Holidays with the In-Laws — Fun with ICD-10
R51 – HeadachenR46.6 – Undue concern and preoccupation with stressful eventsnZ63.1 – Problems in relationship with in-lawsnn
Third Party Payer Update – COLORADO
The Triple Aim:n
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- Improving the patient experience
- Improving the health of populations
- Reducing per-capita cost
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nThe Triple Aim is on all the payer’s minds these days. These three tenants are now being woven into many of the decisions being made about cost, quality, reimbursements, network size, etc. Using these three items in your contracting strategy will help your success. Measuring and being able to report your ability to positively affect these three goals will make your practice more valuable to the health plans.nnThe payers are continuing to engage in the soft-narrowing of their various networks, using the direction of member volume to leverage rates. The “Value Based” PCP relationship appears to be the primary mechanism of this process. Therefore a member is not a member until you have their benefits carefully verified.nnThese days your referral people need to take a couple of extra steps:n
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- Is the member eligible?
- Are we on the PCP and Members list?
- What benefits are available for this plan type, product type, etc?
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PAYER UPDATES:
nAetna is in the process of buying Humana.nnAetna is sub dividing its Medicare Advantage product into sub-groups – watch for proper referrals and authorizations!nnAnthem is buying CIGNA. This is a huge merger and will require FTC approval. It will likely take a year or more to happen. The interesting thing about this merger is CIGNA is almost 100% self-funded (ASO) business. Anthem is currently about 50/50 self-insured and fully insured. They are capturing an enormous amount of the ASO business with this merger, an interesting reaction to the Affordable Care Act.nnJuly 1 Anthem updated its RBRBS year to 2014 – The more recent RBRVS years tend to favor the E&M codes at the expense of some surgical procedural codes – watch your reimbursement!nnMergers – Is There Opportunity for Your Practice? Usually during merger activity the health plans want a stable network. There may be a time for each of these (four different major health plans) to take a look at better rates! They all react to these things differently, so we will all need to keep our ears to the ground and look for opportunity.nnColorado HealthOP – They have had an incredible increase in members this year as a partial result of very favorable rate filings with the state. It will be interesting to see their rate fillings and growth as the New Year approaches.nnUnited Healthcare is updating their RBRVS year! They are also increasing their focus on the use of Out-Of-Network (OON) providers. If you are in-network but routinely refer to OON providers it is nearly impossible to increase your in-network rates. United appears to be following Anthem’s recent program to locate and weed out the use of OON providers.nnMedicare and Orthopedics: Medicare has initiated an Orthopedics bundled program called Comprehensive Care for Joint Replacement (CCJR). This program requires 800 pre-selected hospitals in 75 areas of the country to participate. They call it a Bundled Program but really it is a form of Pay-for-Performance in which the hospital gets the money and makes the decisions. More to come on this!nnICD-10 – so far so good? We haven’t seen any wholesale issues just yet. If you are experiencing any trouble please let us know!
Final Colorado Workers' Compensation Medical Fee Schedule Issued
The Colorado Division of Workers’ Compensation (DOWC) recently issued final utilization standards and the final Colorado Workers’ Compensation Medical Fee Schedule that affect all workers’ compensation billing, and will go into effect January 1, 2016. Among several significant changes are that these rules and regulations require payers to adopt Medicare’s Resource-Based Relative Value Scale (RBRVS) method of payment. You should be aware of regulatory changes that will affect your billing, coding and processes, and make any necessary business adjustments now to ensure a smooth transition.nnThe DOWC set out to ensure that the transition to the new fee schedule and payment system would be budget-neutral overall; however, providers should examine the rules closely and analyze specifically how fee schedule changes may impact their payments for certain specialties.
Colorado Providers – New Credentialing Standards for Pinnacol Assurance!
As part of the ongoing effort to educate providers about the most effective treatment protocols for workers’ compensation, Pinnacol Assurance is amending their SelectNet network credentialing standards for nurse practitioners and physician assistants practicing in the following urban counties: Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas, El Paso, Elbert, Garfield, Jefferson, Larimer, Mesa, Pueblo, and Weld. Mid-level providers in these counties will be required to complete Division of Workers’ Compensation (DOWC) Level 1 training.nnEffective January 1, 2016, Pinnacol’s mid-level provider credentialing requirement for your SelectNet Agreement (Exhibit B, SelectNet Credentialing Policy) is amended/updated to include the following participation requirement: “Evidence that Mid-Level provider successfully audited a Division of Workers’ Compensation Level I course (or compliance within 12 months)”nnFor your convenience, a revised Exhibit B has been created and is available by clicking here. Please print this updated version and use it to replace the current Exhibit B of your SelectNet Agreement. In the next week, impacted mid-level providers will be notified of this new requirement. Registration information for an upcoming DOWC Level 1 training on December 3, 2015, the last training in 2015, is available here and here. You may register for additional Level I seminars in 2016 through the DoWC website. Pinnacol will reimburse a limited number of SelectNet mid-level providers for the cost of this course. Email LevelOne@pinnacol.com to request information about this reimbursement program.nnIf you have questions regarding this notification, please contact Pinnacol’s provider network management department at 303.361.4945 and speak with the provider relations specialist assigned to your contract.
Colorado Medicaid Begins Provider Credentialing Revalidations!
Colorado Medicaid and CHP+ Provider Revalidation & Enrollment Begins September 15, 2015
nNew federal regulations established by the Centers for Medicare and Medicaid Services (CMS) require enhanced screening and revalidation for all Medicare, Medicaid, and CHP+ providers.nnBeginning September 15, 2015, all Colorado providers who want to continue, or begin, providing services to Medicaid and CHP+ members after March 31, 2016, will be required to be validated and enrolled under new federal enrollment screening criteria. To meet these new requirements, as well as to ensure enrollment in the new claims processing system, Colorado providers must revalidate using the new Online Provider Enrollment (OPE) tool. Although the new OPE tool will launch in September 2015, Colorado Medicaid asks that provides complete your revalidation during your assigned revalidation and enrollment wave.nnBased on the CMS provider type and risk designation, the revalidation process may include a criminal background check, fingerprinting, and unannounced site visits – including pre-enrollment site visits for some providers. Visit our provider resources page for information specific to your provider type and information specific to the Home and Community-Based Services (HCBS) provided (if applicable). Providers who fail to revalidate and enroll by March 31, 2016 may have their claims suspended or denied.n
Revalidation & Enrollment Training Announcement
nEnrollment Application Training AvailablenOnline self-paced training for the new Colorado Online Provider Enrollment (OPE) tool is now available.n
Who: All interested providers
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When: Modules available online anytime beginning September 4, 2015
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Where: Online via eLearning modules
nPlease visit the Provider Resources page to register!nn
CLICK TO ENLARGE
Medical Reval FAQ
nWhy am I required to go through the revalidation/screening process?nnNew federal regulations established by the Centers for Medicare and Medicaid Services (CMS) require enhanced screening and revalidation for all existing (and newly enrolling). These regulations are designed to increase compliance and quality of care. The final regulations are being implemented at a federal level and were published in the federal register in February 2011.nnWhat is the difference between revalidation and screening?nnRevalidating is an enrollment process required every 5 years. Screening is verifying the provider is qualified for the risk level assigned.nnAre non-medical service providers subject to revalidation/screening?nnYes, all providers who are enrolled with and bill Medicaid for services under the state plan or a waiver must be screened under this rule.nnWill we be notified when we need to revalidate?nnWe are sending a revalidation notice letter to all currently enrolled providers. This letter will mailed 1-2 weeks prior to your enrollment wave, as a reminder.nnI didn’t receive a Revalidation Notice letter, does this mean I don’t have to revalidate?nnNo, all providers need to revalidate regardless of whether you receive the Revalidation Notice letter. Please visit Colorado.gov/HCPF/Provider-Resources to see your assigned revalidation wave.nnWhat is an enrollment wave window?nnYour wave window is a suggested time frame in which we would like you to complete your revalidation. These waves are just recommendations; if you need to begin sooner or later you can. The most important date to remember is March 31, 2016. Providers not enrolled and revalidated by this date, may have their claims suspended or denied.nnWhat should we do if our agency is spread out across multiple revalidation waves?nnGo ahead and choose between the waves that you are assigned to, you do not need to notify us of this change.
Please, Do Not Feed the Wildlife…
S61.451A — Open bite of right hand, initial encounternW55.81XA — Bitten by mountain lionnY93.01 — Activity, hikingnnIn preparation for the upcoming deadline for ICD-10 implementation, Welter Healthcare Partners presents weekly ICD-10 Codes of the Week! Our goal is to familiarize you with the new and expanded code set and the additional clinical documentation needed from your providers to comply with ICD-10 coding, and more importantly, for accurate and clean claims submission to keep your revenue stream flowing! We are to help YOU prepare for the October 1, 2015 implementation date. Please don’t hesitate to contact us for all of your training and education needs!