Successfully Employing On Target Reimbursement Knowledge, Advocacy Efforts, and Tools to Advance Your Business

Transcription

1 Successfully Employing On Target Reimbursement Knowledge, Advocacy Efforts, and Tools to Advance Your Business Deanne Birch, President HICAP, Inc., Consulting Services, Park City, UT Cynde Derryberry, Vice President, Reimbursement Advisory Services MCG Resources, Nashville, TN Rachel M. Ewell, BSW, Senior Consulting Manager Reimbursement Concepts, Weirton, WV Bill Noyes, Vice President of Health Information Policy NHIA, Alexandria, VA

2 CE Credit in Five Easy Steps! 1. Scan your badge as you enter each session. 2. Carry your Evaluation Packet to every session so you can add session evaluation forms to it. 3. Track your hours on the Statement of Session Attendance Form as you go. 4. At your last session, total the hours and sign both pages of your Statement of Session Attendance Form. Keep the PINK copy for your records. Put the YELLOW and WHITE copies in your Evaluation Packet. Make sure a completed Session Evaluation Form is in your Evaluation Packet for each session you attended. Missing one? Extras are in a file near Registration. 5. Complete the General Attendance Evaluation Form located in your Evaluation Packet and place it back in your envelope. Write your name on the outside of your Evaluation Packet envelope, seal it, and drop it in the box near Registration. Applying for Pharmacy CPE? If you have not yet registered for an NABP e Profile ID, please visit to do so before submitting your packet. You must enter your NABP e Profile ID in order to receive CE credit this year! 2

3 Disclosure Slide The speakers declares no conflicts of interest or financial interest in any service or product mentioned in this program. Clinical trials and off label/investigational uses will not be discussed during this presentation. 3

4 NHIA REIMBURSEMENT RESOURCES Presented by Bill Noyes NHIA VP of Health Information Policy 4

5 NHIA Reimbursement Resources Reimbursement Resource Centers Home Infusion Provider Search Portal Consultant Network NHIA Store Past Education and Conferences Materials NHIA Listserv INFUSION Magazine 5

6 NHIA Reimbursement Resources Newly developed member benefits INFUSION Express electronic newsletter Medicare Documentation, Appeals and Audits 6

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8 Reimbursement Resource Center Medicare Medicare Documentation, Appeals and Audits Medicaid Military Insurance Commercial Payers References Training Resources 8

9 Resource Centers, continued Competitive Bidding Resource Center Medicare Part D Resource Center HIEC Coalition Resource Center NHIA National Coding Standard (free to download) NHIA Quick Code Reference Model Contract Addenda? Member #: Patricia.Adair@nhia.org 9

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11 NHIA Consultant Network ndex.cfm 11

12 NHIA Publications NHIA Medicare Bill for Denial Commercial Claims Crosswalk Tool NHIA Medicare Bill for Denial Reference Tool Reimbursement Toolkit Bundle Medicare Home TPN Billing and Reimbursement Guidelines Home Infusion Therapy Module program 12

13 Education & Conferences Access past educational programs NHIA Annual Conference Library Search specific topics and acquire past conference sessions in audio files with PowerPoint presentation materials and handouts for a nominal processing fee 13

14 The NHIA LISTSERV Message Board Receive critical, timely information You must be a member and signed up to participate Rules: Include a subject line Include your contact information Do not discuss pricing or review products Complete rules available at 14

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16 NHIA Electronic Newsletter 16

17 Payer Advocacy and Relations (PAR) Committee BCBS MEDICARE BY PASS BILLING PRESENTED BY RACHEL EWELL 17

18 PAR Committee Mission: Analyze, educate and advocate on reimbursement coverage for provision of infusion and specialized pharmacy products and services to alternate site infusion patients through outreach to private and government payers. Maintain NHIA National Coding Standard. 18

19 PAR Committee Committee typically includes between members of the home infusion community Chair: Rachel Ewell, Reimbursement Concepts, Weirton WV Secretary: Julie K Runyon, Coram Specialty Infusion Services, Sacramento, CA Staff Liaison: Bill Noyes, NHIA, Alexandria VA 19

20 PAR Committee Committee consists of three separate teams that are typically working simultaneously on different projects Team One: Focus on commercial payer reimbursement and coverage issues Team Two: Maintenance of the NHIA National Coding Standard Team Three: Focus on reimbursement operations 20

21 PAR Committee Past accomplishments: Reimbursement Resource Page Medicare Billing for Denial Reference Tool Medicare Billing for Denial Commercial Claim Crosswalk Tool Annual review and updates for the NHIA National Coding Standard 21

22 PAR Committee Focus of the committee Determine projects based on the following criteria: National payer presence Issue affecting many different providers Area of greatest impact to the membership Any information which is related to pricing or is protected by HIPAA is not shared between organizations. 22

23 PAR Committee Recent areas of focus for the committee: Blue Cross ancillary filing guidelines Blue Cross Medicare for denial mandate Development of the Medicare Documentation, Appeals and Audits Resource Page 23

24 PAR Committee Team 2 Maintain NHIA National Coding Standard Address requests for additional codes that may be required Address coding issues reported by NHIA members Annual review of coding set 24

25 PAR Committee Team 1 BCBS Ancillary Filing Guidelines Implemented on October 16, 2012 Most BCBS plans excluding home infusion from these guidelines Little to no problems reported by membership on the NHIA LISTSERV NHIA members can Bill Noyes with any feedback or challenges 25

26 PAR Committee Team 1 Blue Cross Medicare Bypass Mandate Mandate from the Blue Cross Blue Shield Association Effective 10/13/2013 Allowed for Medicare bypass billing direct to Blue Cross plan for statutorily non covered services Requires use of GY modifier FEP plans are excluded from the mandate 26

27 PAR Committee Team 1 Blue Cross Medicare bypass concerns Inconsistent roll out between all Blue Cross plans Lack of clarification related to billing guidelines for home infusion RN services Significant number of reports of claim denials from many providers NHIA efforts to resolve these concerns 27

28 Medicare Documentation Appeals and Audits NHIA REIMBURSEMENT TOOL PRESENTED BY CYNDE DERRYBERRY 28

29 Introduction Page 29

30 Medicare Intake o Intake tips and links to all 4 DME MAC Provider service portals, Medicare secondary payor information and more Documentation o Dispensing order requirements o Detailed written order requirements o Proof of delivery requirements o Refill record requirements o Medical record documentation o Links to Dear Physician letters 30

31 Reopening information Redeterminations what to include A list of suggested additional documentation to include based on the therapy Appeal levels, filing limits and where to file Reopening & Appeal contact information for all 4 DME MACs 31

32 Defines the types of Medicare audits New Audits to watch for: o SMRC Supplemental Medical Review Contractor Evaluate medical records & related documents to determine if claims were billed in compliance o UPIC Unified Program Integrity Contractor In development stages. Merges some Medicare & Medicaid audits/investigations. UPICs would replace ZPICS and Medicaid Integrity Contractors & program safeguard contractors Links to sample audit letters Recovery Audit Contractor links and phone numbers 32

33 Round 1 Rebid o Enteral Nutrients, Equipment & Supplies Round 2 Rebid expansion o Enteral Nutrients, Equipment & Supplies Round 1 Recompete o Enteral Nutrients, Equipment and Supplies o External Infusion Pumps and Supplies CBA and Product Category links for each round Supplier locator link Fact Sheet links Competitive Bid FAQ link 33

34 NHIA Medicare Reimbursement Tool Link 34

35 NHIA MCAC Medicare Contractors Advisory Committee Presented by Deanne Birch NHIA MCAC Chair Keeping NHIA members informed of Medicare DMEPOS rules, regulations, compliance, and current audit environment

36 NHIA MCAC Members: Region A NHIC: Dana Walker Corporate Medicare Analyst, Walgreens Dana.walker@Walgreens.com Region B NGS: Mike Semon, Owner/President Caring Solutions semon1@bright.net Region C CGI: Susan Francis, National Admissions Director, Coram Susan.francis@coramhc.com Region D NAS: Deanne Birch (MCAC Chair), President HICAP, Inc. Consulting services deannebirch@hicapic.com Staff Liaison: Bill Noyes, NHIA, Alexandria VA Bill.noyes@nhia.org 36

37 Purpose of NHIA s MCAC Monthly NHIA MCAC call Review and compile questions/concerns specific to 4 jurisdictions Issues identified within individual companies, large organizations, industry providers, and state associations Policy and regulatory driven Universal issues Processing issues, system issues specific to jurisdiction Clarification of MLM and articles Consistency within jurisdictions Audit environment 37

38 The DME MAC Council s Function Volunteers from all segments of the DME industry are represented State and national associations Manufacturer supporters, individual supporters Communication vehicle between suppliers of DME and the Medicare contractors Direct channel to: DMEPOS Medical Director(s) and Provider Outreach Competitive Bid Implementation Contractor (CBIC) National Supplier Clearinghouse (NSC) CMS, PECOS 38

39 NHIA MCAC Successes Consolidated Interpretation by 4 MACs Detailed Written Order (DWO) requirements Correct use of GY vs. GA modifier Request for refill exclusion for enteral supply kits Documentation requirements all 4 DME MACs Date Span/Unit Clarification Expand from 5/7 to 10/14 for days to contact/ship to beneficiary 39

40 Today s Challenge PN Local Coverage Determination(LCD) & Policy Article CMR, CERT, ADR, ZPIC audits increase Auditors do not allow any leeway for beneficiaryspecific conditions Criteria sets verbatim ALJ appeals are favorable decisions Can policy changes avoid ALJ reviews? Would DME MACs support these changes? Undue burden to supplier cash flow risk for continued care 40

41 PN Decision Tree Archaic? Criteria Set A H were reviewed for current medical practice Was this acceptable current practice within our industry? Has science and technology evolved to include more beneficial tests or clinical paradigms? Could we support Our ASK for revisions? Non biased opinion industry experts ASPEN American Society of Parenteral and Enteral Nutrition Gastroenterologists NHIA MCAC reached out to supplier community Consensus on audit environment for PN Table with supporting evidence link/reference 41

42 Steps for PN LCD/Article Reconsideration Modifying the LCD does NOT conflict with the National Coverage Determination (NCD) Justification for challenge Published medical evidence to support challenge Evidence compiled from clinical trails or definitive studies Consensus of medical expert opinions recognized authorities in the field Could we provide alternative solutions? **SEE PN TABLE WITH CHALLENGE 42

43 NHIA MCAC Submits the Reconsideration Requests can be ed, faxed or in writing Clearly iden fied changes/omissions Jus fica on and medical evidence included DMDs must respond within 30 days from submission valid or invalid Response from DME MAC in writing if considered invalid If accepted as valid request, review takes days for DME MAC Medical Directors (DMDs) review and final consideration decision 43

44 Final Reconsideration Decision(s) Retire the policy No revision is required More restrictive/less restrictive May be claritive only Language added to clarify intent Revisions may be retroactive 44

45 Where are we today Challenge still pending Anticipate a positive response NHIA will communicate the final determination results Supplier education If at first you don t succeed. Repeat the process Experience is invaluable 45

46 Question and Answer Session 46