Latest News from POMS

CMS – REALLY?

In order to prove Meaningful Use of EHR systems and thus be eligible for a portion of the incentive bonus, providers are required to collect, organize and report data showing they are meeting certain measures for quality of care .  However the data cannot be sent electronically to CMS because the agency, 2 ½ years after the HITECH Act became law, has not developed the IT technology to accept the data.  As a result, providers must manually prove their compliance with Meaningful Use through attestation – a time consuming process which contradicts the basic premise of electronic records.  It appears CMS is in no hurry to fix its IT gaps as officials in July 2011 indicated Meaningful Use for Year 2 would again be proven by providers through the manual Attestation process. 

 

IDAHO’S MAC AGAIN ON HOLD

CMS announced on August 22 that Noridian Administrative Services was awarded the MAC (Medicare Administrative Contract) for Jurisdiction F which includes Idaho.  CMS has now instructed Noridian to discontinue all work on the contract because a protest has been filed against the award by one of the bidders.  Pending a decision by CMS regarding the protest, CGS Administrators (formerly Cigna Government Services) will continue to be the Medicare contractor for Idaho.

 

CREATING AND RETAINING MEDICAID RECORDS

Idaho requires provider to document every billable Medicaid service at the time it is provided and such records must be maintained for at least five years from the date of service.  In addition, Idaho code requires that the Idaho Attorney General’s Medicaid Fraud Control Unit shall have immediate access to review and copy any and all records in support of the billed services.  Recently, the Medicaid Program Integrity Unit has encountered instances in which providers have not maintained applicable documentation for the required timeframe.  In response, providers are questioning the requirement that documentation be completed at the time of service as well as citing HIPPA as a reason to challenge the Department’s authority to access records.  Regardless of provider concerns, Medicaid will continue to recoup and impose civil monetary penalties for any services billed to Medicaid without supporting documentation.  Documentation created after a Medicaid records request has been made will not be accepted and is considered to be intentional deception.  Per Medicaid, this constitutes fraud and providers will be referred for prosecution.  Providers who refuse to provide immediate access to their records may be excluded from participation in the Medicaid program.

 

IDAHO MEDICAID EHR INCENTIVE PROGRAM

Per information provided by Molina on September 23, 2011 in response to a POMS inquiry regarding attestation for the Medicaid portion of the incentive program:  “Per the State of Idaho, the electronic health records, (the incentive part), is not yet operational in Idaho.  They are currently working on it and an announcement will be made when finalized.”  Providers seeing a higher volume of Medicaid versus Medicare patients will benefit with a higher incentive payment from the Medicaid attestation however it is unclear at this time when the program will be operational.  POMS will continue to update our clients as information is available.

 

2012 MEDICARE FEE SCHEDULE

At this time, no information has been released by CMS or Congress to suggest the scheduled 29.5% reduction in Medicare physician fees will not take place on January 1, 2012.  Given the current Congressional climate in Washington, it is impossible to foresee the outcome.  Congress has 3 options:

  • Do nothing and the reduction will take effect.
  • Implement another temporary fix, thus increasing the eventual cost of a permanent fix.
  • Reform or replace, resulting in an increased Medicare spending on physician services by approximately $300 billion over the next ten years and necessitate offsetting cuts in other areas.

POMS will continue to monitor this situation and will update our clients as information is received.

 

FINAL MEDICARE E-PRESCRIBING RULE

On September 6, 2011, CMS issued its final rule changes Medicare’s E-Prescribe Incentive program.  In an attempt to align the E-Prescribe program with the HER meaningful use incentive program, the “hardship exemption” criteria was more clearly defined.  To recap, all providers who have not yet adopted an E-Prescribing system, either stand-alone or through an EHR system, will be subject to a 1% fee reimbursement penalty beginning January 1, 2012.  Under the final rule, the roughly 100,000 physicians and other health professionals who did not report electronically prescribing at least 10 times from 1/1/11 – 6/30/11 are at risk of being hit with the penalty.  Those providers will be able to submit a hardship exemption request no later than November 1, 2011.  The hardship exemption categories are:

  • The physician has adopted a Certified EHR program by October 1, 2011 and intends to use the EHR to qualify for the Medicare or Medicaid incentive payment for 2011.
  • The physician is unable to prescribe electronically due to local, State or Federal law or regulation.
  • The physician has limited prescribing activity.  Fewer than 10 prescriptions between 1/1/11 and 6/30/11 identifies this category.
  • The physician’s practice is located in a rural area with no high speed internet access
  • The physician’s practice is located in an area with limited available pharmacies for e-prescribing.

Requests  made for an additional hardship exemption for physicians nearing retirement or over 60 years of age were not included in the Final Rule.

 

Physicians may apply for multiple exemptions and will be reviewed on a case-by-case basis.  CMS has launched a special website for physicians to enter the exemption  requests and supporting rationale (https://www.qualitynet.or/portal/server.pt/community/communications_support_system/234 ).  A detailed justification statement is required for each request.  Only individual physicians are able to use the website – group practices must submit the requests in writing and mail them to CMS.  The requests must be postmarked by the November 1 deadline.

 

TRICARE BACK-SCHOOL-PHYSICALS

Tricare Prime will cover required back-to-school  physicals for children ages 5-11 as a clinical preventative service.  Coverage is limited to those physicals required for enrollment – not sports physicals.  Sports physicals are NOT a covered Tricare benefit.  In addition, providers should not use the diagnosis code V70.0 when billing for these physicals as Tricare considers the code to be too vague.  Instead, providers should use the diagnosis code V70.3.

 

TRICARE BEHAVIORAL HEALTH CARE VISITS

October 1 is the first day of the Tricare fiscal year and is the day that the behavioral health care outpatient visit count renews for all Tricare beneficiaries.  Tricare Prime beneficiaries are eligible for eight (8) self-referred routine outpatient behavioral health visits per fiscal year without a referral or prior authorization from their PCM.  It should be noted however, a referral is required for those first eight visits if the provider of service is a licensed professional counselor, licensed mental health counselor or pastoral counselor.  Prior authorization is required for the ninth and subsequent visits for all beneficiaries, regardless of the licensure of the servicing provider.