WCH Spring Times 2015

WCH BulletinSpring 2015

3706readers

Exclusive Interview with Olga amp Conference Presentation page 11-14

URGENT CARE

2 Spring 2015 WCH Bulletinwwwwchsbcom

Welcometo ourSpringedition

For more information please CONTACT USat 718-934-6714 x 1202 or by e-mail to nanakwchsbcom

INSIDE THISISSUE

WCH Corner page 3-14

Healthcare Section page 15-19

Questiones amp Answers page 20

Feedback page 21

Get your CEU credits TODAY


Medical Chart Review services by WCH

Ask any expert and they will tell you that accurate coding is the secret to full and timely reimbursements from your medical claims In fact the most frequent errors in claim processing can be attributed to improper coding andor a lack of necessary documentation It may seem simple but with todayrsquos ever-changing medical codes guidelines and regulations the task of properly putting together your medical charts requires more time and experience than ever before With ICD-10 overhaul of practitioner coding compliance by October 2015 practices need to ensure their coding practices are being migrated to the new standards or risk losing significant reimbursement sumsWCH invests heavily into Chart Auditors training in order to increase the level of expertise and provide highest quality of service WCH Professionals have several industry certifications including CPC CFPC and CPCA and more Our goal is to work with medical providers to protect the practice by ensuring that the medical records are complete and meet guidelines and requirements

Why Choose WCH Chart Review Service

bull WCH Certified Experts provide an effective compliance method in accordance with federal regulations to monitor your practicersquos coding and documentation processes

bull WCH Certified Experts provide protection against issues with medical necessity denied claims bundling issues overbilling and insurance errors

bull WCH Certified Experts identify missing incomplete or inaccurate information and develop an analysis and summary of charts

bull WCH Certified Experts provide a valuable education tool to help providers improve their coding and documentation skills

bull WCH Certified Experts have superior knowledge and 14 years of experience in assisting providers with insurance overpayment cases and protect providers from losing billing privileges in major insurances companies such as UHC Medicare and others

SEND YOUR CHARTS FOR REVIEW TODAY

For more details visit wwwwchsbcomMedi-cal-Chart Auditing

Before responding to insurance audit contact WCH audit specialist


Why I love working in WCH interview with Maria Chechina

What do you do at WCH

At WCH I help medical providers do their job the administrative aspect of it I am an account representative for several WCH clients I provide clients with services that help their practices at every step of the way from patient insurance issues to problems with reimbursement I handle routine documentation work oversee timely payments are received and conduct administrative tasks enabling doctors to spend more time with patients and less time on administration of the practice Together with my team at WCH we ensure that the process of medical billing is flawless As an account representative I manage my accounts with attention to detail and care

What is most interesting about your job

My job is very interesting because I tend to deal with different situations and learn from every experience My work gives me the opportunity to expend my knowledge and grow become more experienced and have a better handle on situations that tend to happen I keep advancing my position as I get more knowledge and I am always eager to keep going I am proud to be a part of a company that gives me the opportunity to grow professionally in this great and interesting filed

What do you like most about working in WCH

The most favorite part of my work at WCH is surely our team The work structure of WCH encourages all staff to work together as a team

I enjoy working with my coworkers to achieve results that are measurable WCH has very nice clever motivated and self-confident staff that always helps and supports each other I have the best colleagues that I can ever ask for I like working at WCH and I love the WCH team as there is always a professional and friendly atmosphere here

What are some of your favorite things about your work day at WCH

I think the most favorite thing about my work day at WCH is surely my clients providers and being able to help them with their daily tasks My clients are often very kind and intelligent They make each day full of good emotions and interesting news

Maria ChechinaAccount Representative


Happy Medical Billers Day to all Professionals in the healthcare industry

WCH congratulates our devoted professional Billers with the Medical Billers DayMarch 26th marks the recognition of Medical Billers throughout the state of NY and Na-tionwide Medical Billing Professionals con-tribute greatly to the system of medical care in assisting physicians and other healthcare professionals ensuring appropriate payment is received for services rendered Nation-al Medical Billers Day was initiated by the AMBA (American Medical Billerrsquos Association) beginning in 2008 in of the importance and involvement of medical billers in the health care industry

WCH Medical Billing professionals are ex-perts in a field that requires attention to detail understanding and proficiency in the laws and regulations related to the insur-ance industry and healthcare industry The work of WCH medical billers helps health-care facilities maintain optimum level of efficiency productive and compliance with rules and regulations on a daily basis

6 WCH Corner Spring 2015 WCH Bulletinwwwwchsbcom

Are youmissing$63750out of your pocket

Medicaid EHR Incentive Payments by Calendar Year

Year Medicaid EPs Who Adopted In2011 2012 2013 2014 2015 2016

2011 $212502012 $8500 $212502013 $8500 $8500 $212502014 $8500 $8500 $8500 $212502015 $8500 $8500 $8500 $8500 $212502016 $8500 $8500 $8500 $8500 $8500 $212502017 $8500 $8500 $8500 $8500 $85002018 $8500 $8500 $8500 $85002019 $8500 $8500 $85002020 $8500 $85002021 $8500Total $63750 $63750 $63750 $63750 $63750 $63750

WCH can help you to get your Medicaid EHR incentive payments for the available years shown below 2016 is the last year to obtain and attest for using EHR program We are also working with our clients to help them achieve meaningful use requirements and receive eligible incentives from payers As well as help you with attestation of meaningful use so that you can receive eligible incentive Donrsquot lose your chance ask your account representative about available options 2016 is the last year that providers are eligible to collect available incentiveTake a look at the available incentive table


Patient Volume Calculation

The Medicaid patient volume calculation method is designated by the State Medicaid Agency and approved by CMS In general patient volume is calculated by dividing the providerrsquos encounters with Medicaid-enrolled patients over the providerrsquos total number of service encounters

Note EPs should include individuals enrolled in Medicaid managed care organizations prepaid inpatient health plans prepaid ambulatory health plans and Medicaid medical home pro-grams or Primary Care Case Management

Timeframe

The last year to begin participating in the Medicaid EHR Incentive Program is 2016 EPs may receive Medicaid EHR incentive pay-ments for up to six years 2021 is the final year for Medicaid EHR incentive payments For more information visit the Medicaid State Information page

Payment Amounts

EPs who adopt implement upgrade or meaningfully use certified EHR technology in their first year of participation in the program and successfully demonstrate meaningful use in subsequent years may be eligible for an incentive payment of $21250 In subsequent years of payment a Medicaid EPrsquos incentive payment will be limited to $8500Pediatricians who meet the 30 percent pa-tient volume requirement may qualify to receive the maximum incentive payments Incentive payments for pediatricians who meet the 20 percent Medicaid patient volume but fall short of the 30 percent Medicaid pa-tient volume are reduced to two-thirds of the incentive payment This means some pedia-tricians may receive $14167 in the first year and $5667 in subsequent years Table 2 illustrates the maximum Medicaid EHR incentive payments an EP can receive by year and the total incentive payments possi-ble if an EP successfully qualifies for an incen-tive payment each year

Note The total for pediatricians who meet the 20 percent patient volume but fall short of the 30 percent patient volume is $14167 in the first year and $5667 in subsequent years This adds up to a maximum Medicaid EHR incentive payment of $42500 over a six-year periodAdditional ResourcesFor more information on the Medicaid EHR Incentive Program see the EHR Incentive Programs website


iSmart EHR Clinical Quality Measures (CQM)

According to national EHR Vendor data there are far fewer EHR systems that are stage 2 certified than EHR systems that are stage 1 certified Generally EHR vendors are faced with difficulties develop-ing features to satisfy the Clinical Quality Measures (CQM) CQMs are part of the certification require-ments Unlike many other EHRs WCH EHR development team makes every effort to meet the require-ments for certification of the iSmart EHR WCH iSmart EHR is fully designed with features to support Meaningful Use based on the objectives and measures set by CMS

WCH iSmart EHR currently has 29 CQM features that are certified for meaningful use The following lists the CQM measures that iSmart EHR currently features

Measure Title Current Version in iSmartEHR

Measure NumberCMS NQF PQRS

Diabetes Hemoglobin A1c Poor Control v2 122v3 0059 001Diabetes Low Density Lipoprotein (LDL-C) Control (lt100 mgdL) v2 163v3 0064 002Anti-Depressant Medication Management v2 128v3 0105 009Adult Major Depressive Disorder (MDD) Suicide Risk Assessment v2 161v3 0104 107Preventive Care and Screening Influenza Immunization v2 147v4 0041 110Pneumonia Vaccination Status for Older Adults v2 127v3 0043 111Breast Cancer Screening v2 125v3 NA 112Colorectal Cancer Screening v2 130v3 0034 113Diabetes Medical Attention for Nephropathy v2 134v3 0062 119Preventive Care and Screening Body Mass Index (BMI) Screening and Follow-Up Plan

v2 69v3 0421 128

Documentation of Current Medications in the Medical Record v3 68v4 0419 130Preventive Care and Screening Screening for Clinical Depression and Follow-Up Plan

v3 2v4 0418 134

Diabetes Foot Exam v2 123v3 0056 163Ischemic Vascular Disease (IVD) Use of Aspirin or Another Antithrombotic

v2 164v3 0068 204

Preventive Care and Screening Tobacco Use Screening and Cessation Intervention

v2 138v3 0028 226

Controlling High Blood Pressure v2 165v3 0018 236Use of High-Risk Medications in the Elderly v2 156v3 0022 238Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents

v2 155v3 0024 239

Dementia Cognitive Assessment v2 149v3 NA 281Cervical Cancer Screening v2 124v3 0032 309Use of Appropriate Medications for Asthma v2 126v3 0036 311Use of Imaging Studies for Low Back Pain v3 166v4 0052 312Falls Screening for Fall Risk v2 139v3 0101 318Depression Remission at Twelve Months v2 159v3 0710 370Hypertension Improvement in Blood Pressure v3 65v4 NA 373Closing the Referral Loop Receipt of Specialist Report v2 50v3 NA 374Functional Status Assessment for Complex Chronic Conditions v3 90v4 NA 377Children Who Have Dental Decay or Cavities v2 75v3 NA 378Primary Caries Prevention Intervention as Offered by Primary Care Providers including Dentists

v3 74v4 NA 379


In addition to these Clinical Quality Measures (CQM) WCH EHR development team is working on the development and certification 11 additional feature which will be certified in the next certification round of the iSmart EHR The following are CQMs that are under development

Measure Title Measure NumberCMS NQF PQRS

Heart Failure (HF) Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)

135v3 0081 005

Coronary Artery Disease (CAD) Beta-Blocker Therapy ndash Prior Myocardial Infarc-tion (MI) or Left Ventricular Systolic Dysfunction (LVEF lt 40)

145v3 0070 007

Heart Failure (HF) Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)

144v3 0083 008

Ischemic Vascular Disease (IVD) Complete Lipid Profile and LDL-C Control (lt 100 mgdL)

182v4 0075 241

Initiation and Engagement of Alcohol and Other Drug Dependence Treatment 137v3 0004 305Preventive Care and Screening Cholesterol ndash Fasting Low Density Lipoprotein (LDL-C) Test Performed AND Risk-Stratified Fasting LDL-C

61v4 amp 64v4

NA 316

Preventive Care and Screening Screening for High Blood Pressure and Fol-low-Up Documented

22v3 NA 317

Bipolar Disorder and Major Depression Appraisal for Alcohol or Chemical Sub-stance Use

169v3 NA 367

Depression Utilization of the PHQ-9 Tool 160v3 0712 371ADE Prevention and Monitoring Warfarin Time in Therapeutic Range 179v3 NA 380

In addition The PQRS measure reporting option is currently under development for certifi-cation While current iSmart EHR users can record PQRS measures into the EHR at this time once the feature is certified in addition to recording provides will be able to submit informa-tion based on the recorded data that has been entered into the EHR system

Note You can now view the development time line of the iSmart EHR features by going to wwwismartehrcomrdquo

WCH Service Bureau team makes every effort to provide its clients with an EHR system that

meets the requirements set by CMS and other governing bodies therefore we are working

on the development of new features and options to add to our existing Clinical Quality

Measures iSmart EHR will be certifying with Drummond group in May to have all current

features that are in development ready to use by Summer 2015 Clients and users can now

view the progress timeline of the iSmart EHR updates right on our website wwwismartehr

com Stay tuned for more information details and updates

If you are an iSmart EHR user and have any questions or the use of any WCH iSmart EHR features please contact our IT department at 718-934-6714 ext 1111 or by email at ilyamwchsbcom


This 3 day spring convention is a great way to expand practice management knowledge During the sessions participants can find out all there is to know about Urgent Care environment Get the necessary information tools resources and strategies to succeed in Urgent Care by joining other professionals in the field This nationwide panel of Urgent Care experts will provide participants access to a vast variety of information about Urgent Care Centers Among other industry leaders Olga Khabinskay from WCH Service Bureau will make two presentations to contribute to the national panel of speakersOlga Khabinskay the COO of WCH Service Bureau will share her extensive knowledge and experience

Olga has been given not one but two 1 hour long sessions to discuss crucial contracting and regulatory issues of the Urgent Care business model

Managed Care Contracting Presented by Olga Khabinskay WCH Service Bureau Inc

Date Monday April 27th 2015 Time 830 AM- 930 AM

Topics Covered

During this session Olga Khabinskay will discuss contracting requirements for Urgent Care Centers and share information about necessary steps of successful urgent care contracting

Some of the learning objectives are

bull Knowing Insurance requirements for enroll-ment of Urgent Care Centers

bull Preparing for site visitbull Understanding reimbursement difference

between urgent care contracts and Fee for Service Contracts

bull Global Rate Negotiation tips bull Marketing techniques and Marketing strategy

development bull Details on Urgent Care provider billing rights

and responsibilities

Dealing with case rates Presented by Olga Khabinskay WCH Service Bureau Inc

Date Tuesday April 28th 2015 Time 1000 AM- 1100 AM

During this session Olga will talk about important Urgent Care regulatory and procedural factors that contribute to the suc-cess of Urgent Care facilities


bull Understand Urgent care reimbursement rates such as Global and Fee for Service options

bull Tips on how to define and deal with Urgent Care difficulties and challenges

bull Understand the maximum service capacity of Urgent Care staff

bull Define treatment models Low Intensity Vs higher acuity visits billing

bull Detailed strategies on expending urgent care services

WCH is presenting on Urgent Care Conference in Chicago

Topics Olga will cover


Timing is crucial

While it can be tempting to just jump right in and request a high compensation rate Olga Khabinskay credentialing and billing specialist and COO of WCH Service Bu-reau Inc says itrsquos best to wait a couple of years first

ldquoUrgent care providers that have an urgent care contract are allowed to request a fee negotiation after theyrsquove been in the network for two to three yearsrdquo Khabinskay says

Khabinskay says that itrsquos difficult to do a contract negotiation in the beginning of the initial credentialing because the ur-gent care center hasnrsquot had time to prove itself yet

ldquoNegotiations are done typically after the center has been in the network for some time so that itrsquos able to show how it has decreased the number of hospital visits and how valuable it is to the communityrdquo Khabinskay says

The contract negotiating process can be lengthy so providers are urged to start early

ldquoIt can take 30-100 or more days to receive a contract from a managed care organization or payorrdquo David Stern CEO of Practice Velocity says in a blog post

Since it can take so long for a contract to get approved Khabinskay advises urgent care providers to submit a request for an increase in their fee schedule as soon as they see a need for it If therersquos no imme-diate need Khabinskay says she recom-mends asking for an increase every three years

ldquoEvery three years a lot of things can changerdquo Khabinskay says ldquoYour internal overhead expenses will probably increase staff size can increase and equipment might need to be repairedrdquo

Khabinskay also says that every two to three years urgent care facilities will go through a re-credentialing process and that is the perfect time to request a con-tract negotiation

5 TIPS AND TRICKS FOR NEGOTIATING BETTER URGENT CARE CONTRACTS

Negotiating urgent care contracts with payors can be a frustrating experience Insurance companies are always looking to decrease their costs so convincing them that you deserve an increase in compensation can be an uphill battle By following these five tips and tricks you can adequately prepare yourself prior to entering a contract negotiation and increase your chances of getting a higher compensation rate

Exclusive Interview with Olga by Ambulatory Advisor Written by Brittany Belli


Back up your claim

A contract negotiation request typically involves a letter to the director of the network and provides additional information to the insurance companies Attaching additional information such as letters of reference costs of services provided classification of staff members and relevant statistics can help persuade payors to grant you the increase that yoursquore looking for

ldquoMake sure that all of the elements of successfully running your urgent care center are outlined in your letterrdquo Khabinskay says ldquoProvide the overhead costs flexibility of operations or hours and salaries of your staffrdquo

Khabinskay says itrsquos also important to designate whether you have physicians or physician assistants performing services in your center

ldquoUrgent care centers that are staffed with physicians are able to negotiate rates more quicklyrdquo Khabinskay says

Ron Dreskin president of Integrated Healthcare LLC says that providing certain statistics can help improve your chances of getting an increase in your fee schedule

ldquoIf an urgent care center can prove that their services are similar to an emergency room and say that if patients were to go to their center instead of the ER then the payor would gain significant benefits that would be the biggest bang for your buckrdquo Dreskin says

ldquoThe payors are going to react because they can shift monies from paying a hospital or an ER to paying you and they can increase your compensation while still paying you a lot less than an ERrdquo

Khabinskay says that letters of reference can also be a huge determining factor in a contract negotiation

ldquoLetters that show how the urgent care center has changed the community for the better are greatrdquo Khabinskay says ldquoYou can have local schools and daycares write letters that say they come to your center in a time of need or go to your center to receive their flu shots Anything that shows that yoursquore a well-rounded center thatrsquos able to help the community is a plusrdquo

Khabinskay says that local primary care providers and patients can also provide letters that support you and your center

ldquoIf a primary care doctor writes a letter saying that theyrsquore confident with referring their patients to your urgent care center as an after-hours facility that can help convince a payor to increase your raterdquo Khabinskay says ldquoPatients that are a part of the insurance network that yoursquore negotiating with can also write letters saying that theyrsquore very happy with the level and quality of care that theyrsquove been receiving This can also be beneficialrdquo


Get close

ldquoAlways stay close with the network representative from the insurance companyrdquo Khabinskay advises ldquoRemain in a close relationship with that person because they are the one who will present your request for a negotiation to the insurance board and they will be the first person on the team that will be making the increase if itrsquos approvedrdquo

Khabinskay says that you can even invite the representative to come by your facility and promote their insurance company

ldquoThis allows them to sign up patients that are interested in their insurance and it helps you network with the representativerdquo Khabinskay says ldquoItrsquos really important for them to remember your facility and for them to know who you arerdquo

ldquoUrgent cares should be forming a partnership with the payorsrdquo Dreskin says ldquoIrsquove seen payors even promote urgent care centers to their enrollees explaining that these centers provide similar services to an ER but for a lower co-payrdquo

Urgent care centers can also partner up with a hospital or other urgent care centers in order to increase their chances of getting a higher compensation rate

ldquoA single center is going to have a harder time negotiating a contract than a center that is aligned with a merger or multiple centersrdquo Dreskin says ldquoIf yoursquore got 50 or 60 centers your negotiating power is going to be higher than if you only have one or two centers Any large entity is going to have a better opportunity than a smaller entity thatrsquos just a factrdquo

Negotiate

Requesting an increase in your fee schedule can be daunting but donrsquot forget that the whole point of a contract negotiation is negotiating

ldquoWhen writing the letter requesting an increase I would ask for a 5 increase knowing that payors will be negotiating downrdquo Khabinskay advises ldquoThey will usually meet you halfway at 2-3rdquo

If your negotiation is approved Khabinskay says to expect the new increased fee schedule to start in the new fiscal year If you get declined you have the right to appeal but Khabinskay says that the overall process is very difficult

ldquoIf the insurance company is funded by the state you may not be able to negotiate rates at allrdquo Khabinskay warns ldquoIf a negotiation is declined try again in six monthsrdquo

One way to make the negotiation process easier is to look at the insurance that your patients are covered by The more patients you have covered under a payor the more likely they are to grant you an increase in compensation

ldquoPursue the payors that you already knowrdquo Stern says ldquoMake them believe that negotiating with you is in their best interestrdquo

Dreskin advises to make payors see an increase in fee schedule in a mutually beneficial light instead of a negative one

ldquoTelling the payor that you want more while they get less is going to create an adversarial situationrdquo Dreskin warns ldquoGive them something in return Show them that you can save them money by keeping their patients out of the emergency roomrdquo

Dreskin says that if you have statistics demonstrating that your patient volume has gone up while the patient volume at ERs in your vicinity has gone down you can use that as an incentive to get a higher rate


Evaluate

Payors are not always going to agree to increase your compensation rates If a payor declines your request for an increase or counter offers a rate that is lower than what you were hoping for you have to decide if itrsquos worth staying with that insurance company

ldquoYou can negotiate rates but eventually the insurance company will offer you a rate and it will boil down to lsquotake it or leave itrsquo and you wonrsquot really have a choicerdquo Khabinskay says ldquoIf yoursquore not happy with the rate it then becomes a business decision if yoursquore going to stay with that payor for the next two years or notrdquoldquoIf a payor says theyrsquore not going to increase your rate you may choose to drop that insurance companyrdquo Dreskin says ldquoHowever you could also negotiate that if yoursquore the only urgent care center in the area thatrsquos accepting their insurance and if you drop them then their patients wonrsquot have access to care or would be forced to go to a provider thatrsquos more expensive That could be a strong argumentrdquo

That argument could also come with high risks especially if you have an aggressive approach Dreskin warns

ldquoIf yoursquore being aggressive and telling the payor that if they donrsquot give you want you want yoursquore going to drop them a lot of times the insurance company wonrsquot carerdquo Dreskin says ldquoYou want to know where you sit in the delivery of services in your community before you deploy a high risk strategy where you could lose your contract and lose revenuerdquo

Unfortunately there is no magic formula for negotiating better urgent care contracts However the more prepared you are the higher your success rate will be

ldquoSuccess isnrsquot guaranteed but yoursquove got an absolute zero chance if you donrsquot do any of your homeworkrdquo Dreskin says ldquoThere are many different variables that can increase your chances but you have to be prepared with the right information If yoursquore not prepared yoursquore not going to get what you wantrdquo

To find the source of information click here

In order to better serve you and improve our business processes we are implementing changes on our website We are installing updates and making changes to improve your overall user experience on our website In planning the changes coming up we have made every effort to make it easier for you to enjoy the benefits of the WCH website to make payments obtain educational materi-als news and updates company information and more

Some of the updates have already been installed and are live while other changes are still in development Stay tuned for more updated and check out our website for more information

wwwwchsbcom

15 Healthcare Section Spring 2015 WCH Bulletinwwwwchsbcom

CMS Considers EHR Incentive Program Changes for 2015Responding to input from health care providers and other stakeholders the Centers for Medicare amp Medicaid Services (CMS) announced last week that it intends to engage in rulemaking to update the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs beginning in 2015 These intended changes would help to reduce the reporting burden on providers while supporting the long term goals of the programThe new rule expected this spring would address concerns about software implementation information exchange readiness and reflect developments in the industry and progress to-ward program goals achieved since the program began in 2011CMS is considering the following changes 1 Shortening the 2015 reporting period to 90 days to address provider concerns about their ability to fully deploy 2014 Edition software2 Realigning hospital reporting periods to the calendar year to allow eligible hospi-tals more time to incorporate 2014 Edition software into their workflows and to better align with other quality programs3 Modifying other aspects of the programs to match long-term goals reduce complex-ity and lessen providersrsquo reporting burdenThese proposed changes reflect the Department of Health and Human Servicesrsquo commitment to creating a health information technology infrastructure thatbull Elevates patient-centered carebull Improves health outcomesbull Supports the providers who care for patientsThis rulemaking is separate from the forthcoming Stage 3 proposed rule expected in early March CMS intends to limit the scope of the Stage 3 proposed rule to the requirements and criteria for meaningful use in 2017 and subsequent yearsTo find the source information click the links chitrecorg and blogcmsgov

16 Healthcare News Spring 2015 WCH Bulletinwwwwchsbcom

DO NOT BE SURPRISED BY NYrsquoS ldquoSURPRISE BILL LAWrdquoNew Yorkrsquos ldquoEmergency Medical Services and Surprise Billsrdquo law the so-called ldquoSurprise Bill Lawrdquo new legislation included in the 2014-2015 state budget is a response to consumer complaints about inadequate reimbursement for treatment received by out-of-network physicians Given that the implementation date for this law is April 1 2015 it is critical for providers and health plans to create an action plan to ensure compliance with the requirements of this law regulations

With respect to emergency services the law states that patients will not be liable to pay more than their usual in-network cost sharing or co-payments regardless of the network status of the provider who rendered the emergency treatment With respect to other services when a patient receives treatment from an out-of-network provider where there were no in-network providers available or where the provider failed to provide the disclosures required under the law the patient is only responsible for their in-network cost sharing and may assign their claims to the out-of-network provider who must seek any additional reimbursement directly from the patientrsquos health insurer There is an independent review process set up to deal with reimbursement disputes between healthcare providers and health plans ndash however this process excludes bills for emergency services resulting in bills less than $600 (to be adjusted for inflation in the future)

The legislation also imposes ldquonetwork adequacy rulesrdquo upon health plans which are based upon comprehensive provider networks such as PPOs and EPOs (previously these requirements only applied to HMOs and other ldquomanaged carerdquo plans) The health plans must be certified as having provider networks which can meet the needs of their members without the need to seek more expensive out-of-network services

If the plan does not have adequate geographically accessible providers then patients can seek treatment from out-of-network providers without being subject to higher out-of-network costs The legislation also sets up an external review system to determine network adequacy

The statue also requires disclosures regarding out-of-pocket expenses to be made by health plans providers and hospitals With respect to providers these disclosures include

bull prior to providing non-emergency services providers must disclose to patients their right to know what will be billed for the procedure and if the patient requests they must disclose the anticipated cost warning patients that costs could go up if unanticipated consequences occur

bull providers must provide patients with their network and hospital affiliations in writing or on-line

bull when patients make appointments providers must indicate whether they participate in a patientrsquos network

bull If other professionals will be involved in a patientrsquos care the patient must be advised of who might be included and how to learn how much the network will cover for those providers

Finally the legislation sets up an ldquoout-of-network reimbursement rate working grouprdquo appointed by the Governor and including health plan physician and consumer members The group is to examine and study changes in the rules regarding the availability of out-of-network coverage and the rates of out-of-network reimbursement and to make recommendations in these areas to issue a report by January 1 2016

Anna Kim Esq


New York Medicaid EHR Incentive Program Update

The NY Medicaid Electronic Health Record (EHR) Incentive Program provides financial incen-tives to eligible practitioners and hospitals to promote the transition to EHRs Providers who practice using EHRs are in the forefront of improving quality reducing costs and addressing health disparities Since December 2011 over $6453 million in incentive funds have been distributed within 16504 payments to New York State Medicaid providers

Taking a closer look NEW NY Medicaid EHR Incentive EP Program Deadlines

Highlighted below are a number of deadlines coming fast in the NY Medicaid EHR Incentive Program If you have any questions regarding the deadlines below please contact the NY Medicaid EHR Incentive Program Support Team at 1-877-646-5410

March 31 2015 ndash Payment Year 2014 EP Attestation Deadline

Please be aware that EPs intending to attest for Payment Year 2014 must submit an attes-tation by March 31 2015To download the source PDF file click here

16504+PaymentsNY Medicaid

$6453Million PaidIncentive Program

Are youELIGIBLEemednyorgmeipass


NYMEDICAID UPDATE FOR ALL PROVIDERS

Payment Error Rate Measurement (PERM) Upcoming Request for Medicaid Provider

Documentation

The Centers for Medicare amp Medicaid Services (CMS) in partnership with the New York State Office of the Medicaid Inspector General (OMIG) will measure improp-er payments in the Medicaid and State Child Health Insur-ance programs under the Payment Error Rate Measure-ment (PERM) program This will be the third time New York State will be participat-ing The State last participat-ed in federal fiscal year (FY) 2011CMS along with their con-tractor and OMIG have the authority to collect this information under sections 1902(a)(27) and 2107(b)(1) of the Social Security Act The Health Insurance Portability and Accountability Act of 1996

(HIPAA) statutes and regula-tions require the provision of such information upon request and the information can be provided without pa-tient consentDocumentation for a medical review of randomly selected claims will be requested by A+ Government Solutions Inc the CMS contractor If claims you submitted are selected the CMS contractor will request from you in writ-ing documentation to sub-stantiate claims paid in fed-eral FY 2014 (October 1 2013 - September 30 2014) Your cooperation and a timely response are requestedPlease submit the specific medical documents for the patient as requested in the letter you receive from the CMS contractor directly to the CMS contractor with a copy to OMIG at the following addressOffice of the Medicaid Inspector General 800 North Pearl Street Room 328 Albany NY 12204

Attention PERM Project StaffRequests for documentation were originally scheduled to begin in March 2014 Due to a delay in the submission of the universes of paid claims the requests will now start in March 2015 The sampled claims will be claims paid in federal FY 2014 (October 1 2013 - September 30 2014) All requests and receipts or non- receipt of documenta-tion will be monitored for compliance Failure to com-ply with the record requests will result in a determination of erroneous payment and OMIG will pursue recovery of these amountsQuestions Please contact PERM Project staff at (518) 486-7153 or (518) 402-7041

To download the source PDF file click here


CMS says ICD-10 billing system test successfulThe Centers for Medicare amp Medicaid Services says a recently completed end-to-end test shows its billing systems are prepared for the switch to ICD-10 in OctoberBetween Jan 26 and Feb 3 661 physicians other health care providers and billing companies participated in the testing week Of 14929 test claims received 12149 were accepted ndash a success rate of 81 percent CMS points outOf those claims that were rejected 3 percent were because of invalid submission of ICD-9 diagnosis or procedure code 3 percent were because of invalid submission of ICD-10 diagnosis or procedure code

Meanwhile 13 percent were due to non-ICD-10 related errors according to CMS ndash mostly related to issues setting up the test claims such as incorrect claim number or submitter ID dates of service outside the range valid for testing or invalid place of ser-vice

ldquoTesting demonstrated that CMS systems are ready to accept ICD-10 claimsrdquo CMS said

CMS is planning two more end-to-end tests this year

To find the source information click the links cmsgov and healthcareitnewscom

20 Questions amp Answers Spring 2015 WCH Bulletinwwwwchsbcom

Questions and Answers

What about if I hire a Resident

Good question one also addressed by the AMA and limited by State licensure laws The AMA has a policy dedicated to resident hires but before I get to the AMA policy I do want to reiterate that last weekrsquos comments on an ldquounlicensedrdquo person applies to residents as well If the resident does not have a medical license depending on the state laws the individual will be limited In NY that means the resident may not ldquopractice medicinerdquo

The AMA Ethics Opinion follows

Opinion 8088 - Resident Physiciansrsquo Involve-ment in Patient CareResidents and fellows have dual roles as trainees and caregivers First and foremost they are physicians and therefore should always regard the interests of patients as paramount To facilitate both patient care and educational goals physicians involved in the training of residents and fellows should ensure that the health care delivery environ-ment is respectful of the learning process as well as the patientrsquos welfare and dignity1 In accordance with graduate medical educa-

tion standards such as those promulgated by the Accreditation Council for Graduate Medi-cal Education (ACGME) training must be struc-tured to provide residents and fellows with appropriate faculty supervision and availabil-ity of faculty consultants and with graduated responsibility relative to level of training and expertise

2 Residentsrsquo and fellowsrsquo interactions with pa-tients must be based on honesty Accordingly residents and fellows should clearly identify themselves as members of a team that is su-pervised by the attending physician

3 If a patient refuses care from a resident or fellow the attending physician should be notified If after discussion a patient does not want to participate in training the phy-sician may exclude residents or fellows from that patientrsquos care or if appropriate transfer the patientrsquos care to another physician or non-teaching service or to another health care facility

4 Residents and fellows should participate fully in established mechanisms for error reporting and analysis in their training programs and hospital systems They should cooperate with attending physicians in the communication of errors to patients (See Opinion E-8121 ldquoEth-ical Responsibility to Study and Prevent Error and Harmrdquo)

5 Residents and fellows are obligated as are all physicians to monitor their own health and level of alertness so that these factors do not compromise their ability to care for pa-tients safely (See Opinion E-9035 ldquoPhysician Health and Wellnessrdquo) Residents and fellows should recognize that providing patient care beyond time permitted by their programs (for example ldquomoonlightingrdquo) might be potentially harmful to themselves and patients Other activities that interfere with adequate rest during off-hours might be similarly harmful

6 Residency and fellowship programs must offer means to resolve educational or patient care conflicts that can arise in the course of training All parties involved in such conflicts must continue to regard patient welfare as the first priority Conflict resolution should not be punitive but should aim at assisting resi-dents and fellows to complete their training successfully When necessary higher admin-istrative authorities or the relevant Residency Review Committee (RRC) should be involved as articulated in ACGME guidelines (I II V VIII)

21 Feedback Spring 2015 WCH Bulletinwwwwchsbcom

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INSIDE THISISSUE

WCH Corner page 3-14

Healthcare Section page 15-19

Questiones amp Answers page 20

Feedback page 21

Get your CEU credits TODAY

































2011 $212502012 $8500 $212502013 $8500 $8500 $212502014 $8500 $8500 $8500 $212502015 $8500 $8500 $8500 $8500 $212502016 $8500 $8500 $8500 $8500 $8500 $212502017 $8500 $8500 $8500 $8500 $85002018 $8500 $8500 $8500 $85002019 $8500 $8500 $85002020 $8500 $85002021 $8500Total $63750 $63750 $63750 $63750 $63750 $63750






Timeframe


Payment Amounts










v2 69v3 0421 128


v3 2v4 0418 134


v2 164v3 0068 204


v2 138v3 0028 226


v2 155v3 0024 239


v3 74v4 NA 379





135v3 0081 005


145v3 0070 007


144v3 0083 008


182v4 0075 241


61v4 amp 64v4

NA 316


22v3 NA 317


169v3 NA 367

















Topics Covered





















Timing is crucial














Back up your claim













Get close







Negotiate











Evaluate










wwwwchsbcom














Anna Kim Esq














Documentation




























Thank you

































2011 $212502012 $8500 $212502013 $8500 $8500 $212502014 $8500 $8500 $8500 $212502015 $8500 $8500 $8500 $8500 $212502016 $8500 $8500 $8500 $8500 $8500 $212502017 $8500 $8500 $8500 $8500 $85002018 $8500 $8500 $8500 $85002019 $8500 $8500 $85002020 $8500 $85002021 $8500Total $63750 $63750 $63750 $63750 $63750 $63750






Timeframe


Payment Amounts










v2 69v3 0421 128


v3 2v4 0418 134


v2 164v3 0068 204


v2 138v3 0028 226


v2 155v3 0024 239


v3 74v4 NA 379





135v3 0081 005


145v3 0070 007


144v3 0083 008


182v4 0075 241


61v4 amp 64v4

NA 316


22v3 NA 317


169v3 NA 367

















Topics Covered





















Timing is crucial














Back up your claim













Get close







Negotiate











Evaluate










wwwwchsbcom














Anna Kim Esq














Documentation




























Thank you





Timeframe


Payment Amounts










v2 69v3 0421 128


v3 2v4 0418 134


v2 164v3 0068 204


v2 138v3 0028 226


v2 155v3 0024 239


v3 74v4 NA 379





135v3 0081 005


145v3 0070 007


144v3 0083 008


182v4 0075 241


61v4 amp 64v4

NA 316


22v3 NA 317


169v3 NA 367

















Topics Covered





















Timing is crucial














Back up your claim













Get close







Negotiate











Evaluate










wwwwchsbcom














Anna Kim Esq














Documentation




























Thank you








v2 69v3 0421 128


v3 2v4 0418 134


v2 164v3 0068 204


v2 138v3 0028 226


v2 155v3 0024 239


v3 74v4 NA 379





135v3 0081 005


145v3 0070 007


144v3 0083 008


182v4 0075 241


61v4 amp 64v4

NA 316


22v3 NA 317


169v3 NA 367

















Topics Covered





















Timing is crucial














Back up your claim













Get close







Negotiate











Evaluate










wwwwchsbcom














Anna Kim Esq














Documentation




























Thank you





135v3 0081 005


145v3 0070 007


144v3 0083 008


182v4 0075 241


61v4 amp 64v4

NA 316


22v3 NA 317


169v3 NA 367

















Topics Covered





















Timing is crucial














Back up your claim













Get close







Negotiate











Evaluate










wwwwchsbcom














Anna Kim Esq














Documentation




























Thank you






Topics Covered





















Timing is crucial














Back up your claim













Get close







Negotiate











Evaluate










wwwwchsbcom














Anna Kim Esq














Documentation




























Thank you


Timing is crucial














Back up your claim













Get close







Negotiate











Evaluate










wwwwchsbcom














Anna Kim Esq














Documentation




























Thank you


Back up your claim













Get close







Negotiate











Evaluate










wwwwchsbcom














Anna Kim Esq














Documentation




























Thank you


Get close







Negotiate











Evaluate










wwwwchsbcom














Anna Kim Esq














Documentation




























Thank you


Evaluate










wwwwchsbcom














Anna Kim Esq














Documentation




























Thank you














Anna Kim Esq














Documentation




























Thank you














Documentation




























Thank you
























Thank you

WCH Spring Times 2015

Documents

Transcript of WCH Spring Times 2015