AMBULATORY SURGERY CENTERS (ASC)

WORKSHOP

PRESENTED BY BLUE CROSS AND BLUE SHIELD OF KANSAS

TODAY'S PRESENTERS

Janne DentonContract Consultant & Specialty Provider Rep, Institutional Relations, Blue Cross and Blue Shield of Kansas

Connie WinkleyEducation Coordinator, Institutional RelationsBlue Cross and Blue Shield of Kansas

Brent MatileProvider Program SpecialistBlue Cross and Blue Shield of Kansas

Marie BurdiekElectronic Data Interchange (EDI) Account RepresentativeBlue Cross and Blue Shield of Kansas

AGENDA

Introduction

Institutional Relations Department

BCBSKS Website & Availity 

Grace Period (Affordable Care Act) 

Medicare Advantage

2015 Policies & Procedures & MAPs 

Quality-Based Reimbursement Program (QBRP)  

Electronic Data Interchange (EDI)

Blue Cross and Blue Shield of KSInstitutional Relations (IR)

Department

Who are we and what do we do?

Institutional Relations (IR) Org Chart

Sally Stevens, Provider RepHospitals in Southern KS

Cindy Garrison, Provider Rep

Hospitals in Northern KS

Teresa Van Becelaere Manager, IR

Angie Strecker, DirectorInstitutional RelationsDona Hewes

Administrative Coordinator, IR

Fred Palenske, Senior VPProvider and Government Affairs

Connie WinkleyEducation Coordinator

Janne DentonContract Consultant & Provider

RepKatie Dennison

Claims Research Analyst

Brent MatileProvider Program Specialist

Melanie MoriartyAdministrative Assistant

(Topeka)

Kristi DonelanAdministrative Assistant

(Wichita)

Institutional Relations Functions IR Functions Include:

Provider Contracts Mailed annually in July

Includes our Quality-Based Reimbursement Program (QBRP)

Contracts with and services the following facilities: Hospitals – CAH, PPS, Specialty, Limited Services, VA ASCs Home Health Hospice Dialysis Facilities Skilled Nursing Facilities

Education and Training Workshops Webinars One-on-one provider visits Training as requested Newsletters and Manuals eNews Relevant Topics – i.e. ICD-10

Institutional Provider Relations IR Functions include:

Provider Claims Resolutions Katie Dennison – Claims Research Analyst Provider Representative Any IR staff member

Provider Liaison Committees Solicit input from surgical groups – i.e. Optometrist,

Audiologist, etc. Assist in the review and development of BCBSKS medical

policies

BCBSKS Websitewww.bcbsks.com

Public information includes:

Medical Policies

Forms

ICD-10 Web page

Precertification/Prior Authorization Information for Blue

Plans

Newsletters and Latest News (eNews)

SOK & FEP web pages

Availity and BlueAccess Availity (www.availity.com)

Single sign-on to Availity and BlueAccess Eligibility & Benefits Claims Status

Availity Training Workshops Webinars Provider Visit

Availity to BlueAccess Link through Payer Resources Secure tools on BlueAccess include:

Remittance Advice Member ID Look-up Manuals Some forms that can be sent electronically QBRP Form

Affordable Care Act (ACA) Grace Period

Exchange Individual Grace Period

ACA mandates a three-month grace period for those insured through the Exchange who receive a subsidy.

Individual has paid at least one month's premium

The payer is only obligated to pay claims during the first month

During the grace period, the payer may pend claims during the second and third months

Payer must notify HHS of non-payment of premiums

Payer must notify provider of the possibility of denied claims

Affordable Care Act (ACA) Grace Period

Marilyn Monroe01/01/2000ABC123456789Female

123 Anystreet Apt. 1Anytown, KS 1111108/14/2014

07/30/2014

04/01/2014 – 12/31/2014

9999999999

Affordable Care Act (ACA) Grace Period

Rhett Butler01/01/2000ABC123456789Male

123 Anystreet Anytown, KS 11111

08/14/201407/30/2014

04/01/2014 – 12/31/2014

Billy ButlerABC123456789

Medicare Advantage• Medicare Advantage (MA) facilitates the coordination of Blue

Plan Medicare Advantage claims and services for members and providers.

• MA products must cover the same services as original Medicare Part A/B and may include additional benefits.

• MA has expanded to allow Plans to offer several types of MA products.

CMS Employer Group Waiver Guidance

• Allows MA PPO and HMO groups to enroll members in areas where provider networks do not exist.

Medicare AdvantageMA Private Fee-for-Service (MA PFFS)

• Member may receive services from any Medicare provider that accepts the Home Plan's terms and conditions.

Identifying a MA member:

Medicare AdvantageMA Claims Submission

• Submit all Medicare Advantage claims to BCBSKS

• Do not bill Medicare directly for any services rendered to a Medicare Advantage member

• Payment will be made directly by a Blue Plan

• MA claims cannot and will not be processed pursuant to BCBSKS Policies and Procedures

• Member's Plan is solely responsible for determining

pricing

Medicare AdvantageMA Claims SubmissionHome Plans need the following to adjudicate MA claims accurately and timely:

• National Provider Identifier (NPI)• Source of Referral for Admission (one alpha-numeric character

indicating transfer or admission)• Core Based Statistical Area• Treatment Authorization Code• Admitting Diagnosis Code• Height and Weight for End-Stage Renal Disease (ESRD) patients• Ambulance Pick-Up Zip Code• HIPPS Code for Home Health, Skilled Nursing and Inpatient

Rehabilitation• Taxonomy Code (if the provider represents an institutional with more

than one subpart to bill)• Certified Registered Nurse Anesthetists (CRNA) Special Code• Provider Service Location ZIP Code, if different than the billing ZIP

Code• Present On Admission (POA) Indicator

Medicare AdvantageMA Appeals• Reason for appeal may include:

A delay in providing, arranging for or approving healthcare services

The amount a member must pay for a service

• Appeals can be submitted by Member Provider Assignee or the member's legal representative

• Appeals submission: Submit to BCBSKS BCBSKS forwards to member's plan within 3 days of receipt Member's MA Plan will respond to provider within 30 days

• Member's plan determines medical policy• Provider agrees to abide by final determination• Obtain appeals policies and procedures from the MA Plans

2015 Policies & ProceduresUpdates and Changes:

• Language was added to the provider contracts that encompasses all subsidiaries of BCBSKS

A new BCBSKS Subsidiary (a Health Maintenance Organization (HMO)) known as Blue Solutions will be sold to consumers soon with an effective date of January 1, 2015: o Blue Choice networko Limited network with in-state contracting providers only o Empty Suitcaseo Sold to individuals on and off the exchange and small group

(SHOP) marketso Blue Solutions is not a traditional HMO:

Members will not choose a Primary Care Provider (PCP) No referral is needed for visiting a specialty provider Members have open access through the BCBSKS Blue

Choice network Providers reimbursed using Blue Choice payment rates

2015 Policies & ProceduresBlue Solutions

The following alpha prefixes will be used for Blue Solutions members:XSC - Individual Exchange SolutionsXSG - SHOP Exchange SolutionsXSQ - Individual Solutions Off-ExchangeXSR - Small Group Solutions Off-Exchange

2015 Policies & ProceduresUpdates and Changes:

• Language was added to specify a timeframe for organizing a First Level Appeal Panel

• BCBSKS has a credentialing program which: consists of an initial full review of the providers

credentialing application with re-credential at a minimum of every 36 months.

monitors of all network providers for continual compliance with established criteria will occur as needed, but not less than monthly.

• If a provider does not meet credentialing requirements, they will not be allowed to participate as a network contracting provider.

• Providers may appeal this decision by following the appeals process outlined in the Policies and Procedures.

• Credentialing Program requires BCBSKS to have an appeals panel and BCBSKS will have 60 days from receipt of the appeal to organize the appeals panel.

2015 Policies & ProceduresUpdates and Changes:

• A section was added to the P&P to further define the confidentiality provision. BCBSKS requires that all proprietary information be kept confidential. The contracting provider may not disclose any terms of the Agreement to the third party except upon written consent of BCBSKS and as required by state or federal law.

• Added language to strongly encourage contracting providers to use the Limited Patient Waiver (LPW). A waiver should be used for a variety of reasons included the

service is not medically necessary, the benefit is denied per the member contract or the service is considered Experimental or Investigational.

Some providers have their own waivers and they may not meet BCBSKS Requirements. If providers want to use your own waiver form to verify that it includes everything that is on the BCBSKS waiver, then please have your BCBSKS rep review your waiver form.

2015 Policies & Procedures

Updates and Changes:

• A section was added outlining the administrative disputes process to comply with health plan accreditation guidelines.

This is not new; just clarification Provider may dispute issues of concern through their

BCBSKS Rep

Rep will work with the provider to address the

dispute Dispute may be escalated to BCBSKS management, if

unresolved BCBSKS will provide written response within 60 days

of management receiving the request

2015 MAPsCode ChangesBased on additional information submitted by providers, the maximum allowable payments (MAPs) for the following procedures will be increased in 2015 and additional codes will be added in 2015.

ASC MAP'd Codes Increased for 2015

23410 25609 29863

23412 29807 29888

23455 29828 29914

25608 29862 29915

26619

ASC Codes Added in 201519020 23140 23145

23146 26500 26742

27455 29193 43280

53450 65091 65093

65103 67112

2015 MAPs

Payment attachment changes:Page 6, Contract Amendments

A provision was added to amend the Contracting Provider Agreement whereby BCBSKS could make adjustments to the maximum allowable payment (MAP) for services.

"The Contracting Provider Agreement is hereby amended to delete Section IV. B which references certain circumstances under which BCBSKS could make adjustments to the maximum allowable payment (MAP) for services. If the Contracting Provider has signed the Blue Choice Agreement, then Section IV.3 is also amended."

Quality Based Reimbursement Program (QBRP) OverviewReporting periods

• Period 1 is due by November 15, 2014• Period 2 is due by May 15, 2015

Effective dates• Period 1 incentives will be effective January 1, 2015• Period 2 incentives will be effective July 1, 2015

Data submissions• Period 1 – attestations only• Period 2 – data from all of CY 2014

Incentive increases• Incentives earned will be applied to outpatient maximum

allowable payments (MAPs) and do not apply to services with a charge below the MAP.

QBRP Prerequisites

• I attest that this facility will file all claims electronically

• I attest that this facility will accept electronic remittance advices

• Obtain eligibility, benefit and claim status information primarily through electronic transactions

Quality Measure 1 (QM1): Prophylactic Intravenous (IV) Antibiotic Timing (CMS ASC-5)

Period 1: Attest that this facility has a process in place to ensure that

antibiotic infusion is initiated within one hour prior to the time of the initial surgical incision or the beginning of the procedure (e.g., introduction of endoscope, insertion of needle, inflation of tourniquet) or two hours prior if vancomycin or fluoroquinolones are administered.

Period 2: Numerator: Number of ASC admissions with an order for a

prophylactic IV antibiotic for prevention of surgical site infections (SSI) who received the prophylactic antibiotic on time

Denominator: All ASC admissions with a preoperative order for a prophylactic IV antibiotic for prevention of surgical site infection

Incentive: 1.50%

Quality Measure 2 (QM2): Falls Within the ASC (CMS ASC-2)

For Period 1 Attest that a process is in place to capture any ASC

admissions experiencing a fall within the confines of the ASC.

For Period 2 Report the number of ASC admissions experiencing a fall

within the confines of the ASC. Numerator: falls within the confines of the ASC in CY 2014 Denominator: all ASC admissions

Incentive: 1.00%

Quality Measure 3 (QM3): ASC Transfers to Hospital Upon Discharge (CMS ASC-4)

For Period 1 Attest that a process is in place to capture any ASC admission

(patients) who are transferred or admitted to a hospital upon discharge from the ASC.

For Period 2 Report ASC admissions who are transferred or admitted to a

hospital upon discharge from the ASC. Numerator: ASC admissions requiring a hospital transfer or

hospital admission upon discharge from the ASC. Denominator: all ASC admissions

Incentive: 1.50%

Quality Measure 4 (QM4): Surgical/Procedure Time Out

I attest that this ASC has a time-out protocol which requires a hard stop by all after prep and drape and prior to the start of the procedure. The protocol shall include the following:

a) identification of the patient by name

b) the procedure is stated

c) the marked incision site is visible

d) allergies are stated and share with the team and selected prophylaxis antibiotics ordered and given

e) The team is asked about any concerns before starting. Concerns are shared with the team and discussed to

mitigate risk.

Incentive: 0.50%

Form submission Paper forms can be faxed to Brent Matile at 785-290-

0734 or emailed to Brent.Matile@bcbsks.com

The QBRP form is available electronically

Any updates to contact information for Quality Managers should be emailed or indicated on the paper form

AMBULATORY SURGERY CENTERS

(ASC) WORKSHOP

Questions?