Medicare - Electronic Prescribing -IMPORTANT INFORMATION

Medicare and Electronic Prescribing

eRx

FOR THOSE PROVIDERS UTILIZING JUNE 30, 2011 FOR YOUR DEADLINE TO MEET YOUR 10 OR 25 PRESCRIPTION REQUIREMENT - PLEASE READ THIS IMPORTANT MESSAGE....

This information was released today following a meeting held yesterday at the CMS Regional Offices in Kansas City.

This is to clarify significant points related to the electronic prescribing (eRx) incentive program and the related adjustments.

To avoid being subject to the 2012 eRx payment adjustment of 1% of the otherwise applicable physician fee schedule amount, physicians must have submitted at least 10 eRx G-codes (G8553 - at least one prescription created during the encounter was generated and transmitted electronically using a qualified eRx system) on eligible claims with dates of service between January 1, 2011 and June 30, 2011.

For the 2012 eRx payment adjustment analysis, CMS is allowing JUST ONE MONTH to receive submitted claims into the National Claims History (NCH) file. Since claims are only submitted to the NCH every Friday, the last Friday would be July 29, 2011. Eligible professionals are encouraged to submit these special claims to WPS by mid July, 2011, or earlier to ensure they will arrive into the NCH on time!

Simply put - you normally have 365 to file a Medicare claim. However - for claims utilizing the G8553 code (in order to meet the eRx requirement of at least 10 claims) - those claims must be received by WPS prior to July 29, 2011. You are encouraged to submit them by the middle of July to ensure that they will be "counted" towards your requirement in order to avoid the 1% payment adjustment in 2012. Please keep in mind that just because you send your claims on a particular day, your clearing house may take several days to do their processing before they send those claims to WPS.

Another clarification is that if you have already submitted a claim and neglected (for any reason) to include the G8553 code, you CAN NOT resubmit or re-open a claim to add this information.

Some other new developments:

Significant Hardship Exemption:

Under current rules, there are two significant hardship exemption categories under which a physician can be exempted from this 2012 payment adjustment:

- practices in a rural area without sufficient high-speed internet access and reports the code G8642 at least once on a claim between January 1, 2011 and June 30, 2011 or

- practices in an area without sufficient available pharmacies for electronic prescribing and reports code G8643 at least once on a claim between January 1, 2011 and June 30, 2011
In summary, under current law, unless a physician meets one of the existing hardship exemptions, he or she will be subject to reduced physician fee schedule payments in 2012 if the required eRx information described above is not reported.

Notice of Proposed Rulemaking (NPRM):

On May 26, 2011, CMS issued an NPRM that would, among other things, expand the circumstances under which compliance with the eRx payment adjustment requirements would constitute a significant hardship. These include:
- Limited prescribing activity
- Inability to electronically prescribe due to local, state or federal law
- Insufficient opportunities to report eRx measures due to limitations of the measure’s denominator
- Eligible professionals who register to participate in the Medicare EHR Incentive Program or Medicaid EHR Incentive Program and adopt certified EHR technology
If finalized as proposed, the NPRM would also extend the deadline to request a significant hardship exemption for the two original categories, as well as the proposed additional categories, to October 1, 2011. In addition to submission of such request by letter, the NPRM envisions possible submission of such requests via a web-based tool.

The NPRM can be found at the following location: http://www.gpo.gov/fdsys/pkg/FR-2011-06-01/pdf/2011-13463.pdf <http://www.gpo.gov/fdsys/pkg/FR-2011-06-01/pdf/2011-13463.pdf>

The NPRM comment period ends July 25, 2011. We encourage you and your members to submit your comments and concerns.

Aside from commenting on the NPRM, there is no action a physician needs to take at this time related to the proposed expansion of hardship exemptions. If the physician qualifies under one of the existing hardship exemption categories, the claim-related reporting of G8642 or G8643, as appropriate, constitutes that request.

Following is a link to the tip sheet that was mentioned that addresses the PQRS, ERx and EHR Incentive programs. http://www.cms.gov/MLNProducts/downloads/EHRIncentivePayments-ICN903691.pdf

Also, the QualityNet Help Desk is available to answer questions related to the PQRS and eRx incentives. That number is: 866-288-8912.

A few words about the folks at Medicaid

A FEW WORDS ABOUT THE FOLKS AT IOWA MEDICAID

I want everyone to know that I have worked with some very fine individuals at Iowa Medicaid over the years. Even though we didn’t, don’t, and won’t always agree, I perceived that we had a professional respect for each other and a pretty good working relationship.

My writings were not and are not attacks on Medicaid staff, they are issues and problems directed to the program, a program where these people work and sometimes are required to administer policy they may or may not agree with - it goes with the job.

I don’t want it to be construed that any Medicaid staff member is the target of my writings, it's just unfortunate that the further you climb up the chain of command, the more the burden falls on your shoulders. As managers, we all know how this works.

So, for what it’s worth, I’ve never shot the messenger, I may have wounded one or two, but never shot.

Mitch

Mitch Quits IMGMA

AFTER ALMOST 20 YEARS OF SERVICE - MITCH QUITS IMGMA

As of yesterday, I have terminated my almost 20 year relationship with IMGMA.

As I have worked with many of you during this time, I wanted to personally explain my reason.

Two days ago, I received a certified letter from Denise Kaestner, IMGMA President. This letter basically scolded me for being “unprofessional”, because I posted an article on my PERSONAL blog. An article that was signed personally by me and INCLUDED a disclaimer in the first paragraph stating: “As a disclaimer, the views and opinions presented in this document are solely those of this author”.

This article portrayed my ongoing communication with the IME (Iowa Medicaid) regarding their retrospective claims recoupment project. The intent of this article was to allow providers to see the injustice of this project, and provide facts. It did reference IMGMA, as a matter of information, nothing more. The purpose of this article was to inform Iowa providers to the situation and give them information to use in the appeal process. It was not my intent to damage IMGMA in any way. The article was very factual, and has been re-posted. Any reference to IMGMA will be removed.

This writing offended Jennifer Vermeer, Director of the Medicaid program. Honestly, I’m glad she read it, and she should have been offended. The actions of the IME regarding this issue remain to have legal question.

I was offended by the IME’s actions regarding the entire retrospective recruitment program.

I was offended, as all providers should have been that the IME lied to us regarding how there were going to review and recoup on previously processed claims going back to 2007.

What I am most offended by, was the fact that the IMGMA board took the action of sending a letter to me scolding me, probably the only person in IMGMA’s history who has done more for Iowa providers on insurance and reimbursement issues than anyone. However, they they did want me to stay on the committee - I declined. I not only resigned from the Insurance & Reimbursement Committee, I also dropped my IMGMA membership.

The letter from the IMGMA board indicated to me that, as an organization, IMGMA is weak. They became submissive to Iowa Medicaid, the carrier with the most administrative burden and the lowest reimbursement.

I can not support an association that has no backbone. I believe everything in my article was on target. The only item questionable was the acronym I used to describe what the IME was doing to Iowa providers – and honestly, I think I was right on target with that too. In case you hadn’t seen the article, I came up with the acronym of “M-RAPE” (Medicaid Retrospective Administrative Payment Execution).

The political correctness that is epidemic in today’s society is appalling. When we start censoring the people who shine a light on situations, we become sheep. I won’t be a sheep.

I will continue my advocacy work for my practice as well as other health associations, I just have removed my connection with IMGMA. I will continue blogging as time permits and the Medicaid article has been re-posted.

In case you want to keep up with my blog, you can find it at: www.mitchdsm.blogspot.com

I’ve enjoyed the work I have done for the IMGMA membership and will continue my advocacy to that regard….

And if I need to be occasionally “offensive”, it will most likely be because it was warranted!

Mitch

Medicaid Retrospective Claims Program

What you should know about M-RAPE

(Re-Posted from 2 weeks ago)

I have decided to re-name the Medicaid retrospective claim review project to M-RAPE (Medicaid Retrospective Administrative Payment Execution), as theoretically the powers to be at Iowa Medicaid program are doing a pretty good job of financially raping the provider community with this project.

As you all should know, Iowa Medicaid had decided to adopt CCI edits in 2010 and then re-process all claims which were paid and closed – going back to 2007!

I feel it’s important to share the information I sent the State on behalf of Iowa Providers so that by the time you have digested all of this information, you can make your own informed decision on how to proceed for your individual practices. As a disclaimer, the views and opinions presented in this document are solely those of the this author. I do however, give you permission to use any portion of this information in your own appeals to Iowa Medicaid, and do encourage you to appeal. I apologize for the length of this e-alert, but there is much information to share.

On March 2, 2011 – I wrote to Jennifer Vermeer, Director of the Medicaid program as well as Senator Jack Hatch, Representative Dave Heaton, DHS Director Charles Palmer, and Michael Bousselot of the Governor’s Office. :

“This letter was in reply to our letter which objected to most of your retrospective claim review project. We felt that re-processing claims based on policy and procedures not in effect at the time of payment was unusual, uncommon, and perhaps illegal. It would relate to issuing speeding tickets to everyone who drove 70 MPH on the Interstate in 2007, 2008, 2009, and2010 because in 2011, the State lowered the speed limit to 60 MPH.

I would concur that CCI edits have been part of the Medicare program for some time, your need for Iowa Medicaid to implement CCI is quite understandable and as I have mentioned before, _____ did not have issue with this implementation, based on your intent to implement. What we did and still do have issue with, along with other Iowa Medical Associations, is the fact that your intent was to apply those edits retrospectively to claims appropriately paid, based on your edits and policy at the time of service. You assert that Iowa Code 249A.5(1) gives the Department the right to recover claims paid in error. I agree, but also believe that applies to claims paid in error using the POLICY IN FORCE AT THE TIME OF SERVICE,NOT A PAYMENT POLICY APPLIED RETROACTIVELY TWO YEARS after the fact.

The paragraph titled "Our Policies Remain Consistent", doesn't appear to be necessarily accurate. As an example, one office shared an example where there recoupment letter stated that 36416 is not payable separately and yet the 2007 BILLING OF MEDICAL SERVICES guide distributed at Provider Training, page 38 indicates that 36416 is payable. Are you unaware of the conflicting policy?

You reference Info Letter 875, which indicates how Medicaid will start using CCI edits and Medicare bundling rules, etc. It appears that these concepts were not communicated to providers as Medicaid policy until the publication of Info Letter 875. I refer again back to the 2007 BILLING OF MEDICAL SERVICES guide, which was the Medicaid policy guidance until Info Letter 875, and the rules that are now in conflict with Info Letter 875. Please provide me with proof of guidance between the dates of publication of these two documents (2007 Billing Guide and Info Letter875) , where Medicaid informed providers that Medicare bundling and coding rules and Medicare Fee Schedule status B indicators would be applied to claims. The 2007 Billing Guide does not address the polices that Medicaid is now applying retroactively as the result of the adoption of the CCI edits (see Info Letter 875) Providers use the Medicaid Provider Manuals, Informational letters and Provider Training Material as Medicaid Policy guidance.

If providers are to be using another source for Medicaid policy guidance, please direct me to those sources, other than Info Letter 875. As you have been previously notified, Iowa Medicaid did not implement CCI edits prior to 2010. Any failure to implement CCI edits or special bundling policies that occurred was the failure of Iowa Medicaid, not physicians who submitted claims consistent with Medicaid rules in place at the time of submission.

Providers can not be submitted to recoupment based on rules NOT in effect at the time of service. You appropriately paid claims in accordance with your own requirements then in place. Your system would have and could have rejected inappropriate claims that did not comply with your billing policies prior to the implementation of the CCI edits. The reimbursement of E&M codes incorrectly billed may be appropriate to recoup based on review of the situation, but your requests for other monies to be returned I believe is still not permissible.

On behalf of our members, representing over 4,000 providers, you are again asked to issue a letter of correction and to cease your efforts to receive back monies correctly paid to providers based on the guidelines in place at the time of service. I look forward to a prompt reply.” Mitch Harris

To this, on March 17, 2010, Jennifer Vermeer replied:

“Dear Mitch, Thank you for your note. As requested in my previous letter to you, any concerns with a Program Integrity audit result should be addressed through the existing process described in the letter you received that defines the audit findings. Your peers at the Iowa Medical Society are recommending their members follow that process also (see http://www.iowamedical.org/news_detail.cfm?newsID=413 ). This process allows us to fully review all of the specifics for each case to make a consistent decision affecting all similar cases. In implementing this project, we reviewed the test data and policies carefully before moving the audit into production. We understand that in executing a review of this scope and complexity, there could be specific items we may need to re-consider with additional information. This is exactly why there is a defined process for resolution of any specific items at issue. We always consider the balance of our responsibility to ensure appropriate use of the public's program dollars against how oversight activities might impact our provider community. Regarding the specific issue you point to around procedure code 36416, I can let you know that IME has reviewed that concern as it was raised through the regular process (there was a similar one also raised around procedure code 99000). A decision was made recently that both those codes (36416 and 99000) will be excluded from the recovery. In many cases, amended letters have already been sent to notify the affected providers; all such letters should be sent by the end of next week at the latest. I hope that addresses your concerns. Please contact Bob Schlueter or Brian Fisher if you have any further questions. Sincerely, Jennifer Vermeer”

So….from her reply, it appears that some providers who were really paying attention found some definite “flaws” in their edits that were contrary to Medicaid own policy! Hence, they have relaxed those edits. As you review the M-RAPE material sent to you from Medicaid, be a detective. Since all of my concerns were not answers, I wrote back…

On March 20, 2011…

Good Morning Jennifer, et al: Thank you for your reply and I will be issuing an article to ____ membership in the next day or so.

Your reply neglected to provide any answer to the following request in my initial letter:

"I refer again back to the 2007 BILLING OF MEDICAL SERVICES guide which was the Medicaid policy guidance until Info Letter 875, and the rules that are now in conflict with Info Letter 875. Please provide me with proof of guidance between the dates of publication of these two documents (2007 Billing Guide and Info Letter875) , where Medicaid informed providers that Medicare bundling and coding rules and Medicare Fee Schedule status B indicators would be applied to claims. The 2007 Billing Guide does not address the polices that Medicaid is now applying

retroactively as the result of the adoption of the CCI edits (see Info Letter 875) Providers use the Medicaid Provider Manuals, Informational letters and Provider Training Material as Medicaid Policy guidance"

Can you please provide an answer to the information requested above.

Thank you. Mitch Harris

On March 22, 2010, I received this back…

Hi Mitch,

As always, per 441 IAC 79.9(1): absent expressed policy otherwise, Medicaid follows Medicare.

In the case of procedure codes 36416 and 99000 there was specific policy communication we could point to, and those codes have been excluded from the recovery for that reason.

If there is specific guidance from the time indicating Medicaid was not following Medicare on bundling/coding rules and status B indicators to which you refer (your basis for not following the Medicare policy), it would be considered. We are not aware of such guidance.

Bob Schlueter IME Provider Services

I reviewed first, 441-79.9 which is the heading reads: “General provisions for Medicaid coverage applicable to all Medicaid providers and services.”

79.9(1) reads: “Medicare definitions and policies shall apply to services provided unless specifically defined differently.

My interpretation of the heading and sub section (1) I believe pertains to “services provided” and NOT billing guidelines. I believe that Iowa Medicaid is grabbing at straws trying to use this Iowa Administrative Code inappropriately to help them justify their actions with M-RAPE. In addition, the IAC reference above has always been kind of ambiguous. Medicaid’s 2007 billing guide does not even reference the IAC citation. This citation is also not referenced in the Physicians Provider Manual. If this citation is so important to the point that they are trying to hide behind it as an excuse for M-RAPE, why has Iowa Medicaid never made any effort to convey this IAC rule to providers?

It does look to me that Iowa Medicaid is “trying” to work with providers, they admit that due to the scope and complexities of M-RAPE, they are willing to accept appeals. Providers should not feel like they are being forced to re-pay claims that were appropriately billed. I wrote in my appeal letter that my “claims were appropriately submitted and paid based on the billing procedures you had in place at the time of services. Seeking to recoup monies based on billing procedures that were not in place at the time of service, I believe is illegal and unethical.”

I hope that every provider office has reviewed the information sent to them and has responded to Iowa Medicaid. If you have codes that other carriers are paying for and Medicaid has decided, due to the new CCI edits, that they should be denying….those codes are probably inappropriate for them to try and recoup. Medicaid is forcing providers to jump through hoops (and jump quickly), they require you follow their unreasonable time frames for response. They require you reply initially within 15 days of the date of their letter, even though it takes up to 5 days from the date of their letter before you receive it at your door…

You are urged to contact the Governor and your local State Senators and Representatives as well as Representative Dave Heaton and Senator Jack Hatch who provider oversight to the Medicaid finance program. This M-RAPE program isn’t right, it’s not even close to being right.

I have provided much information in this writing to assist you in your appeal process. I personally am prepared to take my appeal, if necessary to the Administrative Law Judge. A class action law suit is not out of the question here…something to think about…

Medicaid is the lowest payor and requires the most from us administratively….they have a lot of nerve trying to M-RAPE us!

Mitch

NO MORE MAIL FROM MEDICAID - August 23rd is the day

August 23, 2010

US mail ends from

Medicaid

Effective August, 2010 - providers will no longer receive payments, informational letters or provider general letters vis US mail. All communications will be exclusively in electronic format.

Informational Letters: will cease on and after 8/23/10 and can be retrieved from their website:

http://www.ime.state.ia.us/Providers/Bulletins.html

General Letters (Manual Transmittals): will cease on and after 8/23/10 and can be received from the website:

http://www.ime.state.ia.us/policyanalysis/PolicyManualPages/medprovgl.htm

For both types of letters, an additional notification mechanism is being desiged for the Iowa Medicaid Portal Access (IMPA) website at:

https://secureapp.dhs.state.ia.us/impa/ (details of this new feature will be sent out as it's completed and tested.

Providers Payments: will only be transmitted via an electronic format effective with the August 23rd payment cycle with funds available the following Thursday, August 26, 2010. Paper checks will no longer be issued as of this date. Providers have until August 9, 2010 to sign up for EFT through Provider Services.

Of note, Medicaid suggests if you don't have a computer, you can always go to your local library to access this information - honest - it's in their letter - they really suggested this!

CMS NOW WANTS TO REVIEW THE ENROLLMENT PROCESS...

The ordering and referring providers listed are inaccurate....continuity of lists of those enrolled in PECOS and those NOT enrolled in PECOS differ...

I'm not sure what's going on with the information below from CMS, which was released on June 30th, from the Office of Public Affairs at CMS. I just received my copy today.

Feel free to read CMS's entire article below in blue - but bottom line - looks like CMS will NOT deny claims from ordering and referring providers and will send out information once they decide how they are going to tackle this problem

The information below is a bit confusing - when I inquired to CMS, the response was they are trying to address many issues with PECOS with regards to who's "in" and who's "not in" - there seems to be many problems with the PECOS list and the claims system with records to the providers who are supposed to be in PECOS and those who maybe or are in, but not on the "list". The "list" being the one published on the CMS website.

EVERYONE IS REMINDED AGAIN - DON'T WAIT!!!

MAKE SURE YOUR PROVIDERS ARE ENROLLED IN PECOS,

IF NOT, COMPLETE THE PAPERWORK NOW!!

CMS TO REVIEW PECOS ENROLLMENT PROCESS

Medicare working with ordering and referring provers and suppliers

to streamline enrollment process

The Centers for Medicare & Medicaid Services (CMS) is working with providers to address concerns about enrollment in the Provider Enrollment, Chair and Ownership System (PECOS) to ensure that Medicare beneficiaries continue to receive the health care services and items they need. PECOS is the electronic system used to enroll physicians and eligible professionals into the Medicare program.

As part of those efforts, CMS will, for the time being, not implement changes that would automatically reject claims based on orders, certifications, and referrals made by providers that have not yet had their applications approved by July 6, 2010. While more than 800,000 physicians and other health professionals have enrolled and have approved applications in the PECOS system, some providers have encountered problems. CMS is continuing to update and streamline the process, and more providers have been enrolled in the past few days.

CMS issued an interim final regulation on May 5, 2010 implementing provisions of the Affordable Care Act that permit only a Medicare enrolled physician or eligible professional to certify or order home health services, durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) , and certain items and services under Medicare Part B. The new law applies to orders, referrals and certifications made on or after July 1. The comment period for the regulation closes on July 6, after which the comments will be reviewed and considered before a final regulation is issued.

The Affordable Care Act provisions and the regulation were designed as steps to prevent fraud in Medicare by ensuring that only eligible and identifiable providers and suppliers can order and refer covered items and services to Medicare beneficiaries.

Many physicians and other providers and suppliers have continued to make good faith efforts to comply with the requirements of the law and regulation. These efforts will be a significant factor in determining the procedures and processes that will be incorporated in the final rule.


While the regulation will be effective July 6, 2010, CMS will not implement automatic rejections of claims submitted by providers that have attempted to enroll in PECOS. However, until the automatic rejections are operational, providers should not see any change in the processing of submitted claims, they will continue to be reviewed and paid as they have historically been reviewed and paid.

Additionally, though CMS is taking a more deliberative approach to using the PECOS enrollment system, the agency will employ a contingency plan to meet the ACA requirement that written orders and certifications are only issued by eligible professionals effective July 1.

CMS will continue to send informational notices to providers reminding them of the need to submit or update their enrollment and will work with the provider community to provide guidance on enrollment and will process all applications expeditiously.

Final Notice for PECOS

CMS SENDS FINAL REMINDER NOTICE FOR PECOS ENROLLMENT

CMS directed all Medicare carriers to send ONE notice to providers who are still NOT enrolled in PECOS. This letter was recently mailed from WPS within the last week. This will be your final and only reminder to providers who need to enroll in PECOS.

If you haven't checked your status, contact the Provider Enrollment Hotline at WPS to verify if your providers are enrolled in the PECOS system! Call 866-503-7664. Callers will have to provide one of the following: Provider PTAN, Social Security Number, or Federal Tax ID number.