Section 1332 State Innovation Waiver Checklist Released by CMS
Centers for Medicare and Medicaid Services (CMS) Issues Section 1332 State Innovation Waiver ChecklistnChecklist Aims to Help Stabilize State Health Insurance Markets for 2018nnThe Centers for Medicare and Medicaid Services (CMS) released new information to help states seek waivers from requirements in the Affordable Care Act (ACA). The new tool is intended to help states complete waiver applications that allow them to establish high-risk pools/ state-operated reinsurance programs. Section 1332 waivers, generally can be used by states to opt-out of some mandated provisions under ACA.nnCMS is helping to provide guidance to states who want to pursue solutions to help lower costs and increase coverage choices for Americans struggling with unaffordable premiums and reduced competition in the insurance market, brought on by the ACA. Individuals obtaining coverage in the ACA marketplace have faced double-digit premium increases and insurance issuer exits.nnNationally, premiums on Healthcare.gov have increased by an average of 25 percent for 2017. The state of Arizona saw insurance costs go up more than 100 percent and one-third of counties in the U.S. currently only have one insurer participating in the exchange. Two insurance carriers in Iowa recently announced they were exiting the market, leaving Iowans in jeopardy of having no insurers participating in the exchange in 2018.nn“Today’s guidance addresses the ACA’s impact in driving up insurance costs and reducing choices,” said CMS Administrator Seema Verma. “State initiated waivers that implement high-risk pool/ state-operated reinsurance programs will help lower premiums, stabilize the health insurance exchange, and meet the unique needs of each state.”n
CMS published three informative resources to guide eligible clinicians participating in Merit-based Incentive Payment System (MIPS) in 2017: a fact–sheet on MIPS participation, another on MIPS data reporting for clinical improvement activities, and a list of qualified registries available for reporting MIPS data.nnWith eligible clinicians transitioning to the federal program this year, these clarifying resources will answer many lingering questions regarding MIPS reporting for the Quality Payment Program under MACRA.nnThe MIPS participation fact–sheet offers a concise overview of who is expected to participate in MIPS, what participation entails, and the guidelines for voluntary participation. Additionally, the MIPS participation fact–sheet provides information on what is expected of clinicians practicing in rural areas (RHCs) or federally qualified health centers (FQHC).nnThe fact–sheet specifies RHCs and FQHCs are not required to participate in MIPS if they are billed as such, but clinicians practicing in critical access hospitals must participate. Further, the MIPS participation fact–sheet outlines who is exempt from MIPS and all special rules for certain MIPS eligible clinicians.nnThe MIPS improvement activities fact–sheet is designed to help clinicians understand the requirements of the MIPS clinical improvement activities performance category. Given these activities are an entirely new performance category, additional information is likely welcomed by clinicians.nnThis CMS fact–sheet lists which improvement activities eligible clinicians can choose from, how to submit information for this performance category, and what the reporting criteria are for receiving credit. The fact–sheet also lays out the scoring methodology for groups including the different weights of each activity and how these weighted activities translate on the point scale.nnFinally, CMS addresses scoring for alternative payment model (APM) participants and the procedure for submitting potential future improvement activities to add to the list of existing CMS-approved improvement activities eligible clinicians can choose in the coming yearsn
As part of the new coding format for our newsletter, Welter Healthcare Partners is excited to offer you a new surgery coding series in which we want to help you! The 2nd week of every month we will highlight a complicated surgical case. This week we are highlighting a general surgery case. We want to hear from you! If you have a complicated surgery case and need help with coding, please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. Welter Healthcare Partners will not use any medical records submitted in which PHI is not removed and protected. 
The Colorado Department of Health Care Policy & Financing recognizes some providers have had difficulties submitting claims during the transition to the new claims payment system (the Colorado interChange).nnIn an effort to ensure providers are appropriately paid for services to members, they are temporarily changing the limit for timely filing.nnEffective May 12, 2017, the timely filing limit will be extended to 240 calendar days.nnTherefore, they recommend providers hold claims with a DOS after December 1, 2016 (that are outside the 120 days timely filing limit) and do not submit those claims until after May 12, 2017. The system will automatically calculate the additional time and providers do not need to take action to receive the extension during claims submission.nnEffective November 1, 2017, the limit will be changed back to 120 calendar days.nnOn November 1, 2017, all claims with a DOS prior to July 4, 2017 will be outside the timely filing limit of 120 days, and providers will need to submit additional documentation to request a timely filing extension.nnExamples:n
Week 1 – Industry Hot Buttons!nnModifier 25: Modifier 25 landed itself on both private payer and the OIG hit lists again this year for overuse and blatant misuse leading to millions in overpayments – and everyone wants their money back! Applying Modifier 25 incorrectly can cost your practice tens of thousands of dollars! Understanding this modifier’s appropriate application can be very tricky.nnHere are a few questions to consider before sticking that modifier on your next claim:n