Blue Membership as of November Penalty Due for Failure to Obtain Authorizations. Physician Anatomical Pathology Services Medicare Moratorium

Transcription

1 3rd/4th Quarter 2008 Blue News is a quarterly publication for hospital administrators from Blue Cross and Blue Shield of Louisiana Baton Rouge, New Orleans, Northshore area providers: Merle Francis Regional Director (225) Merle.Francis@bcbsla.com Alexandria, Lafayette, Lake Charles, Monroe, Shreveport area providers: Susan Slocum Regional Director (337) Susan.Slocum@bcbsla.com Executive Contact: Tom Groves Director, Provider Contracting & Servicing (225) Thomas.Groves@bcbsla.com Dawn Cantrell Vice President, Network Administration (225) Dawn.Cantrell@bcbsla.com Blue Membership as of November 2008 Alexandria 39,000 Baton Rouge Area 176,288 Lafayette Area 131,531 Lake Charles Area 63,360 Monroe Area 41,971 New Orleans Area 238,372 Shreveport Area 87,626 Out-of-State 6,710 ITS (includes BlueCard members) 331,680 Dental only 1,142 Total 1,117,680 Penalty Due for Failure to Obtain Authorizations Beginning January 1, 2009, the following changes are being made to most Blue Cross and Blue Shield of Louisiana member policies: Outpatient Authorization Penalty for PreferredCare PPO and HMO Louisiana s POS Plan Providers: A 30 percent penalty will be imposed on PreferredCare and HMOLA s POS plan network providers for failing to obtain authorization prior to performing outpatient services that require authorization. This penalty will be applied to the provider s benefit payment of the allowable charge. The network provider is responsible for the penalty amount. The member is responsible for any applicable deductible, copayment, coinsurance and/or non-covered services. Inpatient Authorization Penalty for HMOLA s POS Facilities: A $1,000 penalty will be imposed on the allowable charge of the HMOLA s POS network facility s reimbursement for failure to obtain an authorization on inpatient stays. A penalty will not be applied to professional services related to the inpatient stay. The facility is responsible for the penalty and may not bill the member for the penalty. There is no co-pay for new group HMOLA s POS plans with deductibles; therefore, the $1,000 penalty will be applied to Blue Cross payment based on the deductible/co-insurance benefit. Physician Anatomical Pathology Services Medicare Moratorium A limited number of large pathology groups have always been grandfathered by Blue Cross and Blue Shield of Louisiana to allow them to bill the anatomical technical component for members receiving hospital services. Although we philosophically consider this service to be an integral part of a hospital s reimbursement, we have continued to keep our policies consistent with Medicare s policy. In the final physician fee schedule regulation published in the Federal Register on November 2, 1999, the Centers for Medicare & Medicaid Services (CMS) stated that it would implement a policy to pay only the hospital for the technical component (TC) of physician pathology services furnished to hospital patients. (Prior to this proposal, any independent laboratory could bill the carrier under the physician fee schedule for the TC of physician pathology services for hospital patients.) At the request of the industry, to allow independent laboratories and hospitals sufficient time to negotiate arrangements, the implementation of this rule was administratively delayed. Subsequent legislation formalized a moratorium on the implementation of the rule. During this time, the carriers and, more recently, Medicare Administrative Contractors (MAC) have continued to pay for the TC of physician pathology services when an independent laboratory furnishes this service to beneficiaries who obtain inpatient and outpatient services at a covered hospital. >> Page 1 of 5 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company

2 The most recent extension of the moratorium, established by the Medicare, Medicaid, and State Children s Health Insurance Program (SCHIP) Extension Act (MMSEA), Section 104, expired on June 30, A new extension of the moratorium has been established by the Medicare Improvements for Patients and Providers Act of 2008, Section 136, retroactive to July 1, It was previously communicated by CMS that the moratorium had ended and that independent laboratories may no longer bill Medicare for the TC of physician pathology services furnished to patients of a covered hospital, regardless of the beneficiary s hospitalization status (inpatient or outpatient) on the date that the service was performed. This prohibition is rescinded and the moratorium will continue to be effective for claims with dates of service on and after July 1, 2008, but prior to January 1, Blue Cross intends to follow Medicare on this issue and stop paying the grandfathered pathology groups after the Medicare moratorium is lifted. CMS No-Pay Rule The Centers for Medicare & Medicaid Services (CMS) is taking several actions to improve the quality of care in hospitals and reduce the number of never events - preventable medical errors that result in serious consequences for the patient. A final acute care inpatient prospective payment (IPPS) rule that was published in the Federal Register on August 19, 2008, updates Medicare payments to hospitals for fiscal year 2009 and provides additional incentives for hospitals to improve the quality of care provided to people with Medicare. The final rule was effective for discharges on or after October 1, To read the complete press release from CMS, visit this link: checkdate=&checkkey=&srchtype=1&numdays=3500&srchopt=0&srchdata=&keywordtype=all&chknewstyp e=1%2c+2%2c+3%2c+4%2c+5&intpage=&showall=&pyear=&year=&desc=&cboorder=date. In addition to the final rule, CMS is encouraging states to adopt the same or similar non-payment policies outlined in the final Medicare rule. Several states either already have or are considering methods to reduce or eliminate payment for some never events. Blue Cross and Blue Shield of Louisiana is working toward a revised payment poicy to either limit or not pay for select serious adverse events that are reasonably preventable. This policy would be implemented as hospital contracts are renegotiated beginning in We will keep hospitals informed of our progress. New Diagnostic Facility Credentialing Policies Effective January 1, 2010, we will require all participating freestanding diagnostic radiology facilities to be accredited for certain high tech imaging modalities in order to continue participation in our networks. Any newly credentialed diagnostic center has to be accredited before being accepted into the network. As of January 1, 2010, all participating freestanding diagnostic radiology facilities must be accredited by either the American College of Radiology (ACR) and/or the Intersocietal Accreditation Commission (IAC) for the modalities listed below: Computed tomography (CT) Magnetic resonance imaging (MRI) Nuclear Cardiology Positron emission tomography (PET) At this time, hospitals and physician offices are not affected by this requirement. If you have any questions, please contact Network Administration at (800) , option 2 or Network.Administration@bcbsla.com. Page 2 of 5

3 Blue Cross and HMO Louisiana Issuing New Member ID Cards In an effort to increase efficiency and reduce administrative costs, Blue Cross and HMO Louisiana began using new and improved member ID cards in November While the card has a new look, all of the key information remains the same. We don t expect this upgrade to cause any service interruptions or affect coverage. Because it will take up to two years for all members to receive an upgraded card, please continue to accept both old and new formats during the transition period Medicare Deductibles Effective January 1, 2009, Medicare will increase its deductible and copayments (see below). Letters are being mailed to our Medicare supplement (BlueChoice 65) members informing them of the 2009 Medicare changes. Services 2009 Medicare Pays 2008 Medicare Paid Medicare Part A HOSPITALIZATION First 60 days 61st through 90th day 91st day and after while using 60 lifetime reserve days SKILLED NURSING FACILITY CARE First 20 days 21st through 100th day 101st day and after Medicare Part B All but $1,068 All but $267 per day All but $534 per day All approved amounts All but $ per day $0 Deductible $135 $135 All but $1,024 All but $256 per day All but $512 per day All approved amounts All but $128 per day $0 Update on TRICARE Proposal Blue Cross is awaiting the Department of Defense s decision on who will be awarded the TRICARE contract for the South Region. While the official contract award will be effective June 2009, and the delivery of healthcare coverage for the next contract period will not begin until early 2010, we anticipate notification of the government s intent in the near future. When we hear more from the Department of Defense, we will let providers know. In the meantime, many thanks to all providers who signed letters of intent with Blue Cross. Page 3 of 5

4 Value of Blue Distinction Centers for Specialty Care Blue Distinction is a designation awarded by Blue Cross and Blue Shield companies to medical facilities that have demonstrated expertise in delivering quality healthcare. The designation is based on rigorous, clinically meaningful measures (or selection criteria ) established in collaboration with leading doctors, medical societies and professional organizations. The goals are to: encourage providers to improve the overall quality and delivery of healthcare, resulting in better overall outcomes for patients, and help consumers find healthcare facilities that have demonstrated better overall outcomes (e.g., fewer medical complications, fewer readmissions and higher survival rates) in the delivery of specialty care. To date, the Blue Cross and Blue Shield Association has designated nearly 800 Blue Distinction Centers across 43 states in the areas of Bariatric Surgery, Cardiac Care, Transplants and Complex and Rare Cancers. A few Plans and Accounts around the nation now require their members to use Blue Distinctiondesignated hospitals to receive full contract benefits. Always verify members eligibility/coverage prior to rendering services. For more information concerning the Blue Distinction program, contact Kim S. Gassie, Network Initiatives Administrator, (225) or Kim.gassie@bcbsla.com. Preparing for ICD-10 International Classification of Diseases is embarking on its 10th revision, ICD-10. Currently, the version is to take effect as early as October Most agree that the new system is necessary to keep up with new medical developments constantly emerging ICD-10 will have nearly 10 times as many codes as are currently used with ICD-9. Centers for Medicare and Medicaid Services (CMS) says the new system will allow providers to include more details on patient records. The coding changes will also make it easier to track new disease outbreaks. However, because of the time and expense involved in converting to ICD-10, many providers and health plans have requested the deadline be extended at least five years. The transition is expected to be extremely labor intensive to implement and cause an increase in billing errors and delays, ultimately affecting consumers. More time, before the system takes effect, is needed to avoid or reduce the affect of these issues. Because ICD-10 may overlap the transition to version 5010 of the HIPAA electronic transaction standards causing more difficulty with either transition, Blue Cross Plans have proposed a five-year schedule outlining actions necessary for a successful transition to ICD-10 without overlapping the two new system transitions. The proposed plan recommends that CMS adopt a timely process in advance of the October 2011 compliance date to respond to the industry s questions regarding all aspects of the implementation. Blue Cross Plans will continue to work to have the deadline extended. Hospitals Encouraged to Become Tobacco-Free We at Blue Cross and Blue Shield of Louisiana applaud the many Louisiana hospitals that have taken the step to make their campuses tobacco-free. Healthcare providers and insurers alike have a responsibility to encourage good health practices by supporting and following the Louisiana Smoke-Free Air Act, which prohibits smoking in most public places. For those hospitals that have not yet become smoke-free, we encourage you to kick the habit. For more information on the Louisiana Smoke-Free Air Act, visit the Department of Health and Hospital s official website for the Louisiana Tobacco Control Program at or Page 4 of 5

5 Company News Blue Cross to Celebrate 75th Anniversary in 2009 The year 1934 was a notable time in Louisiana history: Huey P. Long served in the U.S. Senate, Tulane won the Sugar Bowl, Bonnie and Clyde were ambushed near Shreveport... and Blue Cross opened its doors in New Orleans with two employees to serve our customers. A lot has changed since 1934, but our commitment to Louisiana has never wavered. Today, Blue Cross and Blue Shield of Louisiana employs more than 1,600 residents across the state. And the once-small, one-room company now makes a $3.5 billion impact on the state s economy. Throughout 2009, we ll celebrate our diamond jubilee in a number of ways. Blue Cross is proud of the fact that we can count nearly 9 out of every 10 Louisiana doctors in our networks, as well as every full-service acute care hospital in the state. Our four straight No. 1 rankings for provider satisfaction help to show our commitment to serving you as well as your patients our mutual customers. We ve served those customers since 1934 through good times and bad... in sickness and in health. We re proud of our 75 years of commitment to the health of all Louisianians. Join us as we look forward with a vision for a healthier Louisiana to come. Important Notes & Reminders: NPI Billing Information for ER Physicians Emergency Room physician NPIs must be included at the Billing Level (FL 33) and at the Rendering Level (FL 24J) on claims submissions to Blue Cross and Blue Shield of Louisiana. Correct Taxonomy Codes Essential To avoid delays in claims processing, facilities must file claims with the correct taxonomy codes as well as NPI. An incorrect taxonomy code could result in claims being either paid with the wrong reimbursement or returned to the facility to re-file correctly. Reminder for Long Term Care Acute Facilities Remember to file your claims with the appropriate revenue codes that you are authorized to use with the service level options as outlined in your contract. It is our intention to pay your claim at the appropriate service level authorized according to your contract, but we have some system limitations that may result in your claims being reviewed for accurate payment. In the case of overpayment, an adjustment will need to be made. Page 5 of 5