Bureau for Medical Services & Molina Medicaid Solutions Provider Workshops June 2011
Agenda Welcome and Introductions Healthcare Reform Provider Incentive Program 5010 Electronic Transactions Provider Enrollment & Screening Provider Re-Enrollment Policy & Program Updates Managed Care Updates BMS Website General Billing Information Innovative Resource Group (APS) 2
Healthcare Reform What is Healthcare Reform? Key areas of Reform Purpose of PPACA (Patient Protection and Affordable Care Act) PPACA and the States PPACA provisions for Medicaid PPACA funding opportunities 3
What is Health Care Reform This presentation provides a high-level overview of the purpose, provisions, and related funding of the Patient Protection and Affordable Care Act (PPACA, Act), as well as an overview of how the Act will affect the West Virginia Department of Health and Human Resources (DHHR) and Bureau for Medical Services (BMS). The Act is also referred to as the Affordable Care Act (ACA). The Obama Administration has stated that the intent of the Act is to put individuals, families, and small business owners in control of their healthcare. 4
Key Areas of Reform Much of the PPACA must be resolved through regulations. Many of the provisions became effective upon enactment, and requirements of the Act continue through 2019. Most of the reform activities will occur between 2010 and 2014. > Health Insurance Reform > Employers offering health insurance to employees > Public Programs including Medicaid, the Children s Health Insurance Program (CHIP), Medicare, and Public Health > Healthcare workforce training > Elimination of fraud, waste, and abuse in healthcare > Improving the quality of healthcare 5
The Purpose of PPACA PPACA starts to change the way healthcare is delivered. PPACA deals in great part with insurance reform. Among those reforms: > Holding insurance companies accountable to keep premiums affordable and prevent denials of care and coverage, including for preexisting conditions > Making health insurance affordable for middle class families and small businesses with tax credits for health care, and reducing premiums and out-of-pocket expenses. PPACA creates powerful incentives so that more healthcare providers can begin to deliver the kind of coordinated, patient-centered care that has been shown to get best results. 6
PPACA and the States The critical role of State government is in managing and financing the Medicaid and CHIP Programs. The PPACA creates new requirements for expanded coverage and accountability mandates for those programs. States must also create, manage, and regulate new insurance exchanges for both individual residents and businesses. The extensive new regulations for the health insurance plans must be enforced by the States as well. 7
PPACA Provisions for Medicaid Continues Medicaid coverage to any individual who has been in foster care under the age of 26. Develops a core set of health care quality measures for Medicaid-eligible adults. Eliminates fraud, abuse and waste in the system which may require outside vendor procurement and outside contracting meeting the federal requirements. Provides new options to States to provide Medicaid long-term care services and support. 8
PPACA Funding Opportunities The Medical Home State Options offers states enhanced match of 90 percent FMAP (Federal Medical Assistance Program) for two years and small planning grants may be available to promote the use of medical homes for enrollees with chronic conditions. West Virginia has been a leader in developing the medical home concept. WV has applied and received a planning grant for this opportunity. Health Homes for Members with Chronic Conditions. WV has applied and received a Money Follows the Person grant. 9
Provider Incentive Program (PIP) The Electronic Health Records (EHR) Provider Incentive Program (PIP) is a federal program offering financial support to assist eligible providers to adopt, implement, or upgrade certified EHR technology. The Medicaid EHR Incentive Program will provide incentive payments to eligible professionals, eligible hospitals, and critical access hospitals (CAHs) as they adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology in their first year of participation and demonstrate meaningful use for up to five remaining participation years. Incentives will be available through both Medicaid and Medicare. > Eligible healthcare professionals will be required to choose between Medicaid and Medicare. > Those in border counties should choose the state from which they will receive the incentive payments. Hospitals may be able to receive incentive funds from both programs. > The Bureau for Medical Services (BMS) will administer the Medicaid EHR Incentive Program for West Virginia. 10
Provider Incentive Program (PIP) Providers eligible for payment are: > Physicians, Dentists, Pediatricians, Nurse Midwives, Nurse Practitioners, Physician Assistants who practice in a Federally Qualified Health Center (FQHC), Critical Access Hospitals, Acute Care Hospitals Estimated Go-Live date is July 2011 Payments will be made through the claims processing system Link for provider attestation will be available through Molina s webportal > www.wvmmis.com Payment information will be reflected through provider s remittance advice Questions related to PIP will be handled through Provider Relations 11
Provider Incentive Program (PIP) Key dates from Centers for Medicare and Medicaid Services (CMS): > January 2011 - Medicaid providers can register with the Federal National Level Repository (NLR). > July 2011 - Attestations from Medicaid providers can be submitted through state MMIS portal. > Late July 2011 - WV State payments to Medicaid providers are expected to start. > September 30, 2011- Last day of the federal fiscal year. Reporting year ends for eligible hospitals and CAHs. > October 1, 2011 - Last day for eligible professionals to begin their 90-day reporting period for calendar year 2011 for the Medicare and Medicaid EHR Incentive Program. 12
Provider Incentive Program (PIP) Key Dates continued: > November 30, 2011-Last day for eligible hospitals and CAHs to register with NLR and attest to receive an incentive payment for federal fiscal year (FY) 2011. > December 31, 2011- Reporting year ends for eligible professionals. > February 29, 2012 -Last day for eligible professionals to register with the NLR and attest to receive an incentive payment for calendar year (CY) 2011. 13
5010 and D.0 Electronic Transactions CMS is monitoring the States compliance with the regulatory requirement to convert from Health Insurance Portability and Accountability Act (HIPAA) Accredited Standards Committee (ASC) X12 version 4010A1 to ASC X12 version 5010 and National Council for Prescription Drug Programs (NCPDP) version 5.1 to NCPDP version D.0. All covered entities are targeted to be fully compliant on January 1, 2012. The new HIPAA 5010 electronic transaction standard will drive billing, reimbursement, and many administrative functions, as well as accommodate the larger ICD-10 code sets. Version 5010 has more than 2,500 generic and 1,000 unique changes ranging from field size increases to entire new segments of data, resulting in considerably more data than its predecessor 4010A. 14
5010 and D.0 Electronic Transactions Readiness of provider community Testing process > Providers will need to test with outside vendor (Edifecs) before testing with Molina > If the provider submits through clearinghouse, the individual provider is not required to test Testing schedule > Once the provider/clearinghouse is certified from outside vendor, the provider /clearinghouse will be required to have three successful tests before submitting 5010 transactions Companion guides and comparison XML will be posted on the web portal 15
5010 and D.0 Electronic Transactions The following transactions will be affected by 5010: > 837 I/P/D Inbound > 276/277 > 270/271 > 835 Outbound Direct Data Entry (DDE) into the web portal will not be affected by 5010. All screens will remain the same. Batch uploads via the web portal will need to be submitted in the new 5010 standard. All real-time pharmacy transactions will be impacted by the new D.0 standard. 16
General Policy Updates National Correct Coding Initiative New funding opportunities > Money Follows The Person > Health Homes for Members with Chronic Conditions Revised BMS chapter changes Assistant-at-Surgery > Must be billed with appropriate modifier (-80) & operative report must reflect services provided by assistant at-surgery Orthopedic update > Effective 6/1/2011, CPT code 64455 (Nerve Block Injection, Plantar Digit) may now be billed by physicians that have the specialty of Orthopedics. Certified Nurse Midwife > May bill for vaginal delivery in a hospital when facility has approved these services via credentialing & delineation of services Radiology services CTs, MRIs or PET Scans in office setting > Effective 1/1/2012, CMS requires accreditation by American College of Radiology, Intersocietal Accreditation Commission or Joint Commission 17
General Policy Updates (Target Effective Date 9/1/2011) Anesthesia > All anesthesia codes, except for 01996 must be billed with a modifier. > Anesthesiologists must bill AA, AD, QK, QS or QY modifier; CRNAs must bill with QS, QX or QZ. > Anesthesia service with time units of 40+ requires paper claim and documentation (anesthesia and operative reports) Reminder 1 time unit = 15 minutes Mastectomy or related, covered, reconstructive procedures will not require prior authorization (PA) with diagnosis of breast cancer Occupational Therapy > CPT Codes 97003 & 97004 will be restricted to Revenue code 0434 Physical Therapy > CPT codes 97001 & 97002 will be restricted to Revenue code 0424 Speech Therapy > CPT codes 92506, 92507 and 92508 must be billed by the speech therapist on a CMS 1500 or 837P > If employed by hospital or CAH, pay-to must be facility 18
Managed Care Updates Effective July 1, 2011, when a Managed Care (MCO) member switches to fee for service (FFS) while inpatient, the MCO will be responsible until discharge You may contact Brandy Pierce at 304-558-1700 for questions related to this change 19
Diabetes Education Program Collaborative effort - Medicaid and Bureau for Public Health s WV Diabetes Prevention and Control Program Web-based training program access thru BMS (www.dhhr.wv.gov/bms) or CAMC website (www.camcinstitute.org/education) Based on American Diabetes Association s Clinical Practice Recommendations Primary Care Providers and other health care professionals > 2 courses Initial certification Recertification required every 2 years Must complete/maintain certification to be reimbursed for providing diabetes education sessions under program > HCPCS codes for billing Code S0315 - initial assessment & initiation of self management training session Code G0108 30 minute (individual) diabetes education session Code G0109 30 minute (group of 2 or more patients) diabetes education session > Limited number of sessions per patient per year 20
Provider Enrollment Provider enrollment application > Current application with supplemental pages > New paper application > User Manual Ownership Information > Owners, managing employees, and agents > Must provide information for each individual with 5% or more ownership interest > Must provide information for owners who are related to each other > Must provide information if ownership is present in other organizations that bill Medicaid > Ownership information must be completed in its entirety 21
Provider Enrollment Application fee $505.00 for 2011 > Required for institutional providers ICF-MR, Hospitals, PRTFs > Application fee waived if paid to Medicare or another State s Medicaid program or CHIP > CMS has the authority to change the fee yearly Hardship Exception Request > Form must be requested from Molina > Form and supportive documentation must be submitted with enrollment application > Request for hardship exception is sent to CMS by Medicaid > CMS makes decision and notifies Medicaid > Enrollment application on hold until CMS decision received 22
Provider Screening Risk Levels > Apply to all providers > Based on risk of fraud, waste or abuse Database Checks > Federal Office of Inspector General s List of Excluded Individuals & Entities (LEIE) > General Services Administrations Excluded Parties List System (EPLS) > State Medicaid Exclusion Lists > State Licensing Boards Criminal background check Fingerprinting Site visits 23
Risk Levels by Provider Types Each provider type has been designated as limited, moderate, or high risk by CMS > Limited - Physicians or non-physician practitioners and medical groups or clinics > Moderate - Community mental health centers, comprehensive outpatient rehabilitation facilities, hospice organizations, independent diagnostic testing facilities, independent clinical laboratories, non-public, non-government owned or affiliated ambulance service suppliers, and currently enrolled home health agencies and DMEPOS suppliers > High - Prospective (newly enrolling) home health agencies and suppliers of DMEPOS At State s discretion, the risk level may change. 24
Provider Enrollment Site visits are required for providers in moderate and high risk levels > States are required to conduct pre-enrollment (unannounced) and post enrollment (announced) site visits. > Molina staff will conduct both visits. > Failure to permit access for site visits would be a basis for denial or termination of Medicaid enrollment. > Site visits are waived if conducted by Medicare or another State s Medicaid program or CHIP. 25
Provider Re-Enrollment Provider enrollment and screening requirements and need for additional information from providers > Medicaid providers will need to be re-enrolled Scheduled to begin in Fall of 2011 > Phased-in approach by provider type/risk level > Schedule will be placed on the web portal and banner pages > Providers will be notified by mail Provider Re-Enrollment will be electronic through web portal > Providers will receive letter with access code to re-enroll > Providers will have 30 days to complete re-enrollment or provider will be placed on pay hold 26
New BMS Website BMS has created a new website that provides new navigation features > www.dhhr.wv.gov/bms Providers and members may subscribe to feeds related to the changes within Medicaid Updated Provider Manual MediWeb Portal Mountain Health Choices State Medicaid Plans 27
BMS Website 28
Helpful Websites Bureau for Medical Services > www.dhhr.wv.gov/bms Molina Medicaid Solutions > www.wvmmis.com Centers for Medicare and Medicaid Services > www.cms.gov 29
Timely Filing Claims must be received within one year from the date of service If Medicare is primary, claims must be received within one year from the Medicare paid date > One additional year with proof of timely filing Corrected claims with reversal-replacement form can be submitted within two years from the date of service Claims over two years old will not be processed without a back dated medical card Original claims and corrected claims with reversal-replacement form that are over one year are to be sent to: > Molina Provider Relations, PO Box 2002, Charleston, WV 25327 30
Common Errors Resulting in Denied Claims Rendering provider not approved for services billed Missing/incomplete/invalid HCPCS code > Validate code is keyed correctly > Validate code is current for date of service Missing/incomplete/invalid NDC code > For resolution refer to the drug code/ndc information on the BMS website, www.dhhr.wv.gov/bms 31
Common Errors Resulting in Denied Claims (continued) Primary payer information not provided with claim > Paper & Electronic Claims Charges are covered under capitation agreement or managed care plan > For members who have a PAAS provider, PAAS approval is required on the claim > View member s card to verify MCO or PAAS > Utilize AVRS to verify MCO or PAAS 32
Errors Resulting In Returned Claims Member ID not 11 digits NPI and Tax ID not in the appropriate fields Missing Diagnosis Codes Missing Dates of Service Missing Place of Service Print is not legible and data is not aligned within applicable blocks on the claim form 33
34 Molina s Provider Relations Representatives