FOR HEALTHCARE PROFESSIONALS

one oneTO

SPRING 2012

In the era of ever-increasing healthcare costs, many healthcare providers are offering to waive or discount coinsurance, copayment or deductible amounts that are the personal responsibility of the patient. This practice is not only a violation of the terms of a provider’s contract with Blue Cross of Idaho but may also violate state and federal laws.

Insurance premium rates are calculated with the assumption that members are paying the full amount of the coinsurance, copayments or deductibles. By allocating some of the cost of each healthcare service back to the member, the insurer is assured that each member is financially motivated to make an informed choice in purchasing healthcare. The sum of all of these choices in the purchase of healthcare is reflected in the premium paid by each policyholder and their employer. Waiving or discounting coinsurance, copayments or deductibles gives members incentive to seek more services and increases utilization dramatically, unnecessarily contributing to the rising cost of healthcare.

Though as a general rule providers should not waive or discount coinsurance, copayments or deductibles, Blue Cross of Idaho’s contracts allow providers to waive or discount coinsurance,

copayments or deductibles under limited exceptions. A provider may discount these fees on an occasional basis when services are provided at a reduced rate for charitable purposes due to patient indigence, or to settle a genuine controversy related to the billed charges.

Of course, this discretionary contractual exception does not excuse providers from their duty to comply with state and federal law. Routinely waiving or discounting patient liability amounts may constitute illegal inducements under the federal Stark law or state and federal anti-kickback statutes. Idaho Code 41-348(b)(2) also prohibits the regular practice of discounting patient liability. If you are unsure about your discounting practice, you should consult with your legal counsel.

Provider Alert

New Policies

2.04.77 BRAF Gene Mutation Testing to Select Melanoma Patients for BRAF Inhibitor Therapy – investigational/ medically necessary

2.04.76 Quantitative Assay for Measurement fo HER2 Total Protein Expression and HER2 Dimers – investigational

9.03.27 Intravitreal Angiogenesis Inhibitors for Retinal Vascular Conditions – medically necessary/ investigational

Policy Statement and Other Area Revisions

2.02.08 Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry – medically necessary/ not medically necessary/ investigational

2.03.07 Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy for the Treatment of Pseudomyxoma Perieonei, Peritoneal Carcinomatosis of Gastrointestinal Origin and Peritoneal Mesothelioma – medically necessary/ investigational

2.04.58 Intraepidermal Nerve Fiber Density Testing – medically necessary/ investigational

5.01.06 Human Growth Hormone – medically necessary/ not medically necessary/ investigational

5.01.10 Immune Prophylaxis for Respiratory Synctial Virus– medically necessary/ not medically necessary/ investigational

6.01.30 Screening for Lung Cancer Using CT Scanning or Chest Radiographs – medically necessary/ investigational

6.01.43 Contrast-Enhanced Computed Tomography Angiography (CTA) for Coronary Artery Evaluation – medically necessary/ investigational

7.01.116 Facet Joint Denervation – medically necessary/ investigational

8.01.05 Immune Globulin Therapy – medically necessary/ not medically necessary

9.03.24 Intravitreal Angiogenesis Inhibitors for Choroidal Vascular Conditions – medically necessary/ investigational

Medical Policy UpdatesThe following medical policies have been updated. Please refer the Medical Policies located on bcidaho.com.

When a Patient Refuses a ColonoscopyAs a physician, you usually recommend that your patient has a screening colonoscopy. But if the patient refuses, what do you do then? Our clinicians have found that many times, the conversation between doctor and patient ends there. Did you know there is another option to consider? It is called the Fecal Occult Blood Test (FOBT) and payable by Blue Cross of Idaho. There are two types of FOBT tests:

m Guaiac (gFOBT)

m Immunochemical (iFOBT)

These tests require no prep, are less invasive to the patient, and can be done at home. We have found that many patients are more likely to follow-up with a colonoscopy if results from an FOBT are positive.

If you would like free FOBT test kits for your office, please contact Kathryn Harsch at Blue Cross of Idaho at 208-331-7336.

Medicare Advantage Preventive vs. Diagnostic Services BillingWith the advent of Medicare preventive service coverage, there is no patient cost share for Medicare-covered preventive services. This has led to some confusion when billing preventive versus diagnostic services.

m To process with no patient cost-share for Medicare-covered preventive services, please bill these services with the designated CPT/HCPCS and diagnosis codes. The link below provides the appropriate CPT/HCPCS and diagnosis codes for billing these services. cms.gov/MLNProducts/downloads/MPS_QuickReferenceChart_1.pdf

m Diagnostic lab services may incur patient cost-share and must be billed with CPT/HCPCS codes and the appropriate medical diagnosis code. These services are covered in accordance with the CMS Lab National Coverage Determinations, available at the link listed below. cms.gov/CoverageGenInfo/04_LabNCDs.asp

Partnering with Members to Battle Prescription Drug AbuseAccording to several national surveys, approximately 20 percent of people (a rate second only to marijuana)abuse prescription medications, like those used to treat pain, attention deficit disorders, and anxiety. It is a serious and growing problem marked by increases in treatment admissions, emergency room visits, and overdose deaths.

However, there are treatment options for individuals who abuse or are addicted to prescription medications. Initially, someone may need to undergo medically supervised detoxification to help reduce withdrawal symptoms. In addition, counseling in an inpatient or outpatient setting can help people overcome addiction. Additional options for effectively treating addiction to prescription medications are typically tackled on a case-by-case basis. It’s sometimes tricky determining the best course of action, but the important first step, is deciding there needs to be any action at all.

That’s one reason Blue Cross of Idaho developed the Prescription Drug Abuse Program. Our staff is available to help members who have prescription drug addiction receive the help needed. Participants work one-to-one with a Blue Cross of Idaho case manager to ensure the treatment plan includes the necessary tools and materials needed for success. Additionally, our case managers are dedicated to making sure members receive the personalized care needed through the often-difficult rehabilitation phase, and available to answer questions or address concerns.

For more information on this program, or if you have a patient that would like to speak with a case manager, call Blue Cross of Idaho at 208-331-7535 or 800-743-1871.

The Idaho Immunization Program The Idaho Immunization Program (IIP) provides free vaccination products, including influenza vaccines, for all children residing in Idaho, including those with private insurance coverage like Blue Cross of Idaho.

Therefore, effective July 1, 2012, Blue Cross of Idaho will no longer provider reimbursement for privately purchased childhood influenza vaccines and will include the childhood influenza vaccine in the 2012-2013 immunization assessment. Refer to Provider Administration Policy 505 for immunization billing guidelines and Provider Administration Policy 244 for flu shot roster billing guidelines.

While Blue Cross of Idaho helps fund the IIP, we are not always prospectively aware of program changes and not always able to notify providers in advance. Being the case, please periodically check the IIP website for a list of immunizations provided free of charge.

The list is located on the Health and Welfare website at: healthandwelfare.idaho.gov/LinkClick.aspx?fileticket=BmbdHJdWYFs%3d&tabid=388&mid=2798

For additional information about the IIP, please visit: healthandwelfare.idaho.gov/Health/Immunizations/HealthcareProviders/tabid/388/Default.aspx

Thank you for your continued support of Blue Cross of Idaho. If you have any additional questions, please contact your Blue Cross of Idaho provider relations representative.

Alternative Medicine Integration of Idaho Alternative Medicine Integration of Idaho (AMI) now manages the Chiropractic Quality Initiative Program. Implemented by Blue Cross of Idaho on September 1, 2011, Chiropractors are required to enter provider and patient data into the AMI Clinical Outcome Management System (ACOMS) on all current and future patient episodes of care except for excluded groups specified in Provider Administrative Policy 264. Specific program information and access the ACOMS system is available after the provider login on our website, bcidaho.com/provider, under Chiropractic Management.

Chiropractors familiar with the AMI program may have noticed changes and updates to the ACOM system so we appreciate your patience

as we migrate to this new process and system and work out the glitches. Blue Cross of Idaho is working diligently with AMI to enhance the ACOM system to feature all the necessary tools providers need to comply with the Chiropractic Quality Initiative Program. After we complete the updates, we will send revised timelines and program criteria to chiropractors. Since the ACOM system requires data in a time sensitive fashion, chiropractors need to continue entering patient data as we make the updates.

For additional information on the AMI program, contact your Blue Cross of Idaho Provider Representative or an AMI Provider Relations Representative at 855-432-2667 (1-855-ID-ACOMS).

2012 Save the Date19th Annual Idaho HealthCare Conference

Idaho Falls – May 8, 2012

ISU Idaho Falls Campus • 1776 Science Ctr. Drive

Pocatello – May 9, 2012

Clarion Inn • 1399 Bench Road

Burley – May 10, 2012

Best Western Burley Inn • 800 N Overland Avenue

Lewiston – May 22, 2012

Red Lion Hotel • 621 21st Street

Coeur d’ Alene – May 23, 2012

Best Western CDA • 506 W Appleway Avenue

Boise – May 31, 2012

Doubletree Riverside • 2900 Chinden Blvd

Medicare Advantage Part D ClaimsBlue Cross of Idaho does not reimburse for Medicare

Advantage outpatient Part D medication claims and no longer

forwards claim information to Express Scripts for processing.

Outpatient Part D claims submitted to Blue Cross of Idaho

Medicare Advantage will deny as patient responsibility.

As with any of your Original Medicare patients, Medicare

Advantage members may submit their own claims to their

Part D plan for reimbursement. If you have processes in place

to assist your Original Medicare patients with their Part D

claims submission, we ask that you also use those processes

to assist our True Blue HMO and Secure Blue PPO members.

New FacesBlue Cross of Idaho’s Provider Services Department welcomes our newest employee.

Whitney DeHaven joined our team in April 2012 as a Health Data Analyst. Whitney grew up in the Los Angeles area, before moving to Bellingham Washington in 2005. There she worked for Sterling Health Plans, a moderate-sized insurance company that specializes in Medicare Advantage and Medicare Supplement products. She moved to Idaho last summer with her two kids, Eli (8) and Gracie (6). In her spare time she likes crafting (sewing, crocheting and painting) and dance.

Medical Management

Managed Health Care/Review, Preadmission/Admission Certification, or Individual Benefits Management and Case

Management

n 208-331-7535 n 800-743-1871 n Voice mail available after office hours and on holidays and weekends

Blue Cross of Idaho Help Desk

Electronic Billing Errors, Error and Acceptance Reports

n 8 a.m. – 5 p.m. (Monday – Friday), MT n 888-BCI-EDIA, 888-224-3341 or 208-331-8817

Provider Contact Center for Commercial and Medicare Advantage

Benefits, Claims Status or Reconsiderations

n 8 a.m. – 5 p.m. MT (Monday, Tuesday, Thursday, Friday) 8:30 a.m. – 5 p.m. MT (Wednesday)

n Commercial: 208-286-3656 or 866-482-2250

n Medicare Advantage: 208-286-3656 or 866-482-2250

Email: csproviderinquiries@bcidaho.com

External Provider Relations – questions regarding website applications such as electronic billing, eligibility,

claims, authorizations, internet services or requests for FREE on-site training n 866-283-5723 or 208-286-3602,

Ext. 8309: Jamie Hunihan – Treasure Valley West

Ext. 8307: Kathy Brock, CPC-P – North Idaho, WA, OR & MT

Ext. 8308: Diane Mortensen, CPC – South, Southeastern, NV, WY & UT

Any Questions?

An Independent Licensee of the Blue Cross and Blue Shield Association