Centers for Medicare & Medicaid Services delegated Quality Improvement Organization. In Michigan, KEPRO® is the delegated QIO.


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Evicore & Med Plus Blue• When a member appeals Providers must:

• ∙ Deliver to the member a valid Detailed Explanation of Non‐Coverage.

• ∙ Respond to the QIO’s Expedited Appeal Documentation Request.

• ∙ Submit supporting documentation within the timeframe set by the QIO.

• If the QIO says a provider didn’t deliver a valid NOMNC per CMS requirements

• ∙ The provider will be held financially liable for the continued services until two days after the member receives a valid notice, or until the start date of the valid notice, whichever is later (see CMS 100‐04, Medicare Claims Processing Manual, Chapter 30, §260.3.6.)

• ∙ The provider may not bill members for the balance of these services.

• CMS forms and instructions Find Notice of Medicare Non‐Coverage and Detailed Explanation of Non‐Coverage forms and instructions here.

• *Post‐acute facility providers include skilled nursing facilities, comprehensive outpatient rehabilitation facilities and home health agencies.


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Date of Onset Medicare Part B


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Part B Modifier


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Priority Health SCIO Health Analytics

• https://www.sciohealthanalytics.com/core‐capabilities/payment‐integrity/facility‐

audits/skilled‐nursing‐facility‐audits

• Claims for Medicare members treated at Skilled Nursing Facilities are reimbursed based on the

patients’ RUG (Resource Utilization Group) score, which is determined using the Minimum

Data Set (MDS). Using SCIOʹs robust analytics, claims and/or providers that merit review are

selected for audit. SCIOʹs auditors conduct a detailed review of the complete medical record

and associated MDS to determine if the billed RUG score is valid. In the event the review

determines that an incorrect RUG score was billed, SCIO® provides the valid score, reports the

reason the change was necessary, and calculates the resulting overpayment.


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Social Security Number CMS Medicare


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DiagnosisEDITS ARE INCREASING


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Concerns Currently

• Specific Coding of Diagnosis

• S & T diagnosis codes being reviewed by payer. Sending letters to families to tell where

the accident or poisoning was.

• Z51.89 Encounter for other specified after care

• Z48.89 Encounter for other specified surgical after care


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Fracture Coding

• A: Initial encounter for fracture

• D: Subsequent encounter for fracture with routine healing

• G: Subsequent encounter for fracture with delayed healing

• K: Subsequent encounter for fracture with nonunion

• P: Subsequent encounter for fracture with malunion

• S: Sequela


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Medicare & Medicaid New Edits On Claims

X223.187.2300.HI01-2.025

New Edit External Cause of Injury codes (E-codes) cannot be submitted as the Admitting Diagnosis

277CA Received with:CSCC A7: "Acknowledgement /Rejected for Invalid Information…"CSC 232: "Admitting Diagnosis"CSC 509: "External Cause of Injury"


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Examples of External Cause Codes

• They are intended to provide data for injury research and evaluation of injury

prevention strategies. These codes capture how the injury or health condition

happened (cause), the intent (unintentional or accidental; or intentional, such as

suicide or assault), the place where the event occurred, the activity of the patient

at the time of the event, and the person’s status (e.g. civilian, military). Therefore

they don’t actually describe a condition, rather they just provide additional data.

• V43.63xA Car passenger injured in collision with pick‐up truck in traffic accident,

initial encounter (Example)


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Medicaid Diagnosis Claims

December 5, 2016: Attention Medicaid Fee-For-Service Nursing Facility Providers: Please be reminded to verify that the correct diagnosis code is being reported on a claim and is appropriate to the patient’s age and/or status. The incorrect diagnosis code may suspend the claim and cause a delay in claim status.

Providers with further questions can contact Provider Support by phone 1-800-292-2550 or by email [email protected].


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Diagnosis Rejection Medicaid Reason Code

• 9 The diagnosis is inconsistent with the patientʹs age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 09/20/2009

• 10 The diagnosis is inconsistent with the patientʹs gender. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 09/20/2009

• 11 The diagnosis is inconsistent with the procedure. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. Start: 01/01/1995 | Last Modified: 09/20/2009

• 12 The diagnosis is inconsistent with the provider type. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF),

• B22 This payment is adjusted based on the diagnosis. Start: 01/01/1995 | Last Modified: 02/28/2001


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Onward, and Upward she shall prevail. We are here to care for the residents, and provide a

wonderful service.

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Cheers


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References

• www.michigan.gov

• www.cms.gov

• www.ngsmedicare.com


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Documents

Kearney &Associates,Inc. 1 How to Be in the New · • They have a computer programming issue end dating the LOCD. It ... • Then Click on Provider Basic Information • The Look