WV BUREAU FOR MEDICAL SERVICES 2014 FALL PROVIDER WORKSHOPS

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1 WV BUREAU FOR MEDICAL SERVICES 2014 FALL PROVIDER WORKSHOPS Ed Dolly, DHHR Chief Information Officer Jon Cain, MIS Director of Integrated Systems Management Tanya Cyrus, RN, BMS Director of Policy Administrative Services Meghan Shears, Manager, WV CARES Nicole Becnel, Manager, BerryDunn October 27 - Martinsburg, WV October 28 Morgantown, WV October 29 Beckley, WV October 30 Charleston, WV

2 Medicaid Expansion As of September 20, 2014, approximately 148,611 have enrolled in Medicaid as a result of the expansion: 42% are between 19 and 34 years of age 37% are between 35 and 50 years of age 20% are between 51 and 64 years of age Less than 1% fall outside of these age ranges Approximately 54% of the new enrollees are female and 46% are male. Approximately 28% (513,481) of West Virginia s population is now covered by Medicaid. About 41% of these individuals are receiving services through Mountain Health Trust, the State s Managed Care Program. 1

3 Medicaid Expansion July 9, according to an article in the Charleston Daily Mail WV has seen the biggest drop in adult uninsured rate and has the most new Medicaid enrollees per capita than any other state that expanded Medicaid. WV now has the sixth-lowest uninsured rate in the country. As of April 30, 2014, expenditures for the expansion population were over $225 million. The three highest expenditure categories were: Outpatient Hospital Services $35.3 million Prescription Drugs $47.4 million Inpatient Hospital $38.6 million 2

4 Medically Frail Update Definition (42CFR ): Individual having a chronic substance use disorder, serious and complex medical condition, or a physical, behavioral, intellectual, or developmental disorder that requires additional care. A member can self-identify at any time during their eligibility period. Claims Reprocessing Update 3

5 Enhanced Primary Care Payments Provision under the Affordable Care Act (42 CFR (a)) Required that Medicaid reimburse eligible primary care providers at parity with Medicare rates in 2013 and 2014 for certain evaluation and management (E&M) and vaccination codes beginning with January 1, 2013 dates of service Enhanced payments expire on December 31, There will be a second review required of provider compliance during CY 2015, which will examine provider participation in CY

6 Hospital Based Presumptive Eligibility (HBPE) Currently, 37 hospitals participate in the HBPE program. Hospitals must meet two performance measures in order to continue participation in the program: 75% of the individuals who are determined presumptively eligible must complete a full Medicaid application and Of those who complete a full Medicaid application, 50% of them must be approved for Medicaid coverage. September 12, ,384 people have been determined presumptively eligible for Medicaid and 2,246 of them have become fully eligible for Medicaid. To keep informed about the progress of Medicaid expansion check the Medicaid expansion section at on the BMS website. 5

7 BMS Policy and Program Updates Drug Screening Policy Coverage changes delayed until 2015 CPT codes evaluated Take Me Home, WV Expanding network of Transition Navigator provider agencies ADW and TBI agencies For more information, go to program s website at Home and Community Based Waivers Renewal applications to be submitted to CMS December 2014 Quality Program CMS Adult Quality Measures Medical Record Requests Delayed - Pending CMS Response 6

8 BMS Health Homes Program WV Health Homes Launched July 1, 2014 Medicaid members with bipolar disease who have or are at risk of having Hepatitis B or C Must be receiving services from provider in Cabell, Kanawha, Mercer, Putnam, Raleigh or Wayne counties Health Home Providers must offer team approach to assist member with Managing medical conditions and medications Understanding medical tests and results Remembering medical appointments Other health care needs 7

9 BMS Health Homes Program Currently eight (8) BMS-approved Health Home Providers: Cabin Creek Health Systems FMRS Health Systems Marshall Health Prestera Center for Mental Health Process Strategies Southern Highlands Community Health Center WV Health Right WomenCare, Inc. (FamilyCare) Additional Health Home Program information is available on the Bureau for Medical Services website: or the APS Healthcare-WV website: Questions/concerns contact APS Healthcare at or

10 New Hospice Rule BMS will follow new Federal Rule, effective October 1, 2014 Final Rule Implements changes to coding guidelines for diagnosis reporting on Hospice claims Specifies that Alzheimer s, Dementia, and adult failure to thrive diagnoses cannot serve as the sole/primary determinant for Hospice services Located in August 22, 2014, Federal Register page 50498, item #4: Coding Guidelines for Hospice Claims Reporting APS has attached message to all Hospice submissions with a sole/primary diagnosis of Alzheimer s/dementia or adult failure to thrive indicating that an additional primary diagnosis for prior authorization of Hospice services is required. Some providers have begun submitting the additional information on their submissions and are now compliant with the new rule. 9

11 ICD-10 Compliance Date October 1, 2015 Changes to MMIS completed BMS Policy Remediation to be completed by January 1, 2015 Policies to be released using current process Draft policy posted to BMS website 30-day Public Comment Period Internal testing CMS Level I is 90% Completed External testing - to begin 1 st Quarter 2015 Provider Readiness Surveys will continue For more information: Molina s website under ICD-10 Transition link Molina Biweekly Webinars 10

12 ICD-10 Policy Remediation New Format for BMS Policy NOTE: This is a sample of the new policy format that BMS will be using when existing policy is remediated for ICD-10. This is not an actual policy CARDIAC REHABILITATION CARDIAC REHABILITATION POLICY METADATA Policy ID = Policy Author = Professional Services Policy Status = Pending Creation Date = 4/1/2013 BACKGROUND Initial Approval Date = 4/1/2013 Initial Effective Date = 4/1/2013 Last Revised Date = 10/14/2014 Revision Approval Date = TBD Next Review Date = Date. Cardiac rehabilitation is a comprehensive outpatient program of medical evaluation, prescribed exercise, cardiac risk factor modification, and education and counseling that is designed to restore members with heart disease to active, productive lives. The central component of cardiac rehabilitation is a prescribed regimen of physical exercises intended to improve functional work capacity and to improve the member s well-being. POLICY Cardiac rehabilitation programs are regulated exercise programs which are effective in the physiological and psychological rehabilitation of many members with cardiac conditions. The program consists of a series of supervised exercise sessions with continuous electrocardiograph monitoring. Cardiac rehabilitation can be performed in a specialized, freestanding physician-directed clinic or in an outpatient hospital department. Members who use tobacco must be referred to the tobacco cessation program. Please see , Tobacco Cessation Services. The goals of cardiac rehabilitation are to: Increase exercise tolerance Reduce symptoms of chest pain and shortness of breath Improve blood cholesterol levels Improve psychosocial well-being Reduce mortality These services are considered medically necessary for selected members when they are individually prescribed by a physician within a 24 week (6 month) window after any of the following: Acute myocardial infarction Other acute and subacute forms of ischemic heart disease Old myocardial infarction Angina pectoris Other forms of chronic ischemic heart disease Other diseases of endocardium (e.g. valve disorders, mitral, aortic, tricuspid, pulmonary, endocarditis) Cardiac dysrhythmias Heart Failure Cardiomegaly Functional disturbances following cardiac surgery Complications of transplanted organ, heart Organ or tissue replaced by other means; heart Organ or tissue replaced by other means; heart valve Other post procedural states; unspecified cardiac device Other post procedural states; automatic implantable cardiac defibrillator Other post procedural states; percutaneous transluminal coronary angioplasty status Personal history of other cardiorespiratory problems; exercise intolerance with pain: at rest, with less than ordinary activity, with ordinary activity FREQUENCY AND DURATION The medically necessary frequency and duration of cardiac rehabilitation is determined by the member s level of cardiac risk stratification. High risk members who have any one of the following are eligible for cardiac rehabilitation: Exercise test limited to less than or equal to 5 metabolic equivalents (METS) Marked exercise-induced ischemia, as indicated by either angina pain or 2 mm or more ST depression by ECG Severely depressed left ventricular function (ejection fraction less them 30%) Resting complex ventricular arrhythmia Ventricular arrhythmia appearing or increasing with exercise or occurring in the recovery phase of stress testing Decrease in systolic blood pressure of 15 mm HG or more with exercise Recent myocardial infarction (less than 6 months) which was complicated by serious ventricular arrhythmia, cardiogenic shock or congestive heart failure Survivor of sudden cardiac arrest PROGRAM DESCRIPTION FOR HIGH RISK MEMBERS The cardiac rehabilitation program is composed of: 36 sessions (e.g., 3x/week for 12 weeks) of supervised exercise. For members of the expansion population under the alternative benefits plan service limits include both rehabilitative and habilitative services. Please see Chapter 400, Member Eligibility for additional information. Educational program for risk factor/stress reduction Creation of an individual outpatient exercise program that can be self-monitored and maintained If no clinically significant arrhythmia is documented during the first three weeks of the program, the provider may have the member complete the remaining portion without telemetry monitoring. Following the initial evaluation, services provided in conjunction with a cardiac rehabilitation program may be considered reasonable for up to 36 sessions, usually 3 sessions per week, for a 12 week period. 11

13 Upcoming Changes New X modifiers NCCI Edits To be used in place of Modifer-59, if appropriate Date of Service MUEs Currently in Medicare NCCI edits A date-of-service MUE sums the submitted units of service for a given HCPCS / CPT code on all lines of the presenting claim and all paid claim lines on claims in history billed by the same provider for the same member for the same DOS. CMS current plan is to phase in DOS MUEs over several quarters Target date to begin implementation is after April 1,

14 Ordering/Referring/Prescribing (ORP) Providers Ordering/Referring/Prescribing (ORP) Providers Do not bill WV Medicaid directly If ORP not enrolled in WV Medicaid, then servicing provider claim will not be paid Initially, edits will be implemented with warning message and claim will not deny After short period, edit will be set to deny claim July 1, both ORP edits implemented as warning September edit revised to look only for required ORP information December edit for ORP information will be fully implemented to deny AND edit for ORP enrollment status will be implemented as warning 13

15 Provider Revalidation Payholds & Termination All Providers must be revalidated by February 15, 2015 Notices for last phase (Phase 10) mailed last week Phases 1 through 4 on payhold WV Medicaid participation will be terminated 11/14/14 Phases 5 through 7 to be placed on payhold in November Provider names, NPI and address will be posted on Molina and BMS website for 2 weeks After 2 weeks, payhold for 120 days After 120 days on payhold Participation with WV Medicaid will be terminated Partial Revalidation for Groups Applies when outreach efforts to obtain missing information on rendering and/or ordering/referring/prescribing providers are exhausted Providers with complete information will be validated Providers with missing information will have group affiliation terminated Group will receive notification 14

16 BMS Program Integrity Several reviews: Payment Error Rate Measurement (PERM) 2013 Completed but final error rate for WV not released yet Only 2 of 284 providers reviewed had error in documentation resulting in recoupment Medicaid Integrity Group (MIG) Audits Draft reports from onsite hospice review being developed by CMS Recovery Audit Contractor (RAC) Electronic Health Record (EHR) Audit Questionnaire to Select Providers, followed by Reports to Document Compliance with Meaningful Use Requirements Enhanced Payments to Primary Care Annual audit underway Medicare-Medicaid Data Match 15

17 Reminders Claims, coding, etc. Assistant surgeon or assistant at surgery Operative record required for certain surgical procedures Procedures identified on BMS RBRVS Fee Schedule with D under ASST SURG Column Modifier AS for Advanced Practice RN or Physician Assistant Modifiers -80, -81 and -82 for assistant surgeon DME Claims Cost invoice required for certain DME and for not otherwise specified HCPCS Codes, such as L5999 BMS DME Fee schedules for 2012, 2013 and 2014 at Equipment-(DME)-Fee-Schedule.aspx 16

18 Choosing Wisely in WV National Initiative of American Board of Internal Medicine Foundation Goal is to promote patients and health care providers working together and having meaningful discussions on the appropriate and wise use of health care to improve the quality of health care and contain cost. Over 60 physician specialty groups and health care organizations involved Each identified at least five (5) tests, procedures or drugs in their area of expertise that have questionable value. 250 low-value procedures have been identified, such as: Using antibiotics for a viral infection Imaging for uncomplicated low-back pain Thirty-one two-page summaries available for providers to print and give to patients on these low-value services, plus other helpful discussion guides for consumers To print summaries/guides go to 17

19 WV CARES WV Clearance for Access: Registry & Employment Screening (WV CARES) Provision under Affordable Care Act of 2010 All direct access employees are required to undergo a comprehensive fingerprint-based background check. Required Registry Checks Criminal Background Checks Legislation to be introduced in the 2015 Legislative Session Will authorize the WV CARES staff to receive criminal background check results. WV CARES staff will perform fitness determination for prospective new long-term care employees. 18

20 WV CARES WV CARES System Web-based system to be implemented in 2 phases Phase 1 - Allows employers to conduct required registry checks Current employee upload function Conducts monthly required registry rechecks Initial provider pilot testing November 2014 Phase-In Process for all long term care providers December 2014 Phase 2 Fitness determination based on Fingerprint-based Background Check Dependent on Passage of Legislation 19