MANAGING MEDICARE

1. MANAGING MEDICARE Hawaii Medical Association July 29, 2008

2. WE WILL DISCUSS • Palmetto Transition (A & B) • Coverage: Local & National • Documentation Principles • How to Respond to Requests for Records • PQRI: Physician Quality Reporting Initiative • Q&A

3. PALMETTO GBA • Who is Palmetto? • One of largest Medicare contractors • Division of BCBS of South Carolina • Offices in 5 states Headquartered in Columbia, South Carolina, Palmetto GBA is a wholly owned subsidiary of BlueCross BlueShield of South Carolina. With over 2,700 employees in 14 states, Palmetto GBA spans the nation with customers in 45 states, two U.S. territories and the District of Columbia www.palmettogba.com/J1

5. CUTOVER DATES

6. WHAT’S A DOCTOR TO DO ? • Browse and bookmark the J1 Web site, http://www.palmettogba.com/j1 • Review the Timeline at http://www.palmettogba.com/j1 to keep updated with the important dates involving the implementation of the J1 MAC.

7. WHAT’S A DOCTOR TO DO ? • Register to receive the J1 MAC Implementation E-mail updates at http://www.palmettogba.com/palmetto/j1.nsf/ Person?OpenForm?open&cat= . • Visit and review the J1 FAQs page at http://www.palmettogba.com/Palmetto/J1.nsf/docsCat/Frequently%20Asked%20Questions?opendocument?open&cat= for answers to common questions

8. WHAT’S A DOCTOR TO DO ? • For questions not addressed in a posted FAQ, please feel free to submit that question for consideration by e-mailing your concern to j1mac@palmettogba.com • Review “Events” at http://www.palmettogba.com/j1 to check the schedule for all upcoming training seminars, Web casts, and teleconferences

9. SPECIFIC ACTIONS REQUIRED • EFT (Electronic Funds Transfer) • EDI (Electronic Data Interchange) • Early Boarding • Claims and Appeals • LCDs (Local Coverage Determination) • Medical Review • Provider Enrollment • Other

10. Electronic Funds Transmission • Need to fill out form CMS 588 • www.cms.hhs.gov/cmsforms/downloads/ CMS588.pdf • Fill out form and send along with • Current bank information & voided check • Palmetto GBA FinanceJ1 EFT P.O. Box 100277 - Columbia, SC 29202-3277 • Due Dates: California Part B Aug. 15, 2008 • Help: (866) 749-4301 or for e-mail EFT.Admin@PalmettoGBA.com Aug. 15, 2008

11. Electronic Data Interchange • Fill out J-1 EDI Enrollment form • All current EDI submitters • Separate form for new submitters or options • J-1 EDI Enrollment form from Palmetto Website • Software, manuals & assistance also on Palmetto Website • For Help: • 1-866-749-4301 for EDI Assistance • medicare.edi@PalmettoGBA.com.

12. EARLY BOARDING • Extended period to test your connectivity & communication with Palmetto EDI • Early Boarding Schedule: Send your forms in now and can test before transition occurs. • EDI transition and to-do listserve are on the Palmetto Website

13. CLAIMS AND APPEALS • Palmetto will get all claims & appeals from former contractor after cutover • Send all info to current contractor until you hear otherwise • Palmetto will handle all claims not completed by former contractor • If small provider can still use paper claims • Mutual of Omaha claims will not transition until CMS gives date • Possible dates are in 2010 • See Q and A section on Website

14. Local Coverage Determinations • Palmetto will merge A & B LCDs from former contractors • Least restrictive LCDs will be used • Input from CAC representatives involved • New LCDs posted on the website with connections to CMS Medicare Data Base • CAC (Carrier Advisory Committee) structure will continue in each state • After cutover, reconsideration always possible.

15. PROVIDER ENROLLMENT • No need to document current enrollment unless asked • Information from current contractor will be passed to Palmetto • Be certain you have a correct NPI

16. NATIONAL COVERAGE DECISIONS • National: NCDs come from CMS • Based on scientific studies & data collected • Presented often at MCAC-open meetings • Notice and comment welcome • Reconsiderations always possible • NCDs cover entire country • May specify services always covered • May specify services never covered • Published in CMS Coverage Manual • May change as science changes, new studies emerge, or as laws change. • Reconsiderations always possible

17. LOCAL COVERAGE DECISIONS • Local: LCDs from 1 or more states/areas • Written by local CMDs about situations that are data based & need control or instruction • Presented at state CACs open to medical and specialty societies representatives • Notice and comment welcome • Reconsiderations always possible • LCDs cover a Medicare Jurisdiction • Usually give codes & conditions for payment • May state frequency of service and diagnoses Always published locally and nationally • Reconsiderations always possible

22. HOW YOU COPE WITH LCDS • Know what is covered and which diagnoses and CPT codes to use- they’re written • Know the frequencies or time frames that will be paid • Document any unusual cases or exceptions you may need • If you believe Medicare will not pay: • Have patient sign an ABN (Advanced Beneficiary Notice) • ABN is downloadable from CMS www.cms.hhs.gov/bni

24. DOCUMENTATION • DOCUMENTATION SHOULD PAINT A PICTURE OF: • HOW PATIENT IS DOING / WHAT IS NEW DURING HIGHER CODE VISIT • NEED FOR UNUSUAL / ATYPICAL DRUGS, LABS OR UNUSUAL DIAGNOSTIC TESTS • NEED FOR FREQUENT VISITS OR HIGHER E&M VISITS • ANY SPECIAL PROBLEMS WITH THAT INDIVIDUAL PATIENT • INCLUDE OBSERVATIONS AND SUPPORTIVE DATA AS NEEDED • DOCUMENTATION NEED NOT BE EXTENSIVE • BUT MUST BE LEGIBLE!

25. DOC: TRY TO PAINT A PICTURE CHOOSE A NORMAN ROCKWELL OR ANDREW WYETH PAINTING NOT A JACKSON POLLOCK OR VASILY KANDINSKY PICTURE

26. DOCUMENTATION POINTS • Templates/forms are fine, but must be individualized for each patient & visit • Patient name, date, time, and ID of who documented chart • Computerized notes are okay if individualized, but medical necessity still rules on review • Note time when service is time related-e.g. therapy & crit. care • If poorly legible, send typed or printed copy with original

27. DEALING WITH DENIALS • Know correct codes for what you do • Check national or local coverage policies • Send all data requested in a timely manner and to the correct address • If necessary, speak to the group asking for records—get name of someone • Ask assistance from HMA or your specialty society---they can help. • Review your documentation • Appeal if you think you have grounds Review your documentation Appeal if you think you have grounds

28. DEALING WITH MISTAKES • Physicians & their offices do sometimes make mistakes • If challenged, check your coding and billing processes • Check your CPT, ICD-9, and with your colleagues or with expert coders • Acknowledge mistakes; if you correct problems many reviews will stop there • Be decent with reviewers they are doing their jobs • Humbleness never hurt any review situation…

29. DEALING WITH MISTAKES not again • Make sure coders and billing personnel understand the services you actually did • For special types of practice: be able to demonstrate it • Medicare cannot by law tell you how to practice but it can refuse to reimburse • Know your rights and appeals process-with many levels • You have the right to get out of Medicare / Medicaid

30. RESPONDING TO MEDICAL REVIEW • WHO CAN ASK FOR RECORDS / DOWNCODE OR DENY PAYMENT • MEDICARE A/B ADMIN. CONTRACTORS • MEDICAL INTEGRITY (FRAUD) CONTRACTOR • CERT CONTRACTOR • RAC CONTRACTOR • BUNDLING AND MEDICAL UNLIKELY EDITS • PRIVATE INSURANCE COMPANIES (FOR MEDICARE ADVANTAGE)

31. MAC (A/B) CONTRACTOR REVIEW • Must be written strategy submitted to CMS • Based on accumulated claim data • Statistically different from peers in other states, areas, jurisdictions • Follow Progressive Corrective Action • 20-40 CHARTS REQUESTED • % DENIAL CALCULATED • Based on published NCD, LCD or reviewed medical necessity • Review by clinicians (often MD specialists in the field) • Several levels of appeals available • Contact at Palmetto GBA always available

32. WHO GETS REVIEWED DATA OUTLIERS • UNUSUAL FREQUENCY • UNUSUAL LEVEL OR PLACE OF SERVICE • POOR DOCUMENTATION IN PROBE REVIEW • PATIENT COMPLAINTS • REPEAT FALLOUTS & WARNINGS • POSSIBILITY OF FRAUD

33. PREPARE FOR REVIEWS:DO 1. GET PERSONALLY INVOLVED 2. COPY ALL OFFICE, FACILITY OR OTHER RECORDS REQUESTED: --PROGRESS/THERAPY NOTES (CURRENT AND EARLIER IF HELPFUL TO EXPLAIN) --NURSING NOTES, CLINICAL OBSERVATIONS, AND ANY CONSULT NOTES IF HELPFUL --LAB & DIAGNOSTIC TESTS IF RELATED TO SERVICE --CHANGE IN DX, MEDS, OR IN THE CURRENT CONDITION 3. WHEN IN DOUBT SEND MORE RATHER THAN LESS TO SUPPORT MEDICAL NECESSITY OF SERVICE

34. PREPARE FOR REVIEWS:DO 4.CHECK FOR CORRECT DATES & NAMES---CORRECT PATIENT & DATES ---CORRECT PHYSICIAN 5. SUBMIT TIMELY AND TO CORRECT ADDRESS REQUESTED ON LETTER 6. KEEP RECORD OF INDIVIDUAL ASKING FOR YOUR RECORDS AND WHY THEY ARE ASKING 7. CHECK FOR LEGIBILITY – CAN RETYPE NOTES IF ALSO SEND ORIGINAL 8. CALL IF ANY QUESTIONS – THE LOCAL CONTRACTORS PROBABLY HAVE ANSWERS

35. PREPARE FOR REVIEW:DO NOT 1. HAND OFF TO OTHERS AND LEAVE 2. IGNORE REQUESTS FOR INFORMATION— REVIEWERS WILL NOT GO AWAY 3. CREATE NEW (& STILL WET) PROGRESS NOTES OR DOCUMENTATIONTHAT CLEARLY DID NOT EXIST BEFORE ---CAN SEND CORRECTIONS ---CLARIFICATIONS WITH ORIGINALS 4. DELAY BEYOND DATES STATED 5. CALL MEDICAL DIRECTOR AND SWEAR

36. PREPARE FOR REVIEW:DO NOT 6. DO NOT PANIC • YOU HAVE VARIOUS LEGAL AND APPEAL RIGHTS---TO BE DISCUSSED • MOST AUDITS EDUCATIONAL, NOT PUNITIVE, AND CAN BE RESOLVED

37. PROBLEMS YOU CAN’T RESOLVE? DON’T LOSE CONTROL DON’T BLOW UP!! • CALL CONTACT PERSON AT PALMETTO GBA & ASK FOR AN IN PERSON OR TELEPHONE MEETING • YOU SHOW YOU CARE ABOUT THE SITUATION • THE CONTACT OR VISIT ALONE MAY TEACH YOU HOW TO SOLVE THE PROBLEM • CALL HMA STAFF OR 3RD PARTY RELATIONS COMMITTEE OF YOUR SPECIALTY ASSOCIATION • MEDICARE CONTRACTORS CARE ABOUT GOOD RELATIONS WITH ORGANIZED ASSOCIATIONS • REMEMBER, HMA STAFF CAN ALWAYS CALL US AT PALMETTO TO HELP EXPLAIN THE REGS AND SOLVE THE PROBLEMS – WE ARE HERE TO HELP

38. CERT AND MEDICAL INTEGRITY CONTRACTORS • CERT Contractors (Document & Review) • Ask for only a single chart or case • Purpose to review the reviewers • If denied money must be returned • Appeals possible if you disagree • MIP Contractors (Medical Integrity) • CalBisc and TrustSolutions in Calif. • Potential fraud or abuse cases • Respond promptly, get all info, may be misunderstanding with patient

39. RECOVERY AUDIT CONTRACTOR Recent legal actions and Congressional complaints may lead to changes !! • Contractor PRG Schulz of Atlanta, Ga. • Reviews old claims (up to 4 years from date of claims) • Demonstration Project in 3 states • Paid 20-25% of what it brings in • Will be nationwide in in next few years but rules not final • Looks at medical necessity and incorrect coding for over and underpayment • Can appeal denials several levels

40. PHYSICIAN QUALITY REPORTING INITIATIVE Medicare Payment For Reporting Data… Continues in 2008 with up to 1.5% bonus

41. PQRI CONTINUES THROUGH 2008

42. PQRI CONTINUES THROUGH 2008

43. ELIGIBLE PROFESSIONALS • MEDICARE PHYSICIANS: • MD, DO, DPM, Optometrists, Oral Surgeons, Dentists, Chiropractors • PRACTITIONERS: • PA. NP, Clinical Nurse Specialist, CRNA, Certified Nurse Midwife, Clinical Social Worker, Clinical Psychologist, Registered Dietician, Nutrition Professional • THERAPISTS: • PT, OT, SLP

44. 2008 PQR1 WWW.CMS.HHS.GOV/PQRI/ • The 2008 PQRI measures list and the descriptions of those measures are available in the "Downloads" section below. • Final specifications for the 119 2008 PQRI measures are listed on the CMS website

45. ENROLLMENT Eligible professionals need not enroll or file an intent to participate for the PQRI. Eligible professionals can participate by reporting the appropriate quality measure data on claims. In order to satisfactorily meet requirements of the program & receive the bonus, certain reporting thresholds must be met. When no more than three quality measures are applicable to services provided by an eligible professional, each such measure must be reported in at least 80% of the cases in which the measure is reportable. When four or more measures are applicable to the services provided by an eligible professional, the 80% threshold must be met on at least three of the measuresreported.

46. ENROLLMENT Eligible professionals should select and report measures applicable to their practice. Reporting for the 2008 PQRI began with claims for dates of service as of January 1, 2008. Physicians should become familiar with the 2008 PQRI measures and coding for the measures. Mid year reporting was July, 1, 2008 TRHCA section 101 specifies that, for 2008, CMS must use the taxpayer identification number (TIN) as the billing unit, so any bonus incentive payments earned will be paid to the holder of the TIN.

47. PAYMENT FOR PARTICIPATION • Eligible professionals who participate in the 2008 PQRI program will have access to a CMS analysis of their reported data. • Those who successfully report quality measure data on claims for services between Jan. 1 or July 1 and Dec. 31. 2008, will be eligible for a single consolidated incentive payment in mid 2009. • The bonus, is the equivalent of 1.5% of total allowed charges for covered physician fee schedule services provided from Jan 1 through December 31, 2008.

48. MORE HELP WWW.AMA-ASSN.ORG/

49. FURTHER QUESTIONS We are here to help