Deadline nears for CMS accreditation proof HMSA reminds DMEPOS providers of the CMS September deadline. See page 4.

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1 HMSA s For Participating Medical Practitioners August 2009 Award program for 12- to 14-year-old members An incentive program involving physician feedback has its own rewards for young HMSA members. See page 7. Deadline nears for CMS accreditation proof HMSA reminds DMEPOS providers of the CMS September deadline. See page 4. Beat cancer with a team approach HMSA members benefi t from HMC s approach to cancer treatment. See page 3. Federal focus 2009: OIG examines cost containment for healthcare. See pages 5-6. TRICARE awarded DOD T3 Contract Connect with TriWest via . See page 12. Captiva conversion update Data from CMS 1500 Interactive may be redundant, but it s necessary. See page 2. Med-school summer HMSA and JABSOM partner to send medical students to Neighbor Isles. See page 2. Questions about information in this publication can be directed to HMSA Provider Services at on Oahu or 1 (800) from the Neighbor Islands. PS Hawaii Medical Service Association 818 Keeaumoku St. P.O. Box 860 Honolulu, HI Phone: (808) Branch offi ces located on Hawaii, Kauai and Maui Internet address: Provider Resource Center: hhin.hmsa.com

2 August 2009 Provider Update - Medical Practitioners 2 Captiva scanning program transition HMSA continues its transition to Captiva medical coding software from Scan Optics. Once fully implemented, the new Captiva system will use higher quality scanners and work with the latest versions of Microsoft Windows software. As the use of Captiva gains momentum at HMSA, some claims documentation received has been flagged because of lack of information. Incomplete claim forms are rejected, require extra attention and delay prompt payment. It s important that claims be filed as completely and as accurately as possible. CMS 1500 Interactive Tip: When completing the CMS 1500 Interactive form, providers must indicate that the Insured Name field is complete. The word Same will be rejected if it appears in box 2. Instead, the form should be submitted with Last Name, First Name, Middle Initial in box 2. Captiva, which is a data entry program, mimics the CMS 1500 claim form for data entry. Information supplied by the provider is scanned, then checked and analyzed for accuracy. The program allows for a simplified and quicker scanning process. Because of its advanced optical character reading capability, better, more accurate images are captured of the claims forms, for our electronic records database. End-to-end testing will occur through August, with Captiva promotion currently scheduled for September 4, Production begins September 8, Future physicians train in Neighbor Island communities Through its Medical School Travel Support Program, so far HMSA has provided nearly $90,000 to subsidize travel and living expenses for 33 medical students assisting physicians on the Neighbor Islands. The program is part of a two-year commitment with the John A. Burns School of Medicine (JABSOM) and gives Oahu medical students experience assisting practices in rural communities. Directed by Kalani Brady, M.D., six firstyear students worked in Kalaupapa, Molokai, to provide assistance to physicians there. Eight students in the Imi Hoola program, a 12-month, post-baccalaureate program in the Department of Native Hawaiian Health for qualified candidates from disadvantaged backgrounds, worked in other rural areas.

3 August 2009 Provider Update - Medical Practitioners 3 Thoracic center uses team approach HMSA is participating with the Thoracic Tumor Clinic at Hawaii Medical Center in an 18-month pilot program to provide clinic services to 200 HMSA members. coordinator in preparation for the team prior to its first meeting. The patient s PCP is apprised of its progress and kept aware of diagnostics and therapies used. A multi-disciplinary team meets twice weekly at the HMC Liliha site to process patients through diagnostic analysis, supporting clinic visits and follow-up navigation through their initial treatment. Team members include a medical oncologist, radiation oncologist, thoracic surgeon, pulmonologist, outreach and billing specialists, primary care physician, nurse and navigator coordinator. The team approach offers prompt and timely decision making regarding the need to identify and undergo key diagnostic studies prior to or immediately after initial clinic visits. Once diagnosed and a treatment plan initiated, a patient s history is reviewed by the clinic navigator/ It has been found that specialists working together on a patient s behalf provide a powerful and effective treatment plan with potentially better outcome in terms of survival and/or quality of life. In Hawaii, approximately 700 new cases of lung and bronchus cancer are diagnosed annually. About 500 die each year from the disease. Since its inception in November 2007, the Thoracic Tumor Clinic at HMC has effectively decreased the number of days from initial presentation to treatment to an average of 49, compared to the industry average of days. To confirm BlueCard eligibility Call the BlueCard Eligibility line at 1 (800) 676-BLUE (2583), or use the Blue Eligibility function on the Hawaii Healthcare Information Network (HHIN).

4 August 2009 Provider Update - Medical Practitioners 4 CMS deadline for accreditation proof nears The Centers for Medicare & Medicaid Services (CMS) has issued guidance regarding Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) furnished by certain healthcare professionals and persons. The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) requires that all DMEPOS suppliers and pharmacies meet quality standards for Medicare accreditation by September 30, Current DMEPOS suppliers and pharmacies must submit proof of their accreditation to the Medicare National Supplier Clearinghouse (NSC) in order to continue billing Medicare. The NSC will revoke a DMEPOS Medicare supplier s billing number and privileges on October 1, 2009, if the supplier fails to obtain and submit supporting documentation that the supplier has been accredited. The MIPPA Medicare accreditation requirements also will apply to both 65C Plus contracting DMEPOS suppliers and medical pharmacies. CMS requires that HMSA s 65C Plus Plan must furnish Medicare covered services to its members through providers and suppliers that meet applicable Medicare statutory definitions and implementing regulations. To assure compliance with these new Medicare requirements, HMSA requires that all 65C Plus contracting DMEPOS suppliers and medical pharmacies send proof of their Medicare accreditation by September 15, 2009, to HMSA s Provider Data and Contract Administration Unit. Questions can be directed to Julie Meyer at (808) This will ensure that DME suppliers and medical pharmacies may continue to bill HMSA s 65C Plus Plan and receive payment for covered services after September 30, Additional information about these new Medicare accreditation requirements may be found at hhs.gov/medicareprovidersupenroll /DMEPOS_DeemedAccreditationOrganizations.asp. LRSP claims processing system retires January 1, 2010 It is important to file claims on a timely basis. In accordance with HMSA provider contracts, claims must be filed within one year of the service date. This time frame also applies when HMSA is a patient s secondary insurance carrier. HMSA has completed conversion of our HMO and PPO plans to the new claims processing system (QNXT). As a result we will begin retiring the old claims processing system (LRSP). Claims with service dates prior to January 1, 2009, should be submitted to HMSA by December 31, 2009, to ensure payment.

5 August 2009 Provider Update - Medical Practitioners 5 Federal audit plan may include medical reviews and chart audits The Office of the Inspector General (OIG) publishes an annual work plan regarding research or studies that will be part of the federal government s cost-containment efforts. The plan includes areas the OIG will focus upon to improve fiscal performance either through audits, utilization studies or other reviews. These efforts may include medical reviews and chart audits that may impact various physicians or other healthcare providers. This article highlights some areas the OIG will focus upon during fiscal year These studies are an important part of federal government cost-containment efforts and may directly impact providers administratively and financially in instances where billing issues are identified as a result of these studies. Place of Service Billing Medicare pays a higher amount when a surgical procedure is performed in a nonfacility setting. The OIG will therefore be reviewing physician billings to determine whether services that are being billed as being performed in a non-facility setting were in fact performed in a hospital outpatient department, which would reimburse at a lower rate. See Federal regulations at 42 CFR Section (b)(5) (i)(b). Evaluation and Management Services During Global Surgery Periods The OIG will review industry practices related to the Medicare global fee reimbursement practices related to paying a global fee to physicians to cover all of their services associated with a surgical procedure, including E&M services provided during the global surgery period. The reasons for the study may include contractor compliance along with the stated reason for the study, which is whether industry practices regarding this type of billing has changed since the global fee concept was developed in See Medicare Claims Processing Manual, Pub. No , ch. 12, Section 40. Medicare Payments for Colonoscopy Services The OIG will be reviewing the appropriateness of Medicare payments to physicians for colonoscopy services. A See page 6

6 August 2009 Provider Update - Medical Practitioners 6 OIG focus on Medicare billing requirements From page 5 colonoscopy generally requires that the patient be placed under sedation in an outpatient hospital setting. The Social Security Act, Section 1833(e), precludes payment to any service provider unless the provider has furnished the information necessary to determine that payments are due to such provider. The OIG will determine whether Medicare payment for colonoscopy services were properly supported, billed, and paid in accordance with Medicare requirements. Physicians Medicare Services Performed by Non-Physicians The OIG will be reviewing physician services billed to Medicare that are not personally performed by physicians. These incident to services are typically performed by nonphysician staff members in the physician s office. The Social Security Act, Section 18610(s)(2)(A), provides for Medicare coverage of services performed incident to the professional services of a physician. However, these services may be vulnerable to overutilization or put the beneficiary at risk of receiving services that do not meet professionally recognized standards of care or payment criteria. These reviews will include a review of the qualifications of the non-physician staff performing the incident to services and assess whether their qualifications are consistent with professionally recognized standards of care. As a general rule, it is of the utmost importance that providers bill government and private payers properly. However, it is especially prudent for providers to review their billing practices regarding service types covered by the annual OIG work plans in order to make sure that they are currently in compliance with the applicable Medicare billing requirements. This should be an ongoing effort for any and all billings submitted for payment to government as well as private payers.

7 August 2009 Provider Update - Medical Practitioners 7 Motivation for 12- to14-year old QUEST members To encourage 12- to 14-year-old members to schedule their Early and Periodic Screening, Diagnosis and Treatment exams, HMSA has implemented an incentive for this QUEST program. A month prior to the member s birthday, HMSA will send a letter to the parents or guardians to let them know what the young member needs to do to get the exam. HMSA will send the youths a birthday card that tells them to get the exam. Have them take the card to the appointment so the physician can fill out a section that confirms the member received the exam, and to mail it to HMSA at the address on the card. The first 50 members of each birth month who send in the completed card will receive a $25 gift card to Wal-Mart. HMSA will award 50 winners each month from July through December The program will then be reviewed and potentially continued. HMSA s Online Care Training dates for HMSA s Online Care Physicians and their staffs interested in offering to their patients a high-tech option to the standard in-office visit, or who need to bring new staff up to speed, are invited to reserve a spot in an upcoming Online Care training sessions. To participate, select one of the dates below and register online at Thursday, August 20th 6:00-8:00 p.m., HMSA Center, Multi-Purpose Room Thursday, September 17th 6:00-8:00 p.m., HMSA Center, Multi-Purpose Room Patricia Avila, M.D., Medical Director of HMSA s Online Care HMSA s Online Care Physicians Advisory Committee S. Kalani Brady, M.D. Fred Brenner, M.D. James Frede, M.D. Ramin Jamm, M.D. Whitney Limm, M.D. Kenneth Luke, M.D. Edwin Montell, M.D. Michele Shimizu, M.D. Robert Sussman, M.D.

8 August 2009 Provider Update - Medical Practitioners 8 Medical record documentation Complete and accurate documentation of visits and services in the medical record is critical to the quality of care that our members receive. It is also important to you as support for your billings as claim audits increase. CMS is actively implementing audits and health plans such as HMSA are also increasing audit and recovery activities for both outpatient and inpatient claims. Medical Management s audits include, but are not limited to, reviews of the site of service, accuracy of coding and medical necessity of the services. Records must be dated, complete and legible. If submitting a code which is timed, the start and end time of service should be noted. A claims audit at HMSA by a CMS contractor noted numerous documentation issues which included: Therapeutic exercise codes, manual therapy techniques and time not adequately documented in physical therapy records Dates of service not matching claims Radiology codes not supported by radiology reports Route, site and vaccine information inadequately documented HMSA highly recommends the Medicare Learning Network (MLN) publication on documentation guidelines at cms.hhs.gov/mlngeninfo on the CMS website. Reviews by HMSA s Medical Management staff are also based on Medicare documentation guidelines. Inadequate documentation for timed codes, no notation of start/end time or total time spent performing a service Lack of documentation to support the level of E&M codes Potential of some E&M visits equating to noncovered physical exam visits Consults which did not include a detailed history, expanded problem focused exam, etc. Critical care and critical care addon codes for additional time spent were not supported by the provider s documentation

9 August 2009 Provider Update - Medical Practitioners 9 Policy News Annual review of medical policies The following policies have undergone annual review and have been updated: Omalizumab (Xolair) Biological Agents for the Treatment of Plaque Psoriasis (combination of two existing policies, Enbrel and Humira, with no significant changes) Home Infusion Pain Management Therapy Home Inotropic Infusion Therapy Home TPN for Adults Hyperbaric Oxygen Therapy Intensity Modulated Radiation Therapy Quantity Limits for Abortive Migraine Agents Small Bowel/Liver and Multivisceral Transplants Stereotactic Radiosurgery and Fractionated Stereotactic Radiotherapy Teriparatide (Forteo) Ventricular Assist Devices and Total Artificial Hearts Please refer to the Provider E-Library to view the individual policies. Copies of the policies are available upon request. Services that Require Precertification Effective August 1, 2009, Speech Therapy Services require precertification. It is now listed in the Provider E-Library s Services That Require Precertification. Codes that Do Not Meet Payment Determination Criteria Effective November 1, 2009, the following code has been added to the list of Codes that Do Not Meet Payment Determination Criteria: G0409 Claim documentation requirements Claims with select codes that require medical record documentation are listed in the Provider E-Library. In the Claims Documents Requirements entry of the E-Library, the following codes now require Description of Service documentation: A0998, A4221, S5501.

10 August 2009 Provider Update - Medical Practitioners 10 Policy News New medical policy effective November 1, 2009 Positive Airway Pressure Devices for the Treatment of Obstructive Sleep Apnea A 90-day notice is being provided for this policy that will be in effect November 1, New draft policy effective November 1, 2009 Artificial Disc Replacement - Cervical This is a new draft policy posted for comment that can be viewed under Draft Policies in the Provider E-Library. A copy is available upon request. Comments are due by August 31, 2009, and can be sent to medical_policy@hmsa.com or faxed to FDA-Approved Drugs Requiring Precertification policy added effective November 1, 2009 Adcirca Canakimumab Rituximab (for non-oncology and non-ra indications only) A 90-day notice is being provided for this policy that will be in effect November 1, Provider input solicited for annual policy review August HMSA s medical directors welcome comments and suggestions from participating physicians regarding existing medical policies that are undergoing annual review. The following is a list of policies for which HMSA is currently soliciting input. Comments are due by August 31, Physicians may comment by fax at (Oahu) or via to medical_policy@hmsa.com. Comments will be taken into consideration during the annual review process. However, HMSA does not guarantee any specific proposed change will be included in the final policy. HMSA s policies rely on the use of evidence-based medicine, typically from peer-reviewed literature. Physicians submitting comments should include supportive citation source material. This will assist HMSA s medical directors in evaluating the comment or proposed change. Bone Mineral Density Studies Brachytherapy, Intravascular Clinical Trials Cox II Inhibitors Hepatitis C Treatment with Interferons and Ribavirin Low Molecular Weight Heparin Radiology Guidelines

11 August 2009 Provider Update - Medical Practitioners 11 Billing and Coding HMO benefit changes Effective August 1, 2009, Health Plan Hawaii Plus coverage codes will be modified with the following changes: HPH Plus (A-A) Current August Benefit Copayments in General $14 $15 Outpatient Lab/Diagnostic Tests $0 10 percent of EC ER Facility Copayment $25 $50 Hospital Stay $0 $50/day Mental Health Outpatient Visit - Physician $14 20 percent of EC Serious Mental Health Outpatient Visit $14 $15 Immunizations 19 years and older $0 $10 Please refer to the HPH/HMO Copay Table page in the Provider E-Library for changes in other areas of the plan. TRICARE TriWest Healthcare Alliance awarded contract In July TriWest Healthcare Alliance was awarded the contract to continue providing military families access to high quality healthcare and to manage the 21-state TRICARE West Region for the Department of Defense (DoD). The contract enables TriWest to continue to support the DoD in meeting the health care needs of 2.7 million active duty personnel, their families and retirees. The contract includes a transition period, plus five one-year option periods for health-care delivery beginning April 1, It has been our great honor and privilege to serve the healthcare needs for those who sacrifice so much in defense of freedom, and we are pleased that the Department of Defense has selected us again for this critical work, said David J. McIntyre, Jr., TriWest s President and CEO. Being awarded our third TRICARE contract is a testament to the focus we have placed on customer service, bringing more than 145,000 high-quality providers into the West Region network through the work of our world-class non-profit owner organizations, and our stewardship of taxpayer dollars in doing what s right for the beneficiaries of this program. Just as we ve done for the past 13 years, we are committed in See page 12

12 August 2009 Provider Update - Medical Practitioners 12 TRICARE Share your address with TriWest TriWest Healthcare Alliance is developing a more effective and efficient means of communicating with providers by collecting provider addresses. The goal is to obtain provider addresses that will allow TriWest to communicate the right information to the right person at the right time. For example, it will allow TriWest to inform you about: New TriWest processes, policies and/ or resources to help you care for TRICARE beneficiaries Educational opportunities or events in your community TriWest will not sell or distribute your e- mail address to other companies with the exception of your local network representative. TriWest will not send spam s as all communications will be TRICARE/Tri- West-related information only, and TriWest will not overload your account. You can share your address(es) with TriWest by registering for the TRICARE enews on our website at by contacting HMSA TRICARE Unit at (808) , Provider_data@hmsa.com, or by calling TriWest at 1 (888) TRIWEST or 1 (888) TRICARE program changes Contract From page 11 this new contract to working alongside our civilian and military counterparts across the system to ensure access to high-quality healthcare and improve an already strong TRI- CARE program for America s military family. HMSA contracts with providers for the TRICARE program. To participate, call (808) TriWest s corporate headquarters will remain in Phoenix. Primary hub offices are located in Tacoma, Colorado Springs, San Diego, Honolulu and Anchorage.