Posts Tagged reimbursement

QIPS Section Webinar Features PQRS Updates

Please register for the next Quality Improvement & Patient Safety (QIPS) “All Section Webinar,” which will feature a presentation from ACEP leaders Dennis Beck, MD, FACEP & Rick Newell, MD, FACEP on the 2014 Updates to the CMS Physician Quality Reporting System (PQRS) and the Physician Value-Based Payment Modifier (VBM) with input from Mike Granovsky, MD, FACEP.

This webinar will take place 11:00 a.m. EDT on Tuesday, April 1.

  • Learn about CMS new requirements for the 2014 PQRS incentive and the 2016 payment adjustment and the PQRS measure set as follows. The penalty for failure to report PQRS has increased from 1.5% to 2%, and non-reporters will also be penalized with an additional 2% penalty for the new Value-Based Modifier.
  • Learn which measures to report in order to earn the PQRS Incentives CMS requires eligible professionals to report 9 Measures Across 3 NQS Domains via the claims-based or registry reporting mechanisms
  • Understand the Measures Applicability Validation (MAV) process, which will allow CMS to determine whether an eligible professional should have reported quality data codes for additional measures.

Please register here or click on the link below and be sure to add the event to your calendar after registering.
https://attendee.gotowebinar.com/register/1561548761077304066

Tuesday, April 1 at 11:00 a.m. ET
Dial in Number: 1-877-366-0711
Participant Code: 14253069
Mute/Unmute: *6

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Remember to Use the Fair Health Discount Code

ACEP has arranged for its members to receive a 20% discount on the FH Fee Estimator, a new source of independent charge data from private insurance claims. Participants can access emergency medicine charge data for 491 geographic areas nationwide. This tool gives physicians and management a better understanding of the marketplace and allows instant compare charge data to Medicare fees.

The FH Fee Estimator website, www.feeestimator.org, is easy to use for small data requests. But if you need a more sophisticated data set, contact FAIR Health for custom analytics. To get the ACEP 20% discount, enter the promotion code 20ACEP13 at the checkout screen.

FH Fee Estimator is brought to you by the not-for-profit corporation FAIR Health, whose mission is to bring transparency to healthcare costs through comprehensive data products and consumer resources. Created in 2009 to provide an objective source of data, FAIR Health owns and maintains a database of billions of billed medical and dental services. This database serves as the foundation for benchmark products that reflect the prices charged for healthcare services in specific geographic markets across the country.

This database is a great resource for emergency physicians groups to inform development of fee schedules and other practice decision making, says David McKenzie, CAE, ACEP’s director of physician reimbursement. The data is available based on an aggregation of zip codes and can be tailored for the geographic area you serve. Because it is drawn from actual claims data, it is a wonderful source of information on fees charged in your area, he adds.

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Why is the Government Targeting the Most Charitable Physician Specialty?

Why is the Government Targeting the Most Charitable Physician Specialty?

I don’t get it.  I do not understand why the US government has decided to paint a target on the backs of physicians who, according to the AMA, provide more charity care than any other specialty, in a program that uses so-called hired gun auditors to recoup over-payments in Medicare’s fraud and abuse prevention strategy.  These are physicians who give away, on average, more than $140,000 a year in unreimbursed services to the poor and uninsured (4-10 times more than any other specialty), and serve a larger proportion of Medicaid and under-insured patients than the vast majority of other physicians.  These charitable physicians are willing to treat everyone, regardless of their insurance status or ability to pay, day or night, Sundays and holidays, whether the patients are upstanding citizens or the disheveled homeless.  These docs provide care to everyone who asks to be treated or comes to their door, even if they are intoxicated to near stupor, or ranting obscenities, or smell like a garbage dump, or shed deadly viruses in an epidemic, or are soaked in toxic chemicals released in an accidental spill or a terrorist attack.

None of these physicians are engaged in a criminal enterprise to cheat Medicare and the tax payers out of millions of dollars for care they never provided, or using stolen or purchased patient IDs to submit fake claims, or billing for tests not performed, or charging for equipment they never ordered.  In fact, these specialists work almost exclusively in hospitals that carefully screen their credentials, and in medical groups that have some of the most extensive claims coding and billing compliance programs in the health care industry.  Nonetheless, the government has selected these physicians for auditing under the Medicare Recovery Audit Contract (RAC) program by focusing on the evaluation and management (E&M) CPT codes that are used almost exclusively in claims submitted to Medicare by these specialists.  Other E&M and procedure codes are also being targeted for audits by these RACs, but these other codes are widely  used by many other physician specialties.

There is no question that fraud and false claims are a serious problem for Medicare, and cost taxpayers hundreds of millions of dollars every year.  For every $1 the government spends on these RACs, it gets back $40.  I am all in favor of dealing a heavy blow to those who try to cheat the system, provided the adjudication process is fair and the focus is on activities that are clearly in violation of the rules.  There are those who believe that hiring these private audit contractors on a contingency basis (based on the amount of overpayments they find) is like paying a bounty hunter to bring in a possible suspect dead or alive, especially since many claims that the RACs deem overpaid are frequently found to be ‘not guilty’ on appeal.   The rules that are applied to these claims are, unfortunately, not always clear and concise:  E&M coding in particular is about how sick the patient is, and how complicated or difficult the medical decisions are to make.  In other words, medical coding is an art, not a science, and using an auditor that is financially incentivized to interpret these rules in the most aggressive way, with the threat of big penalties and forfeitures, is like writing a law that stiffs you with a big fine for ‘parking too close to a fire hydrant’ without specifying how close is too close, or paining the curb red.

I don’t doubt that a few of these ‘charitable physicians’ stretch the coding rules a bit, or even overcharge for their services.  It happens, but it’s not the rule, by any means.   I have talked to quite a few of these particular specialists who have experienced RAC audits.  They usually consider themselves to be good at documenting their care, who employ careful and conscientious claims coders for their billing service.  They come away from the RAC audit experience angry, frustrated, baffled, fearful, indignant, and depressed.  These physicians don’t go out of their way to intentionally up-code their claims, or un-bundle them (charge separately for items that should be covered under a single charge), and they take pride in their willingness to treat patients few other physicians are willing to see, regardless of the patient’s ability to pay.   They are all overworked, sometimes underpaid, subject to stress burnout, and challenged by a seemingly impossible mission; and they do this for over 130 million patients in the US every year.  These docs just don’t understand why their government would go out of its way to paint a target on the backs of emergency physicians.

This post also appears in The Fickle Finger  www.ficklefinger.net/blog/

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What is the Fair Market Value of an Emergency Physician’s Services?

What is the Fair Market Value of an Emergency Physician's Service?

Trying to define the market value of someone’s professional services is difficult when those services are typically paid at vastly different rates, depending on the payer, especially when the party paying is usually not the direct recipient of the service.  So when an emergency physician provides clinical services to a patient, how are those services valued by different payers, and what does that say about the reasonable market value of those services?

For example, let’s say that you come to the emergency department with an acute asthma attack:  you can’t breath well, and your inhaler hasn’t helped to break the attack.  A pretty straight-forward case, really:  your ER doc does a history and physical exam, orders up some oxygen and a few respiratory therapy treatments, some steroids, perhaps an IV to rehydrate you and get access in case your condition worsens and you need IV meds, and returns to re-evaluate you every 15 minuets to make sure the treatments are working.  Two hours later, you are able to go home with a script for three days of Prednisone and a refill for your Ventolin inhaler as the one you have is running low.  You get instructions on how to care for yourself at home, when to see your primary care doctor, and what you should do if the wheezing comes on again despite the treatment.  Chances are, you will likely get a charge for this service from the physician for 99284 level care for around $320, give or take, if you live, let’s say, in central California.

If you didn’t have insurance, you would be expected to pay the full charge.  Unfortunately, many patients can’t afford to pay; or could afford to pay but are just irresponsible, and don’t pay anything.  If the patient pays nothing, the emergency physician may be able to recover about $45 from California’s EMS Fund, a tobacco settlement funded program that pays on average about 15% of the emergency physician’s fee.

However, if you were uninsured with a family income at or below 350% of the federal poverty level; or you are insured and have incurred high medical costs (greater than 10% of family income over the prior 12 months) with a family income at or below 350% of federal poverty, and you submitted a request for a discount; you would (by virtue of California law) only have to pay 50% of median billed charges of a nationally recognized database of physician charges, probably around $150.

If you were covered by your County’s new Low Income Health Program (a family of 4 making less than $41,000/year), the county may pay the emergency physician about 30% of the Medicaid rate, or a whopping $21.

If you were covered by California’s Medi-Cal program, one of the lowest paying Medicaid programs in the country:  $68.

If you were covered by Medicare: the federal program would pay about $125.

If you had HMO coverage, but had to go to a closer out-of-network ER, your HMO would pay the ER doc between $140 and $250.

If you had PPO coverage, the plan would pay between $175 and $240, minus any co-insurance payment, and you would have to pay the rest up to the $320 charge.

So, for a $320 emergency physician service, the emergency physician might receive anywhere from the full $320 down to $21, and about 10% of the time – nothing.  The average emergency physician in California provides about $140,000 a year in unreimbursed care.

Of course, in order to provide these services, the emergency physician has to spend $10 to pay for malpractice insurance, $30 for billing services, and additional costs for other overhead amounting to a total of about $55 for every ED patient treated (even if the payment is $0)

So, what’s the real market value for an emergency physician’s services?  I would argue that it is the full amount that the emergency physician charges, as long as these charges aren’t significantly higher than what other emergency physicians in the same area charge, but then I just paid a heating technician $175 for 10 minutes of maintenance on our furnace.  Others would argue differently, but their estimate would be based on their particular agenda:  protecting those living in poverty, reducing costs for the employer, dealing with government budget deficits, or making higher profits for the insurer.  Unfortunately, none of these advocates actually provides emergency care to anyone.

By the way, if you were suffering from a heart attack or serious injury, and the emergency physician (and his team) actually saved your life (it happens hundreds of times every day), the emergency physician’s charge would be around $800 to (rarely) $2000.  So, what’s the real market value of YOUR life?

This post also appears on the blog The Fickle Finger www.ficklefinger.net/blog/

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The Balance Billing / Fair Payment / Hospital-based Physician Conundrum

Efforts to prohibit balance billing by non-contracted hospital based physicians, especially for emergency care patients, continue to confront ACEP state chapters left and right (or should I say North, South, East and West). It is pretty clear that many legislators and insurance regulators see this as a consumer protection issue, predicated on the fact that in an emergency, most patients do not have the ability to shop for providers that are contracted with their health plan; and that when they go to their ‘networked hospital’, it is with the expectation (often built upon misleading health plan assertions) that all of the docs at this hospital will be contracted with their plan. Health plans, regulators, and legislators are also motivated by the desire to contain costs; and for the plans in particular, prohibiting balance billing by hospital-based docs is the camel’s nose under the tent for control of all physician-related outlays.

The simplest solutions equate to fee setting. Fortunately, no one seems quite willing to go there….yet. I think this is because most folks recognize that setting fees at the wrong level could lead to disastrous unintended consequences, especially given physician shortages in this country. The AMA considers the balance billing issue to be a problem with ‘inadequate networks’, but pressure on plans to include more hospital based docs in plan networks often just results in more coercive contracting.  This is where the plan pressures the hospital to leverage the staffing contracts of the hospital-based docs, to force these docs to accept deeply discounted contract rates with the plans. This has unintended consequences, too. Hospital employment of physicians would certainly ensure that these docs were contracted with all of the hospital’s networked plans; but hospitals are notoriously poor at collecting for physician services, and the downsides of the corporate practice of medicine are real. You would think the marketplace would have resolved this issue; but because of EMTALA and coercive contracting and the burden of the uninsured and the lack of good regulatory oversight; the market for emergency care services is really not a fair and free market.

The conundrum is: how do we make sure that emergency care providers and hospital-based physicians subject to EMTALA’s mandate are sufficiently compensated for commercially insured services so that they can meet their mission to provide care to all those uninsured and under-insured patients, and at the same time keep insured patients out of the middle of disputes between plans and providers over the reasonable value of emergency care and hospital-based physician services? One could argue that the patients should not be excluded from the debate, but the plans and legislators easily trump that argument with tales of egregious charges by a few ‘greedy doctors’. Hospitals and plans could be required to include physicians in three-way network contract negotiations, but that is  impractical. Hospitals could be forced to provide subsidies to make up for the losses incurred by hospital-based docs who are forced to sign contracts with plans at deeply discounted rates; but many hospitals are already going bankrupt supporting flagging ER on-call rosters, and really it is the plans who are making most of the profits nowadays. Plans should not be able to say:  ‘the uninsured are not our problem’.  Some legislators (most recently in Illinois, in exchange for honoring assignment of benefits) have proposed fee arbitration as a solution, but the arbitration of millions of underpaid non-par claims is just ridiculous, not to mention hugely expensive. Any so-called solution that does not result in the vast majority of claims being paid appropriately up-front is doomed to failure.  Others have proposed all sorts of inventive solutions to balance billing that would precipitate one or more serious unintended consequences by failing to address charge outliers or relying on fee setting or ignoring claims dispute resolution or relying on impossible claims management procedures. What is a well-meaning regulator or legislator to do?

One alternative is to try to get at the issue by addressing fair contracting rates for hospital-based physicians. Some advocates of what would essentially be ‘forced health plan contracting’ for hospital-based physicians argue that these physicians should accept contracting discounts from their usual and customary charges because their hospital’s networked relationships provide them with patient referrals, and that the only real question is: what is a reasonable contract rate? There are lots of different considerations that are usually exchanged for a fee discount in managed care contracting, referrals being but one of them. Determining a ‘reasonable contract rate’ is no easy matter, especially since contracting rates are supposed to be confidential between plan and provider, so getting at valid ‘usual and customary contracting rates’ would be difficult, if not an outright anti-trust violation. There are so many other terms and conditions negotiated in contracts with plans that establishing fair-market-driven contract rate standards for hospital-based physicians is probably a hopeless cause.

ACEP has addressed the balance billing / fair payment issue by developing a set of fair payment principles and model legislation. The ‘solution’ eliminates the need for balance billing and is predicated on using usual and customary charges to get close to the reasonable market value of non-contracted services and to address charge outliers, and on the establishment of a fair, fast, and cost-effective claims dispute mechanism to address the other causes of claims underpayment for non-contracted (and contracted) services. These and related documents can be found on the ACEP website: http://www.acep.org/advocacy.aspx?id=22188 This is a complicated issue requiring carefully constructed components and backstop measures to ensure a balanced approach to balance billing and fair payment.

Considering the fragile state of the emergency care system in the U.S., and the proclivity of legislators and regulators to ‘fix’ complex problems without really understanding them first; there are no perfect or easy solutions to the balance billing / fair payment issue that can be enacted without the risk of punching great big holes in the safety net, and making it impossible for emergency care providers to fulfill their mission.  ACEP’s solution is neither perfect nor easy, and not everyone will be happy with it, but it is workable, and reasonable.

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Ten Key Elements to Successful Contracting with Managed Care Plans

In the last ten years or so I’ve had the opportunity to participate in the negotiation of close to half a billion dollars worth of managed care contracts on behalf of my ED partnership. I’ve learned a thing or three from this experience, and wanted to share some observations and suggestions about managed care contracting with my emergency physician colleagues. in part this is because I believe a rising tide raises all boats. Unfortunately, when it comes to managed care contracting, many emergency physician groups have great difficulty just staying afloat. There are lots of reasons for this: coercive contracting (when your hospital ‘encourages’ you to contract with their health plan network partners), lack of attention to the issue, an inability to understand the managed care market in their communities, lack of contracting experience and lack of resources, inadequate billing and collections data, and so on. The result is that many emergency physician groups leave a lot of money on the table – revenues that may be critical to their ability to recruit and retain qualified physicians in their EDs and fulfill their mission. If you think that as a hospital employed ED physician, this does not impact you….well, all I can say is that if your hospital is giving your services away at bargain rates, chances are this impacts your reimbursement in some way or another.

Assuming for a moment that your ER group’s ability to pay you fair compensation for your services is to some extent dependent on the group being able to get the best possible terms in the managed care contracts the group negotiates with commercial, Medicare and Medicaid managed care, and self-insured indemnity plans: here are some considerations that might be important to you.

1. It is absolutely true that, in a negotiation, if you can’t say ‘no, thank you’ and walk away, you are all but screwed. Coercive contracting is a very real issue, and hospitals are frequently enlisted to get their hospital based physician groups to line up and sign deeply discounted, below market rate contracts with plans. The key to neutralizing coercive contracting is to invest the time and effort into convincing your hospital CEO or CFO that it is in the hospital’s interest, over the long term, to give hospital based physicians the room to negotiate fair market rates for their services.

2. Your group’s billing company and claims management team is critical to managed care contracting. You get what you pay for, and going for the cheapest service is penny wise and pound stupid. In contracting, data is king, and a good billing company should be able to tell you more about the financial impacts of contracting terms, current and future, than even the plan itself may be able to bring to bear. In particular, the ability to line item post payments against each code included on a claim is very useful, and a sophisticated claims management system is a must.

3. Most physician groups think that the only thing that needs to be negotiated in a managed care contract is the rates. WRONG. Every line in the plan’s contract is designed to benefit the plan, not you, and every provision is negotiable, and deserves to be review carefully, and challenged when it is either inappropriate to your practice or too adverse to your interests.

4. Once you agree to a rate with a plan, the plan is likely to try to use every other means at its disposal to pay you as little as it can get away with. They do this by aggressively down-coding your claims, bundling your codes, denying coverage, and dragging out the time it takes them to pay. Thus, these ‘terms’ are just as important to address in negotiations as the rate. If, for example, the plan intends to deny payment for ECG interpretation and report, you should know that up front, and negotiate a better rate for E&M and surgical services to make up for this loss.

5. No matter who negotiates these ontracts for your group, they need to have sufficient support, especially data support, to maximize their results for you. Of course, larger groups have an advantage in terms of contracting resources, but both large and small groups can benefit from the assistance of contracting consultants who can provide both negotiating experience and knowledge of contracting markets and plan behavior and strategy.

6. Direct physician involvement in managed care contracting, whether the plan is local or national in scope, is almost always useful. First, who best to advocate for physician reimbursement than a physician; second, physicians have gravitas; and third, physicians understand the nuances of clinical service that often come up in discussions around EMTALA, prudent layperson, necessity of care, medical record documentation, and other claims payment issues.

7. If your group’s billing company or practice management service is not routinely disputing underpaid claims, and you are not taking advantage of whatever regulatory agency claims dispute processes may be available, then you will not have laid the groundwork for successful managed care contracting. Plus, you will be leaving even more money on the table. Having disputed thousands and thousands of underpaid managed care claims, both contracted and non-contracted, I can assure you that the direct and indirect ROI is considerable.

8. If your group has more than a few managed care contracts, you need to maintain a managed care contracting database. This database should allow you to easily access all your contracting terms and key provisions, and also calendar dates for expiration and renegotiation of these contracts. Many contracts have automatic renewal provisions that extend the contract unless you give notice of intent to renegotiate.

9. There are all sorts of resources on the net covering managed care contracting and negotiation strategies, and state medical societies are often a good source of information about contracting and some even assist with contract language review, or have resource materials covering contract provisions. Even if you don’t negotiate health plan contracts, negotiation is something that happens every date in our lives, and it doesn’t hurt to learn some of the ropes.

10. A contract with a managed care plan need not necessarily be the reflection of a winning and a losing strategy – there are plenty of opportunities to fashion contract provisions that benefit both the plan and the provider, that reduce the plan’s cost for claims processing or claims dispute while it reduces hassles or payment delays or claims submission costs for the provider. Win-win is possible in the health insurance industry (though unfortunately, not all that common).

The Central Line has set up a managed care contracting category. I encourage other bloggers to chime in on this important topic. Hope to hear from you.

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Medicaid Recoupment Programs Bypass Providers

The following is a very long blog directed at those responsible for reimbursement issues for your ED group or site.  Though a bit complicated, is pretty interesting, both from a revenue standpoint for Emergency Physicians, not only in California, but throughout the nation, and from the standpoint of maintenance of our reputation with patients.  The basic gist of this issue is that state Medicaid programs have been employing private agencies to recoup payments made to providers through the Medicaid fee-for-service programs in instances where the enrollee MAY have also been covered by a commercial carrier on the date of service.  This process, which in California bypassed the providers entirely, allowed the commercial carriers to escape with millions in unearned profits, and denied providers the opportunity to receive the revenues they were rightfully due.  If this is happening in your state (it probably is), you may find that you have an opportunity to reassert your right to participate in this process, and reclaim these revenues.  I believe that as other health departments in other States become aware of the inadvertent consequences on providers from this program, they may, as the DHCS has in California, willingly consider revisions to the recoupment program.

My ED group first became aware of this Medicaid (Medi-Cal) recoupment program in California somewhat by accident, aided by careful attention to claims management.  More than a year ago, CEP America (CEPA) received a number of notices from Blue Cross requesting additional information to make an eligibility and benefits determination on claims that (we subsequently discovered) were sent to Blue Cross by Health Management Systems (HMS) on behalf of the Department of Health Care Services (DHCS), using CEPA’s group name and our providers’ identification numbers, to try to recoup payments made to CEPA by the MediCal program.  HMS had been contracted by the DHCS to manage this recoupment process (as it has in other States).

What appears to have happened here is that HMS was using Medi-Cal claims data, provided by the DHCS, to try to identify patients who may possibly have simultaneous coverage under the Medi-Cal program and under an indemnity plan like Blue Cross on the date of the provider’s service.  HMS compared the Medi-Cal claims to plan enrollment data provided by several plans, including Blue Cross, obtained under a data sharing agreement with these plans.  HMS then sent claims to these plans in the hope that the patients might have also been covered by the plans, using the CEPA’s provider name and identification number on the CMS 1500 claim form, but using a different PO Box payment address so that any payment is sent to the HMS and the DHCS, and not to CEP America. These claims were supposed to have been processed in a unique manner by these plans, but due to an inadvertent mix-up, BC processed some of these claims as if they came from CEPA.  Since many of these enrollees turned out not to have dual coverage on the date of service; BC inadvertently sent notices to CEPA requesting additional information on the claim hoping to resolve the eligibility question.  HMS indicated that CEPA should never have received these notices, but nonetheless, these notices alerted CEPA to the fact that BC was being billed under CEPA’s provider name and number by HMS.

Furthermore, in a couple of cases, HMS identified patients who appeared to have BC coverage, sent the claim to BC, and it turned out the patient had the same name as the actual BC enrollee, but a different birth date.  One such claim listed both the CEPA provider’s charge of $306 and the payment by Medi-Cal to CEPA of $68.35.  BC then sent their enrollee an EOB indicating that the patient had not yet met their deductible level for the year, and thus the patient owed $186.91 (based on the BC allowable payment).  Had this enrollee met their deductible for the year, BC could easily have sent this $186.91 to the DHCS/HMS PO Box directly.  However, when the patient received the EOB, they contacted BC to say that they had not been treated in the ER on 8/11/2007, and furthermore had not been pregnant at the time (as alluded to in the EOB).  BC then sent CEPA a patient grievance notice asking CEPA to respond to the patient’s grievance.  This is but one of several examples which demonstrated that:

1) The cross-referencing of Medi-Cal claims and commercial plan eligibility logs relied on incomplete data, and misidentified some patients
2) Some of the claims sent to the plans were misleading and inaccurate, and could easily result in incorrect payments by the plan or the patient to DHCS, and damage to the provider (and we were never able to determine how many such claims were previously miss-paid by the plan or the patient)
3) The recoupment process (at least for this program) inappropriately bypassed the provider, thus denying the provider the opportunity to obtain reimbursement at the higher commercial indemnity rate
4) The process made it difficult if not impossible for the provider to subsequently recover proper payment from the health plan if the provider were later to discover that the enrollee had commercial coverage, as the provider’s claim to the plan would be rejected as a duplicate to the claim from HMS.

HMS indicated that it had the right to try to recover these payments directly from the health plan using the provider’s name and ID number, based on existing subrogation rights statutes.  Furthermore, even when the claims screening process actually identified a patient who did have indemnity coverage at the time of CEPA’s service, the claim sent by HMS to the insurance plan might result in payment at the contracted commercial rate referenced under CEPA’s provider number, rather than a payment that rebates DHCS the exact amount of the payment made by DHCS to CEP.

Once we had identified these issues, we asked the DHCS to consider allowing CEPA to participate directly in the claims submission / recovery process, using the list identified by the HMS cross-reference process.  The DHCS was quite willing to consider establishing a pilot program to test this concept, in light of the problems we had identified, and recruited HMS’s participation in the pilot.  Although it took HMS a full year to set up the pilot program, they eventually submitted 3369 CEPA claims paid by Medi-Cal where the enrollees were thought to have simultaneous commercial plan coverage.  HMS requested a total of $248,098 in Medi-Cal payment refunds to the DHCS on these claims.

Of these 3369 claims, 1897 claims have thus far been successfully closed.  These 1897 claims represented $138,626 in potential refunds to DHCS.  We determined that of this amount, only $34,327 was actually due to DHCS in refunds (which will be retracted by the department directly).

No refund was due for 1432 claims representing $104,299 in potential recoupments: 762 claims representing $58,000 related to lack of coverage eligibility under the carrier on the date of service; 361 claims representing $21,000 had originally been billed to and paid appropriately by MediCal as the secondary payer (these claims should probably not have been submitted to HMS in the first place); and 309 claims representing $25,000 were not eligible for recoupment for other various other reasons, which were documented and sent to HMS).

CEPA collected $91,357 from primary carriers from the remaining 465 claims that were actually found to have primary commercial coverage on the date of service.  Thus, CEPA retained $104,299 in appropriate Medi-Cal payments (some of which might otherwise have been inappropriately recouped) and received an additional $57,030 after collecting from the plans and making rebates to the Medi-Cal program.

At this time, we still have 1472 unresolved claims due to the following issues:

1) Carrier denied payment due to untimely filing even though supporting documentation was submitted with the original billing to justify late filing.
2) Carrier indicated (on follow-up calls for claims status) that the claims could not be found, thus requiring resubmission on paper, which allows the carrier to take an additional 45 workings day to respond to the claim.
3) Carrier has failed to respond to the claim within 45 days, requiring additional follow-up calls – status pending.

We anticipate that when all 1472 pending claims have been successfully (and accurately) adjudicated, CEPA may collect an additional $80,000 in revenues, and provide an additional $30,000 in rebates to the Medi-Cal FFS program, for a total net additional revenue of over $120,000 from the 3369 claims identified by HMS.  The cost of managing these claims will probably be around $20,000.  Based on even this incomplete result, the DHCS now appears to be ready to remodel the recoupment program with HMS to enable all providers in California to participate in the process.  Given that CEPA represents about 15% of the California ED physician market, this could mean an additional $1-2 M a year for ED physicians in our state. This is not a huge amount, but it appears to be worth the effort, and perhaps more importantly, eliminates the mistakes that can undermine provider relations with our patients, while allowing the Medicaid program to recoup payments appropriately.

It is likely that the same recoupment process, which has been in place in California for several years, is also in effect in many other states, and may deserve to be remodeled to incorporate, rather than exclude, providers.   I think you will see that HMS is in many states doing what they have been doing for the CA Medicaid program, and by the way, HMS also does this or similar recoupment processes for several other government and private clients.  In fact, in CA they provide recoupment services for Medicaid HMOs, though in this program providers get to participate.  However,  the provider has only 45 working days to adjudicate the claim with the alternate payer before the Medicaid Managed Care payment is retracted.  In CA, HMS  ‘demands’ recoupments without bothering to do the work of checking with the alternate payer’s on-line coverage eligibility database for coverage on the specified date of service, resulting in demands for recoupment for many patients that did not have simultaneous coverage on the date of service.

I would suggest that ACEP members send out inquiries to their Medicaid departments asking if HMS, or any other organization, has been contracted to manage recoupment for Medicaid patients in the state that were thought to possibly have simultaneous commercial or Medicare coverage, and whether this contractor was responsible for submitting claims to these alternate carriers, using the provider’s name and id numbers on these claims.  If the answer is yes, I would suggest stating concerns about the inadvertent impacts such a program might be having, based on the fact that the contractor is likely misidentifying (with their cross-check process) far more instances of simultaneous coverage than actually occur (see the issues listed above), and insisting that providers should have the opportunity to send these claims themselves, and provide rebates to Medicaid when appropriate.

Assuming that the Department in question is willing to revise the program to include provider participation, I would suggest insisting that 1) the provider have at least 120 working days to adjudicate the claim with the new primary before any recoupment or retraction is made, 2) HMS be required to do online eligibility determinations with the potential new primary carrier for the date of service in question before sending the information and recoupment request to the provider, 3) that HMS be required to use the patient’s name and at least one and preferably two additional patient identifiers (date of birth, Medicaid enrollee number) to ensure proper patient identification, and 4), that any retractions done by the Medicaid program should properly identify on the retraction notice (warrant) the specific claim to which the retraction applies.  Ideally, no retractions should be due unless the commercial carrier has paid first.   EMTALA obligated providers can not afford to be bypassed in the recoupment process.

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Senate to Consider Medicare Payment Fix – Make Sure Your Voice is Heard

Angela GardnerStarting this week, the Senate will take a series of critical votes on a bill, the Medicare Physicians Fairness Act of 2009 (S.1776), to abolish the flawed formula used to determine Medicare reimbursement rates. This bill is critically important to all physicians, but especially to emergency physicians who will undoubtedly see a significant increase in Medicare patients if scheduled payment cuts are enacted.

 Under the current system, physicians are scheduled to receive drastic cuts to Medicare payments starting next year. Congress understands that the scheduled cuts would devastate access to care for seniors so each year they “patch” the system by voting at the last minute to cancel the funding cut. However, even though the cut is not enacted, the total accumulated debt for physician reimbursement under Medicare continues to grow.  Picture it as a credit card with a huge balance and a high interest rate.  Congress “forgives” a payment on the debt each year, but that amount is added to the balance, and interest continues to add up.  Without action by Congress, physicians are scheduled to take a 21 percent reduction in reimbursement for Medicare patients next year, with cuts totaling 40 percent in future years. 

 Having health insurance coverage is not the same thing as having access to medical care.  All seniors over age 65 are entitled to insurance under the Medicare program.  Increasingly, however, primary care physicians and other specialists are refusing to take new Medicare patients because of low reimbursement rates. It’s not that those doctors lack compassion, it’s that many lose money on Medicare patients and a 40 percent cut in payments would make it impossible for them to continue to treat those individuals.

 With an aging population, emergency departments already anticipate an increased volume of seniors needing care.  If, however, Congress does not fix the flawed Medicare formula, that increase could be catastrophic.  Seniors unable to find doctors accepting Medicare may have no choice but to seek care in emergency departments, which the Institute of Medicine already calls “dangerously overcrowded.”

Passage of this bill would help to prevent more crowding in emergency departments, provide a reasonable level of compensation to emergency physicians, and help attract on-call specialists. This is a non-partisan issue. Republicans and Democrats claim to care equally about ensuring access to care for seniors. If our elected representatives are sincere in these views, they will take a principled stand on this issue and support S.1776 now.

You can help assure passage of this critical legislation. Contact your two U.S. Senators now and tell them to support S. 1776. Here’s how:

  • Call 1-800-833-6354 to be automatically connected to your two Senators. Urge them to support all procedural motions and final passage of S.1776.
  • Go to ACEP’s Advocacy Center  and send an e-mail urging your Senators to support S. 1776.

Now is the time to become involved. Pick up the phone and make that call.  And check back here often for updates. Working together the emergency physician community can make a difference.

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