In This Issue. Information Releases

Transcription

1 An Informational Newsletter for Idaho Medicaid Providers From the Idaho Department of Health and Welfare, April 2017 Division of Medicaid In This Issue Are You Still Going to Get Paid?... 2 Important Reminder Regarding Progress Notes for Personal Assistance Agencies... 3 Attention DME Suppliers and Medical Providers... 3 Medicaid Program Integrity Unit... 4 The Five Most Important Federal Fraud and Abuse Laws that Apply to Physicians... 5 Provider Training Opportunities in Medical Care Unit Contact and Prior Authorization Information...11 DHW Resource and Contact Information...12 Insurance Verification...12 Molina Provider and Participant Services Contact Information...13 Molina Provider Services Fax Numbers...13 Provider Relations Consultant (PRC) Information...14 Information Releases MA17-01 Swing Bed and AND Rates... 7 MA17-02 Idaho Behavioral Health Plan 1915(b) Waiver Renewal... 8 MedicAide April 2017 Page 1 of 15

2 Are You Still Going to Get Paid? In compliance with federal regulations, Idaho Medicaid will require that claims list the name and the National Provider Identifier (NPI) of the health care professional that ordered, referred, or prescribed (ORP) the items or services. If the ORP provider s information is not listed on a claim, or if the ORP provider is not enrolled with Idaho Medicaid, the provider billing Medicaid will not receive reimbursement. Although this rule has been in effect for several years, the enforcement will begin for claims submitted on or after May 19, Beginning April 1, 2017, the Molina Provider Relations Consultants (PRCs) will begin reviewing claim reports and contacting providers who are not meeting the ORP reporting requirements. Providers who are rendering services to Medicaid participants and submit claims to Medicaid should ensure that such services are being ordered, referred, or prescribed by an eligible provider who is enrolled in Idaho Medicaid. The following individual providers are eligible to order, refer, or prescribe within the Medicaid program and within their scope of practice: Advanced Practice Registered Nurses Audiologists Dentists Nurse Practitioners Optometrists Physicians Physician Assistants Podiatrists Psychologists This means that health care professionals not currently enrolled with Idaho Medicaid will need to submit an application. If the NPI of the physician or health care professional that ordered, prescribed, or referred the Medicaid participant for the service is not included on the claim, Medicaid reimbursement will not be allowed. Idaho Medicaid will enforce ORP requirements on claims submitted by the following provider types: Durable Medical Equipment Suppliers Home and Community-Based Assisted Living Home Health Agencies Hospice Hospitals (inpatient and outpatient) Imaging\Testing Facilities Independent Laboratories Nursing Facilities Outpatient Health Facilities Pharmacies Portable X-Ray Suppliers Private Duty Nurses Therapy Providers There is an abbreviated application process for providers who do not submit claims to Medicaid but who must enroll as ordering, referring, certifying, or prescribing providers. As recommended in previous guidance by IDHW, providers billing Medicaid should be prepared to ensure all referring, ordering, and prescribing physicians and other health care professionals have NPIs and are enrolled in Medicaid. MedicAide April 2017 Page 2 of 15

3 Important Reminder Regarding Progress Notes for Personal Assistance Agencies In consultation with the Medicaid Program Integrity Unit (MPIU), the Bureau of Long Term Care (BLTC) would like to remind Personal Assistance Agencies that progress notes must clearly support all Medicaid services rendered. In a recent review of agency documentation, it has been identified that some agency progress note templates do not adequately differentiate between the delivery and documentation of Attendant Care versus Homemaker Services. Attendant Care and Homemaker Services are authorized and billed as distinct services. As a result, progress notes for these separate services must be documented clearly. Below is an example of a progress note format that illustrates how an agency might distinguish between services rendered. Week of: Attendant Care Homemaker April 10, 2017 Mobility Bathing Dressing Assistance with Eating Total time (hours) Meal Preparation Laundry Light Housekeeping Essential Shopping Total time (hours) Sunday Monday X X X X 3 X X X X 3 Tuesday Wednesday X X X X 3 X X 2 Thursday Friday X X X X 3 X X 2 Saturday Agencies are strongly encouraged to review existing progress note templates and associated policies and procedures to ensure that all services billed to Medicaid have clear supporting documentation. MPIU may take action when progress notes do not support services billed to Medicaid. Attention DME Suppliers and Medical Providers The Medical Care Unit has come across prior authorization requests for items that do not meet the definition of durable medical equipment (DME) I.A.W. IDAPA The definition of DME is as follows: Durable Medical Equipment (DME). Equipment other than prosthetics or orthotics that can withstand repeated use by one (1) or more individuals, is primarily and customarily used to serve a medical purpose, is generally not useful to a person in the absence of an illness or injury, is appropriate for use in the home, and is reasonable and necessary for the treatment of an illness or injury for a Medicaid participant. (Continued on page 3) MedicAide April 2017 Page 3 of 15

4 (DME Suppliers Cont d) There have been requests sent to the Medical Care Unit for a prior authorization which are not covered per Idaho administrative code, the Medicaid Provider Handbook for Basic and Enhanced fee-for-service Medicaid, and Federal C.F.R. These items are those that do not address the medical need of a patient, nor are they used to treat or amend a medical condition. Other items which have been requested but are not considered durable medical equipment are: Household items and supplies Home/vehicle modifications Household equipment and supplies Environmental adaptive requests and/or products Equipment used for physical fitness, sensory/behavior issues, convenience items, or personal recreation DME funded under Basic or Enhanced Medicaid includes those common items such as wheelchairs, prosthetics, and orthotics, and these items are provided under the authority of the Idaho Medicaid State Plan. The Department determines the most appropriate and cost-effective item for each type of service in accordance with IDAPA. There may be other items that do not meet the definition and/or requirements of DME, which could be available under a waiver benefit, if applicable. Items funded through a waiver benefit are in addition to any medical equipment and supplies furnished under the Medicaid fee-for-service Basic or Enhanced coverage. Idaho Medicaid has the authority to cover DME based on established reasonable standards, consistent with the objectives of the Medicaid statute, for determining the extent of such coverage (42 U.S.C. 1396(a)) based on such criteria as medical necessity or utilization control (42 CFR (d)). Medicaid Program Integrity Unit Correct Billing of Mid-Level Provider Services Audits conducted by the Medicaid Program Integrity Unit have identified providers billing nonphysician services as being provided by physicians. State-licensed physician assistants, certified nurse midwives, and nurse practitioners are eligible to participate in the Idaho Medicaid Program. They must obtain an Idaho Medicaid provider number from Idaho Medicaid. Medicaid reimburses mid-level practitioner services on a fee-for service basis. Most midlevel practitioner reimbursement is 85% of the physician fee schedule as posted on the Department of Health and Welfare s website. IDAPA addresses misrepresentation of services and states any representation that a service provided by a nurse practitioner, nurse midwife, physical therapist, physician assistant, psychologist, social worker, or other non-physician professional as a physician service is prohibited. IDAPA addresses reimbursement of mid-level practitioner services and states that billing for services must be as provided by the CRNA, NP, NM, or PA, and not represented as a physician service. Misrepresentation of services by billing non-physician services as physician services under the physician provider number is subject to recoupment and civil monetary penalties. MedicAide April 2017 Page 4 of 15

5 The Five Most Important Federal Fraud and Abuse Laws that Apply to Physicians Spotlight Anti-Kickback Statute [42 U.S.C. 1320a-7b(b)] Most physicians strive to work ethically, render high-quality medical care to their patients, and submit proper claims for payment. Idaho Medicaid and the Federal Government rely on physicians to submit accurate and truthful claims information. The presence of some dishonest health care providers who exploit the health care system for illegal personal gain has created the need for laws that combat fraud and abuse and ensure appropriate quality medical care. While Idaho statute and rule also addresses Fraud and Abuse, here we are only looking at the Federal laws. Over the next few months we will address the five most important Federal fraud and abuse laws that apply to physicians. These laws are the False Claims Act (FCA), the Anti-Kickback Statute (AKS), the Physician Self-Referral Law (Stark law), the Exclusion Authorities, and the Civil Monetary Penalties Law (CMPL). Government agencies, including the Department of Justice, the Department of Health & Human Services Office of Inspector General (OIG), and the Centers for Medicare & Medicaid Services (CMS), are charged with enforcing these laws. It is crucial that providers understand these laws not only because following them is the right thing to do, but also because violating them could result in criminal penalties, civil fines, exclusion from the Federal and State health care programs, or loss of your medical license from your State medical board. This month we are looking at the Anti-Kickback Statute [42 U.S.C. 1320a-7b(b)]. As a physician, you are an attractive target for kickback schemes. Many people and companies want your patients business and would pay you to send that business their way. Just as it is illegal for you to take money from providers and suppliers in return for the referral of your Medicare and Medicaid patients, it is illegal for you to pay others to refer their Medicare and Medicaid patients to you. In some industries, it is acceptable to reward those who refer business to you. However, in the Federal health care programs, paying for referrals is a crime. The AKS is a criminal law that prohibits payment to induce or reward patient referrals or the generation of business involving any item or service payable by the Federal health care programs. A payment includes anything of value and can take many forms other than cash, such as free rent, expensive hotel stays and meals, and excessive compensation for medical directorships or consultancies. Criminal penalties and administrative sanctions for violating the AKS include fines, jail terms, and exclusion from participation in the Federal health care programs. Additionally, under the Civil Monetary Penalties Law, physicians who pay or accept kickbacks also face penalties of up to $50,000 per kickback plus three times the value of the payment. (Continued on page 6) MedicAide April 2017 Page 5 of 15

6 (Fraud and Abuse Laws Cont d) The kickback prohibition applies to all sources of referrals, even patients. In addition to the AKS, the beneficiary inducement statute (42 U.S.C. 1320a-7a(a)(5)) also imposes civil monetary penalties on physicians who offer payment to Medicare and Medicaid beneficiaries to influence them to use their services. The Government does not need to prove patient harm or financial loss to the programs to show that a physician violated the AKS. A physician can be guilty of violating the AKS even if the physician actually rendered the service and the service was medically necessary. Taking money or gifts from a drug or device company or a durable medical equipment (DME) supplier is not justified by the argument that you would have prescribed that drug or ordered that wheelchair even without a kickback. MedicAide April 2017 Page 6 of 15

7 Figure 1: MA17-01 Swing Bed and AND Rates MedicAide April 2017 Page 7 of 15

8 Figure 2: MA17-02 Idaho Behavioral Health Plan 1915(b) Waiver Renewal MedicAide April 2017 Page 8 of 15

9 MedicAide April 2017 Page 9 of 15

10 Provider Training Opportunities in 2017 You are invited to attend the following webinars offered by Molina Medicaid Solutions Regional Provider Relations Consultants. April: Certified Family Homes This training will walk Certified Family Home providers through the process of signing up for a trading partner account, viewing prior authorizations, creating patient rosters, verifying eligibility, accessing remittance advice reports, and submitting and reviewing claims. Training is delivered at the times shown in the table below. Each session is open to any region but space is limited to 25 participants per session, so please choose the session that works best with your schedule. To register for training, or to learn how to register, visit and click on the Training link in the left-hand menu. April Certified Family Homes May Durable Medical Equipment June Personal Care Services July Eligibility August Vision September Long Term Care October Respite Care November Residential Assisted Living Facilities December Home Health and Hospice 10 a.m a.m. MT 10 a.m a.m. MT 10 a.m a.m. MT 10 a.m a.m. MT 2 p.m. - 3 p.m. MT 2 p.m. - 3 p.m. MT 2 p.m. - 3 p.m. MT 4/12/2017 4/18/2017 4/19/2017 4/20/2017 4/13/2017 4/18/2017 4/20/2017 5/10/2017 5/16/2017 5/17/2017 5/18/2017 5/11/2017 5/16/2017 5/18/2017 6/14/2017 6/15/2017 6/20/2017 6/21/2017 6/8/2017 6/15/2017 6/20/2017 7/12/2017 7/18/2017 7/19/2017 7/20/2017 7/13/2017 7/18/2017 7/20/2017 8/9/2017 8/15/2017 8/16/2017 8/17/2017 8/10/2017 8/15/2017 8/17/2017 9/13/2017 9/19/2017 9/20/2017 9/21/2017 9/14/2017 9/19/2017 9/21/ /11/ /17/ /18/ /19/ /12/ /17/ /19/ /8/ /15/ /16/ /21/ /9/ /16/ /21/ /13/ /19/ /20/ /21/ /14/ /19/ /21/2017 If you would prefer one-on-one training in your office with your Regional Provider Relations Consultant, please feel free to contact them directly. Provider Relations Consultant contact information can be found on page 14 of this newsletter. MedicAide April 2017 Page 10 of 15

11 Medical Care Unit Contact and Prior Authorization Information Prior Authorizations, Forms, and References To learn about prior authorization (PA) requirements, QIO review, or print request forms, go to the medical service area webpage at Prior authorization request forms containing the fax to number can be found at Click on Forms under the References section and you will see the PA request forms under the DHW Forms heading. If you prefer to mail in your form, the mailing address is: Medicaid Medical Care Unit P.O. Box Boise, ID Note: The Medical Care Unit (MCU) does not give authorizations for services over the telephone. To Check Prior Authorizations Status Log on to your Trading Partner Account on Choose Form Entry, then choose Authorization Status. If you are unable to identify the reason for a denied service, a Molina Medicaid Solutions representative can provide the medical reviewer s reason captured in the participant s non-clinical notes. If you are unable to view the authorization status, please review the Trading Partner Account (TPA) User Guide located under User Guides on To speak to a Molina Medicaid Solutions representative, call 1 (866) , option 3. MCU Medical Review Decisions If you have any questions about medical review decisions, please refer to the following contact numbers. Fax Number Phone Number Administratively Necessary Days 1 (877) (866) Ambulance* 1 (877) (800) Breast & Cervical Cancer 1 (877) (208) Durable Medical Equipment 1 (877) (866) Hospice 1 (877) (866) Pharmacy 1 (800) (866) Preventive Health Assistance 1 (877) (208) Service Coordination 1 (877) (866) Surgery-Procedure-Lab 1 (877) (866) Therapy: OT, PT, SLP 1 (877) (866) Vision 1 (877) (866) * Idaho Medicaid contracts with Veyo Logistics for all non-emergency medical transportation services. Please go to or call 1 (877) for more information. MedicAide April 2017 Page 11 of 15

12 DHW Resource and Contact Information DHW Website Idaho CareLine (800) Medicaid Program Integrity Unit P.O. Box Boise, ID prvfraud@dhw.idaho.gov Fax: 1 (208) Telligen 1 (866) Fax: 1 (866) Healthy Connections Regional Health Resource Coordinators Region I Coeur d'alene Region II Lewiston Region III Caldwell Region IV Boise Region V Twin Falls Region VI Pocatello Region VII Idaho Falls In Spanish (en Español) 1 (208) (800) (208) (800) (208) (208) (800) (208) (208) (800) (208) (800) (208) (800) (208) (800) (800) Insurance Verification HMS PO Box 2894 Boise, ID (800) (208) Fax: 1 (208) MedicAide April 2017 Page 12 of 15

13 Molina Provider and Participant Services Contact Information Provider Services MACS (Medicaid Automated Customer Service) Provider Service Representatives Monday through Friday, 7 a.m. to 7 p.m. MT Mail Participant Services MACS (Medicaid Automated Customer Service) Participant Service Representatives Monday through Friday, 7 a.m. to 7 p.m. MT Mail Participant Correspondence Medicaid Claims Utilization Management/Case Management CMS 1500 Professional UB-04 Institutional UB-04 Institutional Crossover/CMS 1500/Third-Party Recovery (TPR) Financial/ADA 2006 Dental 1 (866) (208) (866) (208) idproviderservices@molinahealthcare.com idproviderenrollment@molinahealthcare.com P.O. Box Boise, ID (866) (208) (866) (208) idparticipantservices@molinahealthcare.com P.O. Box Boise, ID P.O. Box Boise, ID P.O. Box Boise, ID P.O. Box Boise, ID P.O. Box Boise, ID P.O. Box Boise, ID Molina Provider Services Fax Numbers Provider Enrollment 1 (877) Provider and Participant Services 1 (877) MedicAide April 2017 Page 13 of 15

14 Provider Relations Consultant (PRC) Information Region 1 and the state of Washington 1120 Ironwood Drive Suite 102 Coeur d Alene, ID (208) Region.1@MolinaHealthCare.com Region 2 and the state of Montana 1118 F Street P.O. Box Drawer B Lewiston, ID (208) Region.2@MolinaHealthCare.com Region 3 and the state of Oregon 3402 Franklin Caldwell, ID (208) Region.3@MolinaHealthCare.com Region 4 and all other states 1720 Westgate Drive, Suite A Boise, ID (208) Region.4@MolinaHealthCare.com Region 5 and the state of Nevada 601 Poleline Road, Suite 7 Twin Falls, ID (208) Region.5@MolinaHealthCare.com Region 6 and the state of Utah 1070 Hiline Road Pocatello, ID (208) Region.6@MolinaHealthCare.com Region 7 and the state of Wyoming 150 Shoup Avenue Idaho Falls, ID (208) Region.7@MolinaHealthCare.com MedicAide April 2017 Page 14 of 15

15 Molina Medicaid Solutions PO Box Boise, Idaho Digital Edition MedicAide is available online by the fifth of each month at There may be occasional exceptions to the availability date as a result of special circumstances. The electronic edition reduces costs and provides links to important forms and websites. To request a paper copy, please call 1 (866) MedicAide is the monthly informational newsletter for Idaho Medicaid providers. Editors: Shelby Spangler and Shannon Tolman If you have any comments or suggestions, please send them to: Shelby Spangler, Shelby.Spangler@dhw.idaho.gov Shannon Tolman, Shannon.Tolman@dhw.idaho.gov Medicaid Communications Team P.O. Box Boise, ID Fax: 1 (208) MedicAide April 2017 Page 15 of 15