MANAGING MEDICARE

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MANAGING MEDICARE
Hawaii Medical Association July 29, 2008
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WE WILL DISCUSS

• Palmetto Transition (A B)
• Coverage Local National
• Documentation Principles
• How to Respond to Requests for Records
• PQRI Physician Quality Reporting Initiative
• QA

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PALMETTO 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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CUTOVER DATES
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WHATS 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.

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WHATS 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

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WHATS 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

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SPECIFIC ACTIONS REQUIRED

• EFT (Electronic Funds Transfer)
• EDI (Electronic Data Interchange)
• Early Boarding
• Claims and Appeals
• LCDs (Local Coverage Determination)
• Medical Review
• Provider Enrollment
• Other

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Electronic 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 [phone] or for e-mail
  EFT.Admin_at_PalmettoGBA.com

Aug. 15, 2008
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Electronic 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.

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EARLY 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

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CLAIMS 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

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Local 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.

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PROVIDER 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

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NATIONAL 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

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LOCAL 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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HOW 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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DOCUMENTATION

• 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

• BUT MUST BE LEGIBLE!

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DOC TRY TO PAINT A PICTURE
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DOCUMENTATION 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

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DEALING 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
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DEALING 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

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DEALING 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

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RESPONDING 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)

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MAC (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

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WHO 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

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PREPARE 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

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PREPARE 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

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PREPARE 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

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PREPARE FOR REVIEW DO NOT

• 6. DO NOT PANIC

• YOU HAVE VARIOUS LEGAL AND APPEAL RIGHTS---TO BE
  DISCUSSED
• MOST AUDITS EDUCATIONAL, NOT PUNITIVE, AND CAN BE
  RESOLVED

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PROBLEMS 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

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CERT 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

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RECOVERY 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

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PHYSICIAN QUALITY REPORTING INITIATIVE
Medicare Payment For Reporting Data
Continues in 2008 with up to 1.5 bonus
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ELIGIBLE 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

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2008 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

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ENROLLMENT

• 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.

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ENROLLMENT

• 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.

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PAYMENT 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.

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MORE HELP
WWW.AMA-ASSN.ORG/
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