NOA 3rd Party Newsletter

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1 NOA 3rd Party Newsletter July 2014 Nebraska Optometric Association Volume 14, Issue 7 Please forward to all of your doctors and staff Click FILE and Click PRINT for a Printed Copy of This Newsletter Affordable Care Act Medicaid WPS-CMS AOA BCBS Partners with Nebraska ACO South East Rural Physician Alliance P.1. Differences in Nebraska Medicaid MCOs Visual Care Policies Pp WPS: Proper Use of Modifier 59 MLN Matters Article Released P.6. From the AOA: ODs have opportunity to review Sunshine Act Open Payments data P.8. HIPAA Medical Privacy of Protected Healthcare Information Pp.2-3. Nebraska Medicaid Reimbursement Updated with a 2.25% Increase But Payment Increases May Not Be Implemented by MCOs. P.6. Instructions for Accessing the Fraud Waste, and Abuse (FWA) Medicare Learning Network Training Module P.7. Potpourri New Graduate / New Licensee Resources P.9 BCBS Partners with Nebraska ACO South East Rural Physician Alliance The following information was gleaned from a June 26 th Lincoln Journal Star article By MATT OLBERDING / found at clinicians-take-financial-risk-in-deal-with-blue-cross/article_e3cda0e7-399c-5922-aa04-bb7dedabf6d6.html Dr. Quack recommends you read the complete article. BCBSNE has partnered with the South East Rural Physician Alliance ACO, using total cost of care reimbursement. The care under this reimbursement method is comprehensive: inpatient, outpatient, professional, ancillary, pharmacy, etc. The intent is to improve quality of care, keeping patients healthier, and cutting costs. The system is controlled via the patient s PCP, who coordinates the patient s care, shares financial risk, and is rewarded with higher reimbursement if there are decreased health care costs such as hospital readmissions. According to the Lincoln Journal Star, the clinics included that are in this group include: Lincoln Family Medical Group, LifeCare Family Medicine of Bellevue Central Nebraska Medical Clinic, Broken Bow Butler County Clinic, David City Fillmore County Medical Center, Geneva Family Medical Center of Hastings Family Practice Associates, Kearney Plum Creek Medical Group, Lexington McCook Clinic York Medical Clinic How might this affect Nebraska ODs? If the patient s OD does not have a trusted relationship with the patient s PCP, care that heretofore had been provided by the OD might be channeled elsewhere by the PCP. This risk seems greater in more highly populated areas containing a large numbers of PCPs, resulting in a lesser likelihood of ODs establishing an OD PCP trusted relationship. Dr. Quack suggests regular communication with a patient s PCPs is paramount.

2 Page 2 NOA 3rd Party Newsletter Medical Privacy of Protected Healthcare Information HIPAA does not require patients to sign consent forms before doctors, hospitals, or ambulances may share information for treatment purposes. Dr. Quack continues to receive questions on HIPAA Privacy. The following CMS Learning Network information is from Downloads/SE0726FactSheet.pdf Health Care Professionals Privacy Guide The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that sets national standards for how health care plans, health care clearinghouses, and most health care providers protect the privacy of a patient's health information. HIPAA does not require patients to sign consent forms before doctors, hospitals, or ambulances may share information for treatment purposes. You may share patient treatment information with other health care professionals without obtaining a signed patient authorization. For more information, review: Answers to Frequently Asked Questions (FAQs) about HIPAA at on the U.S. Department of Health and Human Services (HHS) website; The Uses and Disclosures for Treatment, Payment, and Health Care Operations fact sheet on the HHS website at usesanddisclosuresfortpo.html; The Summary of the HIPAA Privacy Rule on the HHS website at privacy/hipaa/understanding/summary/index.html ; and The Federal Register s January 2013 final omnibus rule regarding privacy and security protections for health information established under HIPAA, found at HIPAA does not require you to eliminate all incidental disclosures. The Privacy Rule recognizes that it is not practicable to eliminate all risk of incidental disclosures. In August 2002, HHS adopted specific modifications to the Privacy Rule to clarify that incidental disclosures do not violate the rule when you have policies that reasonably safeguard and appropriately limit how protected health information is used and disclosed. The Office for Civil Rights (OCR) provides guidance about how this applies to customary health care practices (for example, using patient sign-in sheets or nursing station whiteboards or placing patient charts outside exam rooms). Refer to the FAQs in the Incidental Uses and Disclosures subcategory or search for terms such as safeguards or disclosures on the FAQs web page (Continued on page 3) Nebraska Optometric Association 1633 Normandy Court, Suite A Lincoln, NE The NOA Third Party Newsletter is published monthly by the Nebraska Optometric Association with the assistance of Ed Schneider, O.D., Third Party Consultant. To reach Ed (aka Dr. Quack): BEST to contact via at: SchneiderEd@msn.com Fax number is Call Ed before faxing.

3 Page 3 NOA 3rd Party Newsletter (Continued from page 2) Review the Incidental Uses and Disclosures fact sheet on the HHS website HIPAA is not anti-electronic. You may use , the telephone, or fax machines to communicate with patients and other health care professionals using appropriate safeguards to protect patient privacy. Review additional information on this topic at on the HHS website. Guidance is provided regarding patient sign-in sheets, nursing station whiteboards, or charts outside exam rooms. HIPAA does not cut off all communication between health care professionals and the families and friends of patients. As long as the patient does not object, health care professionals covered by HIPAA may provide information to a patient s family, friends, or anyone else identified by a patient as involved in his or her care. The Privacy Rule also makes it clear that, unless a patient objects, hospitals and health care professionals may notify a family member or anyone responsible for the patient s care about the patient s location or general condition. If a patient is incapacitated, you may share appropriate information with the patient s family or friends if you believe doing so is in your patient s best interest. Review the Communicating with a Patient s Family, Friends, or Others Involved in the Patient s Care guide on the HHS website at provider_ffg.pdf. HIPAA does not prevent calls or visits to hospitals by a patient s family, friends, the clergy, or anyone else. Unless a patient objects, basic information such as the patient s phone and room number may appear in a hospital directory. Members of the clergy may access a patient s religious affiliation (if provided) and do not have to ask for patients by name. HIPAA does not prevent child abuse reporting. You may report child abuse or neglect to appropriate government authorities. For more information, search using the term child abuse on the FAQs web page at or review the Public Health fact sheet on the HHS website at Additional Information The HHS complete listing of all HIPAA medical privacy resources is available at on the HHS website. For more information about HIPAA rules, visit the HIPAA Frequently Asked Questions web page at on the U.S. Department of Health and Human Services (HHS) website.

4 Volume 14, Issue 7 Page 4 Differences in Nebraska s MCO Visual Care Policies Over the last few months it became apparent to Dr. Quack that our Nebraska Medicaid Managed Care Organizations interpretations of Nebraska Medicaid Visual Care regulations were less than identical. To clarify differing MCO policies, Dr. Quack submitted to Nebraska Medicaid administrators the following questions, which were in turn forwarded to the MCOs. The questions and the responses, found in the table below, will hopefully assist you in expediting care of your Nebraska Medicaid MCO patients. VISION QUESTIONS ARBOR/Avesis COVENTRYCARES/Block Vision 1. Does Avesis/Block Vision Yes, per the provider manual, the Yes. offer online capabilities for provider can visit the Avesis providers to verify client website anytime at eligibility? utilize Avesis IVR anytime at (866) ; or call Avesis Customer Service Center during normal business hours at (800) Monday UNITEDHEALTHCARE/Block Vision Yes, Block Vision offers online capabilities for providers to verify client eligibility. 2. Does Avesis/Block Vision offer online capabilities for providers to request authorizations? Not currently for vision providers. Yes, Authorization and Eligibility Verification can be obtained online. Yes, Block Vision offers online capabilities for providers to request authorizations. Block refers to this as an Eligibility Verification to connect a member s benefit to a specific Provider. Eligibility Verifications can be obtained online. 3. What is the lifespan of an authorization, i.e. one day, one week? 60 days An Eligibility Verifications is for a single date of service but the verification is active for 21 days before the anticipated date of service and 21 days after the anticipated date of service. An Eligibility Verifications is for a single date of service but the verification is active for 21 days before the anticipated date of service and 21 days after the anticipated date of service. 4. Are providers required to bill exam and glasses separately based on dates of service? Only if the eligibility crosses over years. They cannot bill 2013 and 2014 services on the same claim. Providers bill based on CPT Codes. The CPT codes for exams are different from that of frames or lenses. Each service/material would need to be billed separately. If the exam is performed on a date different from the materials then separate claims are needed Providers bill based on CPT Codes. The CPT codes for exams are different from that of frames or lenses. Each service/ material would need to be billed separately. If the exam is performed on a date different from the materials then separate claims are need 5. When contacting for eligibility what information does Avesis/Block Vision require/accept from a provider, i.e. health plan #, Medicaid #, Member s Medicaid ID # and DOB The provider would need to give the member s Coventry issued identification number or the member s SSN in addition to the member s date of birth. The provider would need to give the member s UnitedHealthcare issued identification number or the member s SSN in addition to the member s date of birth. 6. What is the timeframe for filing a claim? 180-days Timely filing of claims is within 180 days from the date of service. Timely filing of claims is within 180 days from the date of service. Continued on following page.

5 Volume 14, Issue 7 VISION QUESTIONS ARBOR/Avesis COVENTRYCARES/Block Vision 7. What information does Avesis/Block Vision include on their EOB? Avesis does not supply EOBs for Arbor. EOBs are suppressed per the direction of Arbor during the implementation process. Block Vision does not issue member EOBs. Block Vision issues an explanation of payment to the billing provider. Page 5 UNITEDHEALTHCARE/Block Vision Block Vision does not issue member EOBs. Block Vision issues an explanation of payment to the billing provider. 8. Does Avesis/Block Vison have any requirements that require paper submissions? No, not for any Arbor providers. Block Vision requires paper claims if an invoice is presented. This occurs when the frame or lens billed charges is in excess of the standard allowance, or if the provider is requesting a nonstandard benefit. Block Vision requires paper claims if an invoice is presented. This occurs when the frame or lens billed charges is in excess of the standard allowance, or if the provider is requesting a nonstandard benefit. 9. Please confirm frequency of exam, frame and lenses timeframe, i.e. 12 months. Age 20 & Younger--Exam: 1 Every 12 Months; Frame: 1 Every 12 Months; Lenses: 1 Every 12 Months. Age 21 & Older--Exam: 1 Every 24 Months; Frame: 1 Every 24 Months; Lenses: 1 Every 24 Months. Exams are available 1 every 12 months for children and 1 every 24 months for adults. Eyewear is available 1 every 24 months with replacements available. Children can receive services earlier as needed. Exams are available 1 every 12 months for children and 1 every 24 months for adults. Eyewear is available 1 every 24 months with replacements available. Children can receive services earlier if needed. 10. Does children s eye ware require preauthorization? No, unless requesting a specific non-routine item- such as contact lenses, ultraviolet filter coating, or multiple frame breakages within a given year. These items require prior authorization. Block Vision requests that providers verify eligibility in advance for providing services or materials to members of all ages. Block Vision requests that providers verify eligibility in advance for providing services or materials to members of all ages. 11. Are children s lenses polycarbonate? Poly is covered for 20 and under if there is a medical or RX reason for the Dr. to prescribe it. They may bill this without a prior auth IF the member is 20 and under. I also found in our provider manual the following: Standard Polycarbonate Lenses: Covered only if prescribed for Members with significantly monocular vision due to amblyopia, eye injury, eye disease, or other disorder. Prior authorization required for ages 20 and older. Thin Polycarbonate Lenses: Covered for Members only if refraction correction is at least +/ diopters in the meridian of greatest power when placed on an optical cross. Prior authorization required for ages 20 and older. Polycarbonate lenses for children are covered. Polycarbonate lenses for children are covered.

6 Volume 14, Issue 7 Page % Increase in Medicaid Reimbursement...However, Increase May Not Be Implemented by MCOs. The Nebraska Medicaid fee schedules was updated for dates of service beginning July 1, The schedules are available at the Department of Health and Human Services (DHHS) Medicaid web site: med_practitioner_fee_schedule.aspx. (Visual Care fees can be found at The July 1, 2014 Nebraska Medicaid Fee Schedules reflect the 2.25% rate increase included in the State Budget for Fiscal Year Providers are able to receive electronic updates of changes to the Nebraska Medicaid Program, including Fee Schedule updates and Provider Bulletins. Visit the Recent Web Updates page: dhhs.ne.gov/medicaid/pages/med_updates.aspx. Click on Subscribe to this page and follow the instructions. For questions about Fee Schedules, contact the Program Policy staff as listed on this website for the service in question: Medicaid Visual Care MCOs Will the Nebraska Medicaid MCOs (and sub-contractors Block Vision/Avesis) increase reimbursement for visual care? It depends on your individual MCO contract(s). If you have agreed to accept an MCO fee schedule, you will most likely not receive any increase because of that agreement. However, if your MCO contract states your reimbursement will be equal to traditional Medicaid reimbursement, you should receive the increase. WPS: Proper Use of Modifier 59 MLN Matters Article Released MLN Matters Special Edition Article #SE1418, Proper Use of Modifier 59 has been released and is now available in downloadable format from This 8- page article provides education proper use of Modifier 59, including background information and examples. Quack Summary: 1. Look at the NCCI Edits: 2of2.zip For PTP edits that have a 0, the codes should never be reported together by the same provider for the same beneficiary on the same date of service. For PTP edits that have a 1, the codes may be reported together only in defined circumstances which are identified on the claim by the use of specific NCCI-associated modifiers. 2. Modifier 59 is used appropriately for different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered on the same day are performed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ. 3. Modifier 59 is used appropriately when the procedures are performed in different encounters on the same day. 4. Modifier 59 is used inappropriately if the basis for its use is that the narrative description of the two codes is different. 5. Multiple examples are given in the Article. CPT Definition of Modifier 59: Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-e/m service performed on the same date, see modifier 25.

7 Page 7 NOA 3rd Party Newsletter Instructions for Accessing the FWA Medicare Learning Network (MLN) Training Module Recently many NOA member offices have received a post card from Aetna/Coventry about compliance with CMS s Medicare C and Medicare D fraud, waste, and abuse training requirements. The attestation mentioned on the postcard is unrelated to EHR attestation; rather, it is referring to the information found on the CMS web site at Coventry offers a guide to the FWA program, a link to the training program, and a template for documenting that the program was completed. The link is found at: Dr Quack looked at that Coventry web link and indeed found it quite helpful; it is copied below. To take a web-based training course, go to MLNProducts/index.html?redirect=/MLNProducts on the CMS website. 1. Under Related Links, at the bottom of the page, click on Web-Based Training (WBT) Courses. 2. Click on Medicare Parts C and D Fraud, Waste and Abuse Training, not the icon next to it. 3. At the top of the Course Description Window, you will be able to click on either Login or Register. a. If you already have an MLN account, click Login and enter your User ID and Password. b. If you do not have an MLN account, click Register. c. You will be re-directed to a page with an address field stating Please type your address and press Submit. d. Enter an address and click Submit. e. The next screen will read: No account was found matching your search criteria. Please click here to proceed with registration. f. Click the word Here to continue with registration. 4. After logging in or completing the registration, you will be re-directed to your home page. 5. Click on the Web-Based Training Courses link. 6. Click the Medicare Parts C and D Fraud, Waste and Abuse Training title, not the icon next to it. 7. Scroll to the bottom of the page and click the Please click here to access Provider Compliance Web Page not the Take Course button. 8. You will be re-directed to the Provider Compliance Web Page. 9. Under Downloads click on Medicare Parts C and D Fraud, Waste and Abuse Training. 10. You will be asked whether you would like to Open or Save the File. Choose which option you prefer. 11. After you unzip the file, you will see two versions of the same training slides one in PDF format and the other in PPT format. Choose either version to access the training. 12. Once you have finished the training, go to slide 59 for a Certificate of Completion template that can be used to document course completion. If you choose to use this certificate, click on slide 59 in the PowerPoint format, clear the existing fields - Type Your Name Here and Insert Today s Date -and replace the contents with your name and the date that you completed the training. Congratulations! You have successfully accessed the Medicare Parts C and D Fraud, Waste and Abuse Training!

8 Volume 14, Issue 7 Page 8 From the AOA: ODs Have Opportunity to Review the Sunshine Act Open Payments Data From the AOA: The Open Payments program was authorized under the "Sunshine Act" ( ) provision of the Affordable Care Act. In an effort to promote public transparency of financial transactions that take place among members of the health care industry, the program requires that certain manufacturers and others report any payments or gifts provided to ODs and other physicians. Optometrists who wish to review any "open payments" data before the information goes public, take note. There's a two-step registration process you must complete first to access this data. "Every OD needs to register and be aware of what the public will be seeing regarding their professional relations with different vendors." Such information will be made public in September. For this reason, "every OD needs to register and be aware of what the public will be seeing regarding their professional relations with different vendors," says Roger Jordan, O.D., who chairs the AOA Federal Relations Committee. Similar to what the Centers for Medicare and Medicaid Services (CMS) did in posting Medicare reimbursement on a public website, the Open Payments site involves "every physician's reputation and patient relationship," he says. What's important is that the reported data is correct, Dr. Jordan says. Registration is a two-step process To ensure that the manufacturer reports are accurate, ODs can check and review the data, but must first go through a two-part registration process. The first part involves registering with the CMS Enterprise Identity Management portal (EIDM). Registration is now open for this part of the process. ODs can access the portal at this link and select "new user registration." As part of this process, CMS will conduct some identity verification steps including a "soft" credit inquiry. According to Dr. Jordan, the registration process with EIDM is "very quick and painless. All that is needed is your name, social security number, birthdate, home address, and three security questions and answers. You are then sent a confirmation , which needs to be saved." Once ODs have their EIDM registration credentials, they can subsequently request access to the Open Payments system. That part of the registration process will not open until July, however. More information on Open Payments and registering to access data is available at this link unauthportal/home/. Once the review and dispute period begins in July, ODs will have just 45 days to review their reports and attempt to correct any data before the information goes public, Dr. Jordan says.

9 Volume 14, Issue 7 Page 9 Dr. Quentin Quack s Queries and Questionable Quotes ~~~~~~~~~~~~~~~~~~~~~~~~~~ Third Party Questions from NOA Doctors and Staff Dr. Quentin Quack New Graduate / New Licensee Questions Dear Dr. Quack: I am a recent optometry graduate and will be practicing in Nebraska. I was hoping you could give me some advice on a couple insurance questions? Currently, I am waiting on my NE license. All of my paperwork was submitted on May 14th as well as my fingerprints My guess is that the NE license should go through sometime in the next 1-2 weeks. I will then submit applications for my NPI and DEA license followed by my Medicare, Medicaid and 3rd party insurances Do you know if I am then eligible to practice when applications have been submitted or do I need to wait until everything is cleared. Rumor is that it takes quite awhile for the Medicare applications to process? Dr. Quack s Quote: You cannot practice until you have your license, of course. Regarding third party reimbursement, you won t be paid retroactively, so seeing a 3rd party patient prior to being credentialed by their third party is unworkable. (BCBS may be an exception; they may pay retroactively to the date of application if you get prior written approval?). You are correct in that it can take quite some time to become credentialed by the various 3rd parties...sometimes three months or so. And practicing under another licensee s credentials is a no-no. So the first few months can be frustrating, generally limited to seeing private pay patients and doing menial tasks around the office. The NOA has compiled a manual for the OD license applicant or the new OD licensee. It includes information on Licensure requirements How to obtain an employer ID number and a DEA registration number How to become a provider for Medicare, DME, Medicaid, etc. It also provides Nebraska motorist vision requirements, which will come in handy when filling out a patient s driver s license vision form. Just click on to access this material. I would also suggest you take a look at our NOA 3rd party videos for new grads...these YouTube videos help one grasp third party issues. It will take some time to watch all 10 of them (they run about 15 minutes each), but you should find them informative. If you have further questions, let me know...it is best to communicate with Dr. Quack via at SchneiderEd@msn.com. ERRATA: Optomap and 3D Capabilities. Last month, when responding to a question about PQRS Measure #117, Dr. Quack stated he was not aware that Optomap had stereoscopic capabilities. (See below). Apparently, since the old feather-brained duck retired, Optomap has developed such capabilites. However, Dr. Quack s response to the question remains the same: performing a DFE for diabetic retinopathy, since it is the standard of care. In general, the first choice, 2022F, (See code choices in blue below) is best for ODs or OMDs. The other choices (2024F and 2026F) are really for PCPs, internal medicine MDs, etc., who send stereo pix to ODs or OMDs for interpretation and report. In addition, you will note that the requirement is for stereoscopic photos, I was not aware that an To Optomap access now the has NOA stereoscopic 3rd Party capabilities. web page: So, the safest route is using 2022F.

10 Page 10 NOA 3rd Party Newsletter Dr. Quentin Quack s Quacked Humor A family went to a hospital, where one of their relatives would be having a brain transplant. One of the relatives asked, "What will the cost of a new brain be?" The doctor replied, "A female brain costs $25,000 and a male brain costs $50,000." The men smirked, but one of the females asked, "Why is that, doctor?" "Well," the doctor replied, the female brain is less because it has been used." "Cash, check or charge?" the cashier asked after folding items the woman wished to purchase. As the woman fumbled for her wallet, the cashier noticed a remote control for a television set in her purse. "Do you always carry your TV remote?" the cashier asked. "No," she replied. "But my husband refused to come shopping with me, so I figured this was the most evil thing I could do to him." Joe was a single guy living at home with his father and working in the family business. When he found out he was going to inherit a fortune when his sick father died, he decided he needed a wife with whom to share his fortune. One evening at an investment seminar he spotted the most beautiful woman he had ever seen. Her beauty took his breath away. I may look like just an ordinary man, he said to her, but in just a few years, my father will pass, and I ll inherit his large fortune. Impressed, the woman took his business card and three months later, she became Joe s stepmother. Women are so much better at estate planning than men!! A woman decided to have her portrait painted. She told the artist, "Paint me with diamond rings, a diamond necklace, emerald bracelets, a ruby broach, and gold Rolex." "But you are not wearing any of those things," he replied. "I know," she said. "It's in case I should die before my husband. I'm sure he will remarry right away, and I want his new wife to go crazy looking for the jewelry."