In mid-October UHC began terminating physicians in their Medicare Advantage plan. We immediately reached out to UHC when it appeared that the terminations were not isolated, but rather part of a broad initiative. This week, UHC responded to some of our questions. We are disappointed that there was no warning of this termination initiative which appears to be a significant redesign of the UHC Medicare Advantage network, nationwide, and that information is sparse. For example, UHC would not tell us how many physicians in New Jersey were terminated or whether any specialties were immune to the termination initiative. Yet, UHC assured us that the network had been “tested and retested” for network adequacy and that there would not be a specialty access issue.
Network Adequacy: Obviously, MSNJ has no way of evaluating the impact on the network without more information. Therefore, we are asking all physicians who received termination letters, to provide us with information so that we can better evaluate network adequacy concerns. CMS has agreed to help us with that assessment.
Lack of Transparency: In addition to our network adequacy concerns, we are troubled that patients may be enrolling or re-enrolling in the UHC Medicare Advantage plan now, because seniors are in the middle of open enrollment, believing that they will be able to continue to be treated by physicians who are currently in the plan. UHC agreed to consider our complaint on lack of transparency on the 2014 network, given that seniors are enrolling now based on the current network. It is important to note that patients may change their network selection. CMS will honor the last selection made by the patient by December 7 when open enrollment ends.
Continuity of Care: We expressed our concerns about continuity of care and a disruption of established physician-patient relationships. We urged UHC to carve out an exception for patients who wish to continue to see their current physician. UHC agreed to consider this request. We believe that patients should have the right to choose their physicians and must know their network status to make those choices.
Discussions with CMS: With a reopening of the federal government, we have contacted CMS about our network adequacy and continuity of care concerns. Our Region 2 office has been facilitating communication with the Region 9 office which is responsible for the UHC Medicare Advantage network. CMS Region 9 is charged with ensuring network adequacy and transparency for Medicare beneficiaries in their selection of a Medicare product. CMS has offered to test areas for network adequacy. Please provide us with information so that we can identify geographical and specialty areas of concern.
What to do: Last week we urged physicians who wished to stay in the Medicare Advantage network to appeal and provided suggestions for those appeals. We will continue to update our advice to members as more information becomes available to us. Visit our web site for a list of Do’s and Don’ts, Appeal Suggestions, a template letter to inform patients of your imperiled status in the UHC Medicare Advantage Network.
Visit MSNJ’s UHC Webpage for more information.
Save the date for MSNJ’s UHC Termination Update webinar on Tuesday, October 29 at 7:00PM. Details to follow on www.msnj.org.
Medicaid has agreed to pay certain resubmitted claims retroactive to January 1 in response to an MSNJ request. In January 2013, the Medicaid program required that all physicians who order, refer, or attend Medicaid beneficiaries, but do not bill for their services, enroll in the program as non-billing providers. The program confirmed to MSNJ that enrolling will not cause a physician to become a participating provider, but it will allow participating providers to be paid and will bring the program into compliance with the Affordable Care Act.
MSNJ subsequently received complaints from Medicaid participating providers who are not being paid due to the ordering/referring physician’s failure to enroll as a non-billing provider. In April MSNJ requested that the Medicaid program “consider making an exception that allows for resubmission of claims for payment once the non-billing provider has enrolled.” The program recently advised that the treating physician may resubmit denied claims after the ordering/referring physician enrolls as a non-billing provider.
In 2013, non-billing provider enrollment will be retroactive to January 1, 2013. In 2014 and going forward, non-billing provider enrollment will be retroactive to one year prior to receipt of the enrollment application. For instance, a non-billing provider who submits an enrollment application on March 15, 2014 will be retroactively enrolled back to March 15, 2013. This is to allow participating physicians enough time to resubmit claims within the timely filing limit (up to one year).
MSNJ appreciates the Medicaid program’s response to our request.
The Division of Medical Assistance and Health Services (DMAHS) confirmed that all physicians who qualify for the ACA enhanced payments to Medicaid primary care providers must complete an attestation form indicating board certification status in a primary care specialty. The deadline for submission of the ACA Self-Attestation Form for traditional fee-for-service Medicaid has been extended to April 30, 2013.
Physicians must submit the attestation by April 30th in order to be eligible for retroactive incentive payments going back to January 1, 2013. Physicians who submit the attestation after April 30th will receive incentive payments starting from the first day of the month the attestation was submitted. For example, if the attestation is submitted on July 17, 2013, then the incentive payments will apply to claims starting July 1st. An original signature is required; therefore the form must be mailed to: Molina Medicaid Solutions, P.O. Box 4804, Trenton, NJ 08650. Please note: the fee-for-service deadline does not apply to physicians in the MCOs; a deadline will be provided in a letter to the physician from the MCO.
CMS clarified that all physicians who qualify for the ACA enhanced payments to Medicaid primary care providers must complete an attestation form indicating board certification status in a primary care specialty. The deadline for submission of the ACA Self-Attestation Form for traditional fee-for-service Medicaid is March 15, 2013. An original signature is required; therefore the form must be mailed to: Molina Medicaid Solutions, P.O. Box 4804, Trenton, NJ 08650. Fee for service physicians who do not file the attestation form by March 15th will not receive the retroactive payments. Fee-for-service physicians are also being “reminded of the importance of reporting their true usual and customary charges on these claims” to “ensure that adjustment payments for eligible claims can be processed correctly.” Please see the DMAHS newsletter for details. The fee-for-service deadline does not apply to physicians in the MCOs; a deadline will be provided in a letter to the physician from the MCO. Read more.
Medicaid Primary Care Incentive Payments Delayed, but will be Retroactive
MSNJ confirmed with DMAHS that the division will file the necessary State Plan Amendment (SPA) to obtain federal approval for the primary care incentive payments for fee-for service physicians. The SPA is due to the federal government by March 31st. Once the State receives approval and increases the rates, retroactive payments (going back to January 1, 2013) will be made to physicians who qualify under the federal regulations. Read more. DMAHS is also working to ensure that physicians in MCOs will receive the primary care incentive payments retroactively. This implementation process is separate from the fee-for-service process. Read the separate article on steps that fee-for-service providers must take by March 15th to receive retroactive payments.
Medicaid Primary Care Incentive Payment Attestation: March 15th Deadline for FFS Physicians
CMS clarified that all physicians who qualify for the ACA enhanced payments to Medicaid primary care providers must complete an attestation form indicating board certification status in a primary care specialty. The deadline for submission of the ACA Self-Attestation Form for traditional fee-for-service Medicaid is March 15, 2013. An original signature is required; therefore the form must be mailed to: Molina Medicaid Solutions, P.O. Box 4804, Trenton, NJ 08650. Fee for service physicians who do not file the attestation form by March 15th will not receive the retroactive payments. Fee-for-service physicians are also being ” reminded of the importance of reporting their true usual and customary charges on these claims” to ” ensure that adjustment payments for eligible claims can be processed correctly.” Please see the DMAHS newsletter for details.
The fee-for-service deadline does not apply to physicians in the MCOs; a deadline will be provided in a letter to the physician from the MCO. The New Jersey Division of Medical Assistance and Health Services (DMAHS) explained that physicians may have to complete separate attestation forms for the Medicaid Managed Care Organizations (MCOs), if the MCO does not have a record of board certification on file. DMAHS is working with the MCOs to coordinate an outreach effort to the physicians that will need to provide an attestation. MSNJ will continue to communicate with the Medicaid program about MCO attestation requirements and retroactive payments. Please stay tuned to e-News for more information as it becomes available.
Governor Christie’s decision to expand Medicaid is a positive step that will create access to health insurance for many uninsured residents. Importantly, this decision will make additional investment in the program possible. This is also an opportunity to align incentives and create a robust network of physicians and other healthcare providers for the Medicaid program. Expanding an underfunded program will increase access to insurance, but will not deliver adequate access to physician services for our newly insured citizens.
The Medical Society of New Jersey supports reform of the state’s Medicaid Program. Our Medicaid Program is one of the poorest paying healthcare programs in the nation.* Conversely, practice expenses in New Jersey are among the highest in the nation. These unfortunate facts prevent many physicians and other healthcare providers from being financially able to participate in the Medicaid program. We look forward to working with our government and private sector partners to ensure access to quality healthcare for all New Jersey residents.
*Health Affairs August 2012 vol. 31 no. 8 1673-1679
Medicare Fee Cut Averted Through 2013; Sequester Cut Delayed for Two Months On January 1st Congress passed the American Taxpayer Relief Act and successfully averted the average 26.5% cut in the Medicare physician fee schedule The act dodges the scheduled fee cut due to the sustainable growth rate (SGR), but does not repeal the flawed formula. The 2% sequestration cuts to Medicare payments have also been delayed, but for only two months. MSNJ and our members actively lobbied our congressional delegation to stop the Medicare fee cut, repeal the SGR and replace it with new payment models that will be sustainable. This action stops the fee cut and allows a year for the repeal and replacement of the SGR. While we are thankful that Congress prevented the drastic cut in fees, MSNJ still believes that a permanent fix to the SGR is necessary and overdue. See Senator Menendez’s response to MSNJ’s request that the SGR be repealed. We will continue our efforts to repeal the SGR.
This $25 billion band-aid was offset by assorted provisions. Thankfully, as advocated by MSNJ and the AMA, the increase in Medicaid payments to primary care providers and funds for preventive services remain untouched. Unfortunately, the offsets will have a negative impact on payments for advanced imaging services and will extend the statute of limitations on recoupment to 5 years. In addition, the act takes back unobligated funds for health insurance co-ops as a cost savings. Existing obligations will be honored.
For details on Medicare and other health provisions contained in the American Taxpayer Relief Act, visit the AMA’s website.
2013 Medicare Fee Schedule- Billing Update & Participation Deadline Extension
Many members have questions about billing Medicare, now that the cut has been averted. Although the fee cut has been prevented, it is an average, not applicable to each CPT code and there may be other changes affecting the 2013 Medicare fee schedule, besides the SGR. While the SGR cut has been delayed until after December 31, 2013, Relative Value Unit (RVU) changes will be different from last year, thus changing the 2013 fee schedule for certain CPT codes–either up or down.
We have asked for implementation information from Novitas (New Jersey’s Medicare Contractor). So far, there is no official Novitas position, but CMS published notice indicating that it is updating the 2013 Medicare Physician Fee Schedule. CMS also noted that the Medicare contractors may hold claims until January 15, 2013, while they test and implement the fee schedule. This falls within the prompt pay timeframe.
CMS will give Novitas until January 23, 2013 to post the updated fee schedule on its website. As of today, the Medicare fee schedule posted on the Novitas website still reflects the scheduled fee cut. In the meantime, we recommend that members hold claims until Novitas posts the corrected 2013 fee schedule. If a practice uses the wrong fee schedule and bills Medicare less than the new fee schedule amount, Medicare will pay the lesser of the two fees and will not reconsider the claim. CMS has also extended the deadline for changing participation status to February 15, 2013. We will notify members, once additional information is received from Novitas.
First HIPAA Breach Settlement Involving Fewer than 500 Patients Announced
The U.S. Department of Health and Human Services (HHS) recently announced a resolution agreement in which the Hospice of North Idaho (HONI) agreed to pay $50,000 for potential HIPAA violations involving less than 500 patients. This is the first settlement involving a breach of protected health information (PHI) of fewer than 500 patients. HONI also agreed to a corrective action plan (CAP) that requires HONI to notify HHS of any violation of HONI’s privacy and security policies within 30 days of the breach for two years after the date of the resolution agreement. As part of the CAP, HONI must include a description of the events leading up to the breach, a copy of the policy violated, and a description of the corrective actions taken.
The investigation was prompted by HONI’s submission of a breach report to HHS, a requirement under the HITECH Act. A HONI laptop containing electronic PHI was stolen, putting the privacy of 441 patients at risk. After investigation, HHS found that HONI did not perform necessary risk analysis and failed to establish adequate policies and procedures regarding the security of laptops and other mobile devices containing PHI. These inadequacies were in direct violation of the HIPAA Security Rule.
In its article, New Year, Same Old Health Data Breaches, FierceHealthIT noted that security risks continue to be a problem for the healthcare industry and listed several recent cases of PHI security breaches. HHS recognized that physician education is essential to reduce the frequency of such breaches. In response, HHS developed an educational initiative, Mobile Devices: Know the RISKS. Take the STEPS. PROTECT and SECURE Health Information, to assist physicians with HIPAA compliance when using laptops, smart phones, and tablets. Members are encouraged to review the HHS materials and to take the appropriate steps to protect electronic PHI contained in laptops or other mobile devices.
The annual rite of organized medicine seeking congressional action to avert steep Medicare fee cuts before January 1 is upon us. However, this year is different. Not only is a 27% fee cut scheduled to occur because of the flawed SGR formula, but physicians will also be subject to an additional 2% fee cut under the sequestration. Next week Congress and the President will return to Washington to face the fiscal cliff, in addition to resolving the annual Medicare fee issue. In anticipation of this, MSNJ joined virtually all of organized medicine to support SGR Transition Principles in personal letters to the New Jersey delegation. We previously gained the personal support of many of our delegation. (See MSNJ e-News dated February 16, 2012). Members are asked to watch for a strategically timed grass-roots “call to action” on this issue.
This week, the U.S. Attorney General and the Secretary of Health & Human Services announced the launch of a partnership between the federal and state governments, private healthcare insurance companies and other healthcare anti-fraud groups to prevent healthcare fraud. The effort is aimed to safeguard healthcare dollars.
The partnership will share information to improve detection of fraudulent healthcare billing. “A potential long- range goal of the partnership is to use sophisticated technology and analytics on industry-wide healthcare data to predict and detect healthcare fraud schemes.” [Press Release, U.S. Dept. of HHS (July 26, 2012)] According to the Secretary of Health & Human Services, by sharing information across payers—public and private– potential fraudulent activity can be stopped:
In the past, we followed a ‘pay and chase’ model, paying claims first – then only later tracking down the ones we discovered to be fraudulent. … Since we have put this system in place, it has stopped, prevented, or identified millions in payments that should never have been made. And because the system is designed to get smarter over time, as it analyzes more data, it’s only going to be more effective in the future. [Speech of Secretary of U.S. HHS (July 26, 2012)]
The Affordable Care Act permits enhanced screening of physicians who treat Medicare and Medicaid patients and the suspension of payments to physicians engaged in suspected fraudulent activity. This public-private partnership will build on these fraud prevention tools.
The Federal Government has recovered fraudulent payments of $10.7 billion over the past three years. Read more about fraud prevention under the Affordable Care Act.
MSNJ recently joined with the AMA asking CMS to explain its payment policy for Medicare-covered services furnished by physicians who are not enrolled in Medicare. This question was crystallized by a Form-1490S which permits beneficiaries to seek Medicare payments for services rendered by non-enrolled physicians. In addition, CMS had taken the position that non-enrolled physicians would be subject to penalties for using this as a method to obtain payment from the Medicare program. Because this appeared to be a “fourth option” for treating Medicare patients and being reimbursed, it was necessary to formally seek a clarification from CMS on this payment policy. (The three understood options are: participating, non-participating and opted-out).
CMS has formally responded in a letter indicating that the form may not be used by non-enrolled physicians as a method to seek reimbursement. CMS explained that the form has a limited use, for a beneficiary to seek a determination where a physician refuses to submit a claim for covered services.
According to CMS, a physician must submit a claim for covered services rendered to a Medicare patient, whether or not the physician is enrolled. Penalties may be applied for failure to do so.
The following is a message from the AMA, explaining the CMS response:
The Centers for Medicare and Medicaid Services (CMS) has responded in writing to the request of the AMA and over 70 state and medical specialty societies regarding the policy for Medicare-covered services furnished by physicians who do not enroll in Medicare. In the letter, CMS confirmed that physicians can enroll in Medicare as a participating (PAR) or non-participating (non-PAR) physician, or they can choose to opt-out of Medicare and furnish services to Medicare beneficiaries under private contracts. CMS also stated that Medicare requires physicians to enroll in Medicare in order to bill for services furnished to Medicare beneficiaries, whether directly from Medicare or from the beneficiary who is, in turn, reimbursed by Medicare. If a physician furnishes a covered service to a beneficiary, the physician is required to complete a claim form and submit it to Medicare on behalf of the beneficiary. Penalties can apply to physicians who do not follow this requirement. CMS also explained that CMS Form-1490S (which allows beneficiaries to seek Medicare payment) is rarely used since contractors are encouraged to educate physicians about the requirement to submit claims, but is intended to protect a beneficiary’s right to a payment determination in situations where a physician refuses to submit a claim for a covered service on behalf of the beneficiary. CMS’ letter can be found at the following link: http://www.ama-assn.org/resources/doc/washington/cms-fourth-option-response-letter.pdf.
The upshot of the CMS response is that there is no “fourth option” under the Medicare program. Additionally, except for physicians who are formally opted-out, physicians are subject to penalties if they provide and bill for covered services and do not submit a claim to the Medicare program.