2016 Blue's Tour. Presented by Blue Cross and Blue Shield of Kansas

Transcription

1 2016 Blue's Tour Presented by Blue Cross and Blue Shield of Kansas

2 Today's Presenters Sally Stevens Provider Consultant, Southern Kansas Cindy Garrison Provider Consultant, Northern Kansas Marie Burdiek EDI Account Representative 2

3 Today's Agenda Top Denials General Billing IV Therapy Wound Therapy 2017 Policies and Procedures Quality Based Reimbursement Program (QBRP) MAP'd Codes EDI/ASK Updates 3

4 Top Denials 4

5 Top Denials ARC 97 Corrected Claims $406,121, ARC 18 - Exact duplicate claim/service $170,523,

6 Top Denials ARC A1 Additional information is required to make a benefit determination $144,044, ARC 96 This service is not listed as a covered service in the patient's contract $38,902,

7 Top Denials ARC 23 The Medicare payment is greater than or equal to the maximum allowable payment under the patient's contract $38,232, ARC 27 - Expenses incurred after coverage terminated $30,484,

8 Top Denials ARC 32 The patient was not eligible for benefits at the time the service was performed $29,219, ARC 31 - The claim was denied as the patient cannot be identified as our member. $20,767,

9 Top Denials ARC A1/M81 The claim needs to be coded to the highest level of specificity - laterality $19,174,

10 Top Denials Reducing claim denials is a win for everyone! Use Availity Improve Administrative Expenses Better Payment Turnaround 10

11 General Billing 11

12 General Billing No Part B Medicare Medicare Lifetime Reserve Days Exhausted Telemedicine ACA Preventive Services Cancelled Surgeries and Attempted Surgeries Take Home Drugs Discarded Drugs Swing Bed Limited Patient Waiver 12

13 General Billing No Part B Medicare If the member has no Part B Medicare, then benefits are carved out as if the member had Part B Medicare. Medigap policies pay only the deductible and coinsurance not paid by Medicare. The patient is responsible for what Part B Medicare would have paid. 13

14 General Billing Medicare Lifetime Reserved Days The following information is needed to process a claim when the Medicare lifetime reserve days have been exhausted: Report BCBSKS as the primary payer The inpatient claim should show a "from" service date as the first day after Medicare benefits are exhausted Indicate in the Remarks (Form Locator 80) field the date that Medicare benefits were exhausted Medicare Remittance (MSN) Copy of the UB-04 Medicare Inquiry Screen (FISS system) a copy of the Medicare MSN showing how the Part B services were considered (if applicable) If the patient does not have Part B Medicare, then this information needs to be indicated in the Remarks field. If a private room is to be covered in full, then provide the medical reason for the private room as reflected in the physician's order. 14

15 General Billing Telemedicine BCBSKS will provide reimbursement for originating site telemedicine services that meet established guidelines. Billing guidelines are: Service must involve a physician's specialty that is not otherwise available in the community. This includes services provided by Mid-level Practitioner. Telemedicine services for primary care are not covered nor should they be billed to BCBSKS. Originating site telemedicine services meeting these guidelines should be billed to BCBSKS: Use the UB-04 billing format Telemedicine services are billable only on outpatient claims. Revenue code (either of the following): telemedicine general classification 2. The revenue code that identifies where the services were performed (i.e. 0450, 0510, 0761). HCPCS Q3014, telehealth originating site facility fee (This HCPCS code must be used regardless of what revenue code is used). Additional services provided during the telemedicine encounter (e.g. laboratory, x- rays, etc.) are separately billable. Facilities cannot bill an originating site and destination site with either of the following conditions: 1. under the same Tax ID 2. on the same UB-04 bill 15

16 General Billing Preventive Services Preventive diagnosis in the primary location on the UB- 04 claim form If not possible or not correct coding, then it is OK to split the claim. Below is a link to the list of preventive services covered at no cost share ions/professional/manuals/pdf/preventive-services-guide.pdf 16

17 General Billing Preventive Services - Claim Example # 1 17

18 General Billing Preventive Services - Claim Example # 2 18

19 General Billing Cancelled Surgery and Attempted Surgery Inpatient claims: Attempted surgery should be billed with revenue code 0229 and ICD-10-CM diagnosis codes Z53.01, Z53.09, Z53.1, Z53.20, Z53.21, Z53.29, Z53.8 or Z53.9. Hospitals must convert revenue code 0360 (operating room) to revenue code 0229 to avoid edits requiring ICD-10-PCS procedure codes. (When revenue code 0360 is on an inpatient claim, an ICD-10-PCS procedure code is required). Outpatient claims should reflect the appropriate revenue code where the procedure occurred, 045X, 0360, 0761, 0760 etc., and the CPT code of the intended procedure. 19

20 General Billing Cancelled Surgery and Attempted Surgery 20

21 General Billing Take Home Drugs BCBSKS' intent is to allow take home drugs under Revenue Code 250 provided the quantity given is not in lieu of providing a prescription for the drug. If revenue code 0253 is submitted on a UB-04, the charge may be denied as the member's responsibility. 21

22 General Billing Discarded Drugs Bill the units for the entire vial. Do not split the lines for the amount used and the amount discarded. Documentation of the drug amounts used and discarded must be in the medical record. 22

23 General Billing Swing Bed Patient is discharged from acute to skilled care Documentation should clearly reflected the change from acute to swing bed in the medical record. If it is a direct admission to swing bed/skilled care, this must be reflected in the medical record as well. Swing bed/skilled admissions must be prior approved by the BCBSKS medical review staff. 23

24 General Billing Billing for Swing Bed or SNF Provider submits 2 separate claims: If the patient has skilled benefits and the skilled admission is prior approved, the provider will submit the charges for the entire stay (room and board pus all ancillaries) using your skilled provider number. Claim #1: Provider Number Type of Bill 111 Acute Number Date of Service 02/01/16 02/08/16 # of covered days 7 Include in charge R&B plus ancillaries Claim #2: Provider Number Skilled Number Type of Bill 18X for swing bed; 2X for SNF Date of Service 02/08/16 02/16/16 # of covered days 8 Include in charge R&B plus ancillaries 24

25 General Billing Billing for Swing Bed or SNF Provider submits 3 separate claims: If the patient does not have skilled benefits or the stay is not approved, the provider must give the patient an LPW prior to the service in order to bill them for the noncovered room and board charges. Claim #1: Provider Number Acute Number Type of Bill 111 Date of Service 02/01/16 02/08/16 # of covered days 7 Include in charge R&B plus ancillaries 25

26 General Billing Billing for Swing Bed or SNF Provider submits 3 separate claims (continued): Claim #2: Provider Number Type of Bill Claim #3: Skilled Number 18X for swing bed; 2X for SNF Date of Service 02/08/16 02/16/16 # of Days 8 non-covered Include in charge R&B only Provider Number Acute Number Type of Bill 131 Date of Service 02/08/16 02/16/16 # of Days Not applicable Include in charge Ancillary only 26

27 General Billing Limited Patient Waiver (LPW) Some providers have their own waivers and they may or may not meet BCBSKS requirements. If providers want to use their own waiver form, then BCBSKS recommends that you have your BCBSKS Institutional Provider Consultant review your waiver form to confirm that it includes everything that is included on the BCBSKS Limited Patient Waiver (LPW). Submit an electronic claim with a GA modifier appended to the CPT/HCPCS code. The waiver is retained in the patient's file. By obtaining a signed LPW, the not medically necessary, experimental or investigational charges are denied as the patient s responsibility 27

28 IV Therapy 28

29 IV Therapy IV Therapy and Injection Billing When billing for the administration of drugs: The initial code should be selected using a hierarchy whereby chemotherapy services are primary to therapeutic, prophylactic, and diagnostic services which are primary to hydration services. Infusions are primary to pushes, which are primary to injections. This hierarchy does not apply to physician reporting. 29

30 IV Therapy Not Separately Reportable Use of local anesthesia IV start Access to indwelling IV, subcutaneous catheter or port Flush at conclusion of infusion Standard tubing, syringes and supplies If there are orders to hydrate prior to chemotherapy administration, hydration may be reported separately as long as it is not concurrent to chemotherapy. 30

31 IV Therapy Multiple Drug Administrations Only one initial is billed unless there are two separate sites Billing hierarchy: o Primary by drug type: 1. Chemotherapy services 2. Therapeutic, diagnostic, prophylactic services 3. Hydration o Secondary by the administration of the drug: 1 - Infusion 2 - Push 3 - Injection 31

32 IV Therapy Additional Hours 1st hour minutes 2nd hour minutes 3rd hour minutes 32

33 IV Therapy Documenting Drug Administration Document the start and end time for each IV. Name of the drug Strength of the drug Method of administration Location on the body Medical necessity If documentation is not complete: The provider can only bill for administering the IV push. If IV hydration is provided and documentation does not support at least 31 minutes, no service may be reported. If not accurately documented, then an administration charge cannot be billed. 33

34 IV Therapy Billing for Hydration Use CPT codes A minimum of 31 minutes OK to bill hydration separately if done prior to the primary substance Hydration cannot be reported separately when performed concurrently with IV 34

35 IV Therapy Claim Example #1 Is this billed correctly? 35

36 IV Therapy Claim Example #2 Is this billed correctly? 36

37 IV Therapy Claim Example #3 Is this billed correctly? 37

38 Wound Care 38

39 Wound Care Outpatient Wound Care E & M codes o Facilities may establish wound care E&M codes and criteria for use Bill E&M assessment when no debridement services or wound care provided Bill E&M when significant, separately identifiable E&M service provided in the same encounter Should not bill E&M with debridement (CPT ) or wound care ( ) Nonselective wound care (97602) is considered included in payment for selective wound care (97597/97598) and negative pressure wound therapy (97605/97606) if both services provided in same anatomic site during single encounter 39

40 Wound Care Outpatient Wound Care Wound Care provided in physical therapy (PT) o Use Revenue Code 0421 Wound Care for scheduled outpatients in a treatment room o Use Revenue Code 0761 Facilities with wound care clinic only o Use Revenue Code 051X when physician is involved in clinic area o Use Revenue Code 0760 or 0761 when physician not involved in clinic area Exception: Out of town provider use Revenue Code 0510 for 1 st visit and 0761 for subsequent visits, unless there is a new wound and is supported in documentation 40

41 Wound Care Outpatient Wound Care The following is an example of wound care criteria that could be used in establishing documentation and billing guidelines. o CPT codes and are subject to MAP reimbursement. Surgical debridement codes that fall into the debridement section of CPT are also MAP'd. o Before a facility determines to bill wound care services as a series account Consider if CPT codes on the claim are claim level or line level codes If claim level, it may be necessary to file each date of service separately to assure proper reimbursement on these accounts. 41

42 Wound Care Billing Example 42

43 Wound Care Corrected Billing 43

44 Wound Care Outpatient Wound Care: Before a facility determines to bill wound care services as a series account: o Consider if the CPT codes on the claim are claim level or line level codes o If claim level, then it may be necessary to file each date of service separately to assure proper reimbursement on these accounts. 44

45 Wound Care Outpatient Wound Care Example: Since is a Claim level MAP'd code the claim processed at MAP allowance for one date of service only. Facility needed to file each date of service separately to assure proper reimbursement. What else needs corrected on this claim when submitting for separate dates of service for this patient? 45

46 Wound Care Outpatient Wound Care: Corrected Billing 46

47 Wound Care Additional information regarding Wound Care Inpatient Wound Care o Charges for non routine debridement and wound care provided by a physician or nurse practitioner at the bedside should be billed on a CMS 1500 claim form. There would be no facility charge billable for the care. BCBSKS has medical policies related to Wound Care o Policy title: Vacuum Assisted Wound Closure (VAC) Predetermination is strongly encouraged BCBSKS has a medical policy related to Hyperbaric Oxygen Therapy (HBOT) o Policy title: Hyperbaric Oxygen Therapy (HBOT) Review policy for medical necessity or experimental/investigational information Predetermination 47

48 2017 Policies & Procedures Update 48

49 2017 Policies & Procedures The following is a summary of the changes to the BCBSKS Institutional Policies and Procedures for Deleted wording is noted in brackets [italicized]. New verbiage is identified in bold. 49

50 2017 P&P - SECTION II. GENERAL CONDITIONS Limited Provider Network: Language was clarified in this provision if BCBSKS were to consider a narrow network for any geographical area of the State. The overall business climate or some large employer groups may require a benefit plan that provides for a level of reimbursement lower than that available under the ordinary CAP MAP from BCBSKS. To meet these market needs, BCBSKS may, at its sole discretion, offer an amendment to the Agreement, or an additional agreement, providing for such lower level of reimbursement. If a Contracting Provider is offered such amendment or agreement and declines the offer, that [Such amendment or additional Agreement will be offered to all Contracting Providers of Similar licensure, at least within the same geographical area if not statewide. If a provider fails to accept such amendment or Agreement, a] Contracting Provider shall nevertheless accept as payment in full, from BCBSKS and any [a] member covered under such a program, the amounts established as the MAP under the CAP Agreement. Such provider may collect from such member the deductible, copayments, and additional copayment, which apply when such person obtains services from providers who have not signed such amendment or additional agreement. 50

51 2017 P&P - SECTION II. GENERAL CONDITIONS Credentialing: Information pertaining to Professional Relations was removed so that this section reflects only the credentialing process for institutional facilities. In addition, information stated in the provider Agreement or other contract documentation was removed. BCBSKS follows URAC guidelines for credentialing [and has a program that consists of an initial full review of the applicable provider's credentialing application. Contracting Providers, including] acute inpatient facilities, freestanding surgical centers and home health agencies. [, are re-credentialed at a minimum of every 36 months. Monitoring of all Contracting Providers for continual compliance with established criteria will occur as needed and at least monthly.] The Credentialing program consists of an initial full review of the provider's Credentialing application. 51

52 2017 P&P - SECTION II. GENERAL CONDITIONS Credentialing Criteria: 1. Current and unrestricted Kansas license. 2. Liability insurance as required by the state. 3. Hospitals must be Medicare certified and must maintain Medicare certification. If accredited by The Joint Commission, hospitals must provide evidence of such. 4. Freestanding surgical centers must be Medicare certified and must maintain Medicare certification. If accredited by the Accreditation Association for Ambulatory Health Care (AAAHC), freestanding surgical centers must provide evidence of such. 5. Home health agencies must be Medicare certified and must maintain Medicare certification. If accredited, must provide the organization name and evidence of such accreditation. 6. No Medicare/Medicaid sanctions. 52

53 2017 P&P - SECTION II. GENERAL CONDITIONS Credentialing Criteria: Initial Application: Acute inpatient facilities, freestanding surgical centers and home health agencies that do not meet all applicable Credentialing Criteria are ineligible to be considered by the BCBSKS Credentials Committee and are ineligible for participation in the BCBSKS provider network. If the application is denied, the provider may reapply by providing corrected or updated information. If BCBSKS' decision is based on erroneous information, see the Appeals section. Monitoring and Recredentialing: Following the initial Credentialing approval, BCBSKS monitors Contracting Providers for continual compliance with Credentialing Criteria and recredentials Contracting Providers at a minimum of every 36 months. If at any time the Contracting Provider fails to meet any of the Credentialing Criteria, the Contracting Provider's BCBSKS network contract will be subject to the Termination section of the Agreement. When the Credentialing Criteria are again met, the provider may submit a new Credentialing application for consideration. Appeals: If BCBSKS' decision to reject a provider's Credentialing application or continued participation in the provider network is based on erroneous information, the provider may submit a First Level Appeal with supporting documentation for reconsideration. 53

54 2017 P&P - SECTION II. GENERAL CONDITIONS Credentialing Criteria: [If applicants do not meet all applicable credentialing criteria, the applicant is ineligible to be considered by the Corporate Credentials Committee (Committee). The reconsideration and appeal process described below will not be available to such provider. If the Contracting Provider ceases to comply with criteria or has an adverse action taken by the licensing board, credentialing staff will review such adverse action or failure to comply and report to the Committee. Credentialing criteria are available on the BCBSKS Website at If a Contracting Provider is currently subject to any sanctions imposed by any CMS program or by the Federal Employee Health Benefit Program, including but not limited to being excluded, suspended, or otherwise ineligible to participate in any state or federal healthcare program, the reconsideration and appeal process described below will not be available to such provider. 54

55 2017 P&P - SECTION II. GENERAL CONDITIONS Credentialing Criteria: NOTE: If a Contracting Provider's license is suspended or revoked, that provider's BCBSKS network contract is canceled by operation of the terms of the contract. When credentialing staff members become aware of such suspension or revocation they shall notify the Committee, but the Committee is not required to take any specific action since the provider's contract will terminate of its own accord. Credentialing staff shall also notify the institutional relations operations division of such suspension or revocation to ensure that appropriate administrative action is taken. A. Initial/Recredentialing Applicant: The BCBSKS Corporate Credentials Committee (Committee) reviews each provider s credentialing file in accordance with BCBSKS criteria, as well as BCBSKS and URAC standards. If a provider does not meet these standards or there is evidence the facility does not adhere to BCBSKS policies and procedures, the Committee may deny or restrict participation in a BCBSKS network. If the facility disagrees with the denial or restriction and has additional information, they may request reconsideration by the Committee. B. Reconsideration: If the Committee denies or restricts a provider s participation status, the Committee will allow the provider to submit additional supporting documentation for reconsideration. If additional documentation fails to meet the BCBSKS criteria, the denial or restriction is upheld by the Committee.] 55

56 2017 P&P - SECTION II. GENERAL CONDITIONS Credentialing Criteria: First-Level Appeal Panel The provider must send in the appeal within 30 calendar days of the date BCBSKS sends notice of the denial or restriction to the provider. All appealed disputes are referred to a First-Level Appeal Panel consisting of at least three qualified individuals of which at least one must be a participating provider who is not otherwise involved in network management and who is a peer of the participating provider that filed the dispute. BCBSKS will have sixty days from receipt of the First-Level Appeal request to organize a First-Level Appeal Panel. BCBSKS must communicate a decision to the provider within ten calendar days following the First-Level Appeal Panel meeting. Second-Level Appeal Panel If the First-Level Appeal Panel upholds the denial or restriction, the provider may submit a written request for a Second-Level Appeal. [This provides consideration to a Second-Level Appeal Panel consisting of at least three individuals] The request must be submitted within 30 calendar days of receipt of the First-Level Appeal determination letter. The Second-Level Appeal Panel will consist of at least three individuals as defined in the First-Level Appeal Panel and that were not involved with the First-Level Appeal Panel. BCBSKS will have 60 days from receipt of the Second-Level Appeal request to organize a Second-Level Appeal Panel. BCBSKS must communicate a decision to the provider within ten calendar days following the Second-Level Appeal Panel meeting. 56

57 2017 P&P - SECTION II. GENERAL CONDITIONS Audit Requirements: Language was added to clarify the 15 month limitation as it relates to initiation of an audit. Onsite Audits: BCBSKS may conduct on-site audits during the Contracting Provider s regular business hours. These audits may consist of verification of medical necessity of services, MS-DRG assignment criteria, abstract verification and financial and/or claims information. In order to complete such audits, it may be necessary to review records of other-than-bcbsks members. If such is the case, the Contracting Provider may take appropriate measures to protect the privacy of the individual whose patient record is being reviewed. Post-Pay Audits: BCBSKS conducts periodic post-payment audits of patient records and adjudicated claims to verify congruence with BCBSKS medical and payment policies, including medical necessity and established standards of care. Post-payment audits are performed after the service(s) is billed to BCBSKS and payment(s) has been received by the provider. Post-payment audits can range from a basic audit to determine if the level of care is accurately billed, to a complete audit which thoroughly examines all aspects of the medical record. BCBSKS cannot go back further than 15 months following the date of claim adjudication to initiate an audit. Post-payment audits being performed to resolve an allegation of fraud or abuse are not subject to the 15 month limitation. BCBSKS provides education through policy memos, medical policy, newsletters, workshops, direct correspondence, and onsite visits. In audits where findings conclude that education did not occur, BCBSKS will then provide education. If education does not resolve subsequent Medical Necessity findings, BCBSKS will seek refunds for those paid claims. If claims include billing for services not documented, then BCBSKS will request refunds and may refer the case for further investigation. 57

58 2017 P&P - SECTION II. GENERAL CONDITIONS Notification: Language was added to ensure BCBSKS maintains accurate data files on our Contracting Providers. BCBSKS will include the Contracting Provider's name on its Contracting Provider listing made available to members. Such listings may be made available to group leaders for reference by employees in groups, and may be made available through a website or through other mechanisms, and any such mechanism shall be deemed to meet the obligations set forth in the Agreement requiring BCBSKS to provide an annual notification of Contracting Providers to its members. Providers must notify BCBSKS of changes to provider data, including but not limited to EIN, NPI, legal name or address within ten business days. 58

59 2017 P&P - SECTION II. GENERAL CONDITIONS Acknowledgement of Balanced Budget Act (BBA) of 1997: Redundant language was removed for consistency among policy documents and to add clarity. This contract will terminate if the provider is excluded from participation in any federal health care program, as defined under 42 U.S.C. 1320a-7b(f) of the BBA. The Contracting Provider agrees to inform BCBSKS of the commencement of any proposed exclusion within seven business days of notice of the exclusion [and to inform BCBSKS immediately upon any such exclusion] becoming effective with respect to provider. 59

60 2017 P & P SECTION IV. REQUESTS FOR INFORMATION Abstract Information: This section was removed to reflect the decision to discontinue the requirement that hospitals submit abstracts for inpatient admissions to BCBSKS. Hospitals may continue to submit inpatient claim data to the Kansas Hospital Association through the Hospital Industry Data Institute (HIDI). [Kansas Health Data System, a department of BCBSKS, reviews abstract information to verify the MS-DRG assignment for inpatient claims submitted. Abstract elements reviewed include Severity/Intensity elements, Hospital Code Number, Medical Record Number, Patient's Account Number, Abstract Record Counter, Admission Class, Admission Hour, Admission Date, Principal Procedure Date, Discharge Date, Birth Date, Gender, Race, Point of Origin, Primary Payment Status, Discharge Hour, Transfer Destination, Special Units, Primary Service, Attending Physician's Number, Principal Surgeon's Number, Other Physician or Surgeon's Number, Accommodation on Admission and Discharge, Member ID Number, Primary Diagnosis, Admitting Diagnosis, up to 24 Secondary Diagnoses, Present on Admission (POA) Indicator, Diagnosis Dates, applicable External Cause of Injury (ECI) codes and their associated POA values, Principal Procedure, up to 24 Secondary Procedures with Surgeons and Dates, Zip Code, Patient Last Name, Patient First Name, Social Security, Number, Patient Status, Batch Year, Batch Month, Batch Number, Hemoglobin Low, and Hemoglobin Drop. Abstract information is to be transmitted to BCBSKS as needed or on a monthly basis (45 days from the end of each month) on files meeting the above specifications. Failure to submit medical abstract information within the time frame specified above shall result in the Contracting Provider being placed on prepayment utilization review. Severity/Intensity elements are those clinical data elements deemed necessary to augment the utilization review process. Severity/Intensity elements may change from time to time and will be collected in 36 one-digit abstract fields and transmitted as part of the abstract file. Additional file layout specifications are available for those hospitals requiring such information for their particular abstracting service at 60

61 2017 P & P SECTION IV. REQUESTS FOR INFORMATION Medical Records: Language was added to clarify the types of records that must be submitted upon request. The Contracting Provider must provide or make available complete medical records at no charge in a format which can be utilized by BCBSKS or an entity acting on behalf of BCBSKS. When medical records are requested to substantiate a claim for services, each patient record must contain adequate documentation to justify the course of treatment provided and reflect the patient's status and progress during the course of treatment. Medical records shall include all versions, whether handwritten or Electronic Medical Record (EMR) generated. Any applicable audit log documentation must be provided if requested by BCBSKS. BCBSKS supports the efforts of the Kansas Health Information Exchange, Inc. (KHIE) to establish health information exchange in Kansas. When a provider has connected to a KHIE-approved Health Information Organization (HIO), BCBSKS may require electronic submission when requesting clinical information. 61

62 2017 P & P SECTION V. APPEALS DISPUTES / APPEALS / ARBITRATION: This section was re-named to include disputes and appeals to better reflect the content of the section. Provider Administrative Disputes: A paragraph was moved to the beginning of the section for clarity. There was no change to the language in this section. Right of Appeal: Paragraphs were moved from the 'Provider Appeals for Experimental/Investigational or Not Medically Necessary Services' provision to the end of this provision for clarity. There was no change in language in this section. Right of Delegation: This provision was added to cover delegated vendors (i.e. New Directions) for appeals and audits. BCBSKS has the right to delegate any and all aspects of the appeal and audit processes to any qualified entity. 62

63 2017 P & P SECTION V. APPEALS Member Appeals: This provision was re-worded for clarity. When claims are denied as member responsibility, the Contracting Provider may assist the member with an appeal as the member's authorized representative. In such circumstances, the Contracting Provider must follow the guidelines established by the Employee Retirement Income Security Act of 1974 (ERISA) and/or the benefit plan documents applicable to the member. The provider appeal process described herein does not apply. [In situations where services are denied as non-covered and where the member is determined to be financially responsible for the claim and acknowledges responsibility, which includes an approximate amount of the charge, the member shall have appeal rights, which are governed by BCBSKS documents applicable to the member. In such circumstances, the Contracting Provider may appeal as the member authorized representative if the member so request in writing, and must follow the guidelines governed by Employee Retirement Income Security Act of 1974 (ERISA) and/or the benefit plan documents applicable to the member.] 63

64 2017 P & P SECTION V. APPEALS Arbitration: Language was added to clarify and confirm that arbitration is not a part of the appeals process. Any dispute relating to or arising out of the Agreement and/or BCBSKS Policies and Procedures applicable to such Agreement, and that is not or cannot be resolved according to the appeal procedures of these policies, shall be resolved by binding arbitration. Arbitration is the process of resolving disputes between BCBSKS and a Contracting Provider separate and distinct from any appeal procedures described in these Policies and Procedures. Once such appeal procedures are completed, BCBSKS may begin recoupment measures of any refunds due from the audited provider, and initiation of the arbitration process will not delay or otherwise impact the recoupment process set out therein. Such arbitration shall be conducted in accordance with the Healthcare Payor Arbitration Rules of the American Arbitration Association to comply with rules specific to third-party payors. [Arbitration shall be initiated by either party by making a written demand for arbitration upon the other party.] Arbitration shall be initiated by either party filing a written demand for arbitration with American Arbitration Association and payment of all requisite fees. Initiation of the arbitration process will not delay or otherwise impact BCBSKS' determination of refunds for overpayments owed from the provider to BCBSKS. 64

65 2017 P & P SECTION V. APPEALS Transfers or Referrals: This provision was re-named 'Non- Contracting Providers,' and a sentence was removed for clarity.* When necessary, the Contracting Provider agrees to refer and/or transfer both BCBSKS and Blue Plan members to BCBSKS contracting providers. When a Contracting Provider uses a non-contracting provider (either in or out of state) to perform a portion of a service [(e.g., professional component, technical component or other technology utilized in the performance of a service), the Contracting Provider must bill BCBSKS for all services.] and if the non-contracting provider bills the member or BCBSKS, the Contracting Provider will be required to hold the member harmless and/or indemnify the member for any charges incurred by the non-contracting provider. *This language was also clarified in the Payment Attachment 65

66 2017 P & P SECTION V. APPEALS Never Events: This provision was combined with Hospital Acquired Conditions. Medicare has redefined what constitutes a never event or a Hospital Acquired Condition (HAC). For this reason, we have aligned this section with CMS. The [never] events listed below are not billable to BCBSKS. When one of these events occurs, no payment will be made for the error or correction of the error. The patient shall be held harmless and may not be billed for any adverse event. The provider shall refund payments made [for an adverse event] if a claim is filed in error. If the surgical error is corrected in a different facility, payment for that procedure will be made. 1. Surgery performed on the wrong body part 2. Surgery performed on the wrong patient 3. Wrong surgical procedure on a patient 4. Retention of foreign object in surgical patient In cases where a foreign object is mistakenly left during a surgical procedure the following applies: a) If the object is removed in the same facility, then no payment for the correcting surgery will be made and the patient will be held harmless. b) If the object is removed in a different facility, that facility shall receive payment. 5. Blood Incompatibility a) BCBSKS shall not reimburse and the patient shall be held harmless when incompatible blood is administered. The provider shall refund any payment when becoming aware of this event. b) When compatible blood is administered, but the patient suffers an unforeseeable reaction to either the administration of the blood or to the blood itself, this is not considered to be an error. The Provider shall cooperate with BCBSKS in initiatives designed to help prevent or reduce such events and ensure that appropriate payments are made with no additional charges incurred for any condition which was not present on admission. 66

67 2017 P & P SECTION V. APPEALS Outpatient Services Prior to an Inpatient Stay: Language was clarified to reflect how claims are handled when BCBSKS is secondary to Medicare.* Charges for services provided to an outpatient who was admitted as an inpatient before midnight of the following day are considered to be included in the MS-DRG for the inpatient stay and must be billed to BCBSKS as part of the inpatient claim. This applies only to outpatient services performed at the same facility where the patient is subsequently admitted. Medicare secondary claims to BCBSKS are exempt from this provision. *This language was also clarified in the Payment Attachment 67

68 2017 P & P SECTION V. APPEALS Outpatient Claim Level Reimbursement: Language was removed as the outpatient services are not specific to emergency department services. Payment for outpatient claim level procedures will be reimbursed at an allinclusive rate based on the MAP for the procedure billed. When multiple procedures are performed during the same encounter, the all-inclusive rate is based on the highest MAP'd claim level code. All services provided during an outpatient encounter will be reimbursed at the aforementioned all-inclusive rate and must be billed on the same claim. Outpatient services [provided in the emergency department] resulting from an accidental injury that occurred on the same day will be reimbursed at the contracted charges less discount and will not be subject to the claim level MAP. Appropriate all-inclusive procedure codes must be used when available. The Limited Patient Waiver (LPW) cannot be utilized for services determined to be part of the all-inclusive procedure or service provided. 68

69 Quality Based Reimbursement Program (QBRP) 69

70 Quality Based Reimbursement Program (QBRP) What is it? Rewards providers for superior quality outcomes Provides incentive for efforts to enhance quality of care BCBSKS works with providers to select meaningful quality measures Prerequisites must be met to participate in QBRP 70

71 Quality Based Reimbursement Program (QBRP) QBRP Prerequisites include: Attest that hospital accepts electronic remittance advice o Either ANSI 835 or from the BCBSKS secure website Attest that hospital will use the BCBSKS electronic portal for IP hospital precertification and continued stay reviews o Threshold for both precertification and continued stay review must be met to earn incentive for this measure Hospital will obtain eligibility, benefit and claim status information primarily through electronic transactions o Availity interface (eligibility & benefits, claim status) o ANSI 270/271 transaction (eligibility) o ANSI 276/277 transaction (claim status) 71

72 Quality Based Reimbursement Program (QBRP) QBRP Portal Reporting for 2017 to be completed through the QBRP Web Portal found on Blue Access Portal provides o measure definitions and submission requirements o statewide performance charts o scorecard reporting Questions regarding QBRP Web Portal can be directed to Misty Tillman o or Misty.Tillman@bcbsks.com 72

73 Quality Based Reimbursement Program (QBRP) 2017 QBRP semi-annual reporting dates November 5, 2016 for January 1, 2017 effective date May 5, 2017 for July 1, 2017 effective date Reporting results will be mailed to providers within 30 days of reporting deadline Quality incentive will apply to 2017 inpatient MS-DRG MAPs, per diems and outpatient MAPs, except for reference laboratory and pharmacy. 73

74 Quality Based Reimbursement Program (QBRP) Electronic Precertification and Continued Stay Reviews (CSR) New for 2017: Separate incentives for Precertification and CSR Minimum threshold for measure has increased Period 1 o Based on Electronic Precert & CSR submitted between May 1, 2016 through October 31, 2016 Period 2 o Based on Electronic Precert & CSR submitted between November 1, 2016 through April 30, 2017 BCBSKS will monitor and track internally. 74

75 Quality Based Reimbursement Program (QBRP) HL7 Feed with Data Records to an approved Kansas Information Exchange organization HL7 feed must be live & "real-time" 75

76 Quality Based Reimbursement Program (QBRP) Low Volume Incentive Up to five events Kansas Hospital Engagement Network (KHEN) sponsored educational events Other educational events per BCBSKS approval 76

77 MAP'd Codes 77

78 MAP'd Codes Newly MAP'd Codes BCBSKS added MAPs to over 200 codes 2017 MAP listing 78

79 Questions? 79