Archive | January 2013

Horizon Wrong Payee Issue- 5010 Problems Persist

Members are urged to review payments from Horizon, beginning in 2012, to ensure that payments went to the correct tax identification number. Last year several members reported that Horizon was remitting payments to the physicians’ social security numbers, instead of the practices’ tax identification numbers. MSNJ reached out to Horizon regarding our concerns, including possible tax implications. Horizon indicated that the wrong payee issue was a result of the 5010 transition. MSNJ was assured, on several occasions, that the systems issue was “identified and corrected” and that claims would be reprocessed.

Recently, MSNJ was made aware that the issue is ongoing for some member practices and has resulted in continuing incorrect payments, corrections, and recoupments. MSNJ is concerned that many members may not be aware of the issue, due to EFT payments. We advise members to review the “Payee ID” number located at the top of explanations of benefits issued by Horizon, from the beginning of 2012 on, to confirm that payments went to the correct tax identification number. We advise that members review payments from Horizon, from 2012 on, to confirm that payments went to the correct tax identification number. We fear there may be IRS 1099 tax implications for payments sent to the physician’s social security number, when they should be remitted to the practice’s tax identification number. We sent a letter to Horizon again expressing our concern that the issue was not corrected; requesting that Horizon provide us with their plan to rectify the matter and asking Horizon to send notice to all affected physicians. If you are currently experiencing this issue, please contact MSNJ at and put “Horizon Wrong Payee” in the subject line.

MSNJ will keep members apprised of progress on this issue.

MSNJ News Roundup – January 4, 2013

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.