A Message From Your MAC

wpsgha.litmos.com

A Message From Your MAC

Presented for Iowa HFMA/AAHAM 6th Annual Payer PanelNovember 15, 2017

DisclaimerThis program was designed for informational purposes only. The current Medicare regulations will always prevail. The provider alone is responsible for correct submission of claims. The official Medicare Program provisions change frequently and are contained in the relevant laws, regulations and rulings and can be found on the Centers for Medicare & Medicaid Services (CMS) website at www.cms.gov. Recording is not allowed; this includes audio, video, or photographic capture of educational material by any electronic or digital means, either original or copied/shared.

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Today’s Agenda• New for You in Medicare

– Targeted Probe & Educate– Office of Inspector General Report

• Hospital Billing Issues

– Annual Wellness Visit & Advance Care Planning– New Medicare Cards– Appeals Updates

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Today’s Agenda • Exciting WPS GHA Portal Enhancements

– Transactional Side Portal• Self Service Denial Tool

– Public Side of Portal• Code Look-up

– MFA• The Learning Center

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New for You in MedicareNews you can use…

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Targeted Probe & Educate (TPE)Biggest change to claims review in 20 years…

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TPE – CR 10249• Medical review process used by all MACs is

changing– Biggest change to claims review in 20 years

• Based on favorable results of targeted probe and educate review pilots, TPE is being expanded– Decrease in the number of claim errors

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TPE Process• Replace current reviews with up to three

rounds of pre-payment review• MACs:

– Will select topics– Can target providers– Request a limited sample– Have option to refer

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If High Denials Continue• MAC refers to CMS for action that may

include:– Extrapolation– Referral to ZPIC, UPIC, RAC– 100% pre-pay review

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New Medical Review Process

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OIG Reports Two Significant IssuesOffice of the Inspector General (OIG)

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Two Hospital Billing Issues• SE 17017

– Report highlights two hospital billing issues• Improper use of modifier 59• Incorrect procedure coding for mechanical ventilation

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Improper Use of Modifier 59• Issue – Right Heart Catherization (RHC) w/

heart biopsies using modifier 59– Not appropriate if the basis for use is

• The narrative description of two codes is different, or• To describe a different procedure or surgery if both

codes are part of a code pair edit– Check NCCI Practitioner PTP edit files

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Mechanical Ventilation• Issue – MS-DRGs 207 and 870 require > 96 hrs.

of mechanical ventilation– 63 of 200 claims reviewed, did not comply– $1,488,165 in overpayments– Hospitals confirmed

• Improper count of hours, and • Clerical errors

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Advance Care Planning (ACP)An optional element of the Annual Wellness Visit…

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CPT 99497 – ACP 1st 30 Minutes • Payment conditionally packaged under OPPS

– Assigned status indicator (SI) “Q1”• ACP furnished with another OPPS service

– Payment is packaged

• ACP is only service furnished– Separately payable

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CPT 99498 – ACP 2nd 30 Minutes• CPT code 99498 is an add-on code

– Assigned status indicator ‘‘N’’• Payment is unconditionally packaged

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ACP Service with AWV• CMS is including Voluntary ACP as an optional

element of the AWV– ACP services furnished on same day as AWV, by

same provider are considered a preventive service– Report CPT code 99497 in addition to either

G0438 or G0439

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Deductible & Coinsurance for ACP w/ AWV

• Waived when billed on the same day as AWV– Limited to once per year

• AWV is limited to once per year – Deductible and coinsurance will apply to ACP

• If the AWV is denied for exceeding limit

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New Medicare Cards

Formerly Called the SSNRI(Social Security Number Removal Initiative)

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Background• Health Insurance Claim Number (HICN)

contains SSN of primary beneficiary– Prefix or suffix gives additional details

• New rules mandated by MACRA

• Decrease risk of identity theft– Increase safety of Program funds

• Unique numbers and redesigned cards– Deceased, active and new beneficiaries

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Medicare Beneficiary Identifier

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Where:

C – Numeric 1 thru 9

A – Alphabetic Character (A...Z); Excluding (S, L, O, I, B, Z)

N – Numeric 0 thru 9

AN – Either A or N

***NOTE: Alphabetic characters are Upper Case ONLY

Position 1 – numeric values 1 thru 9Position 2 – alphabetic values A thru Z (minus S, L, O, I, B, Z)Position 3 – alpha-numeric values 0 thru 9 and A thru Z

(minus S, L, O, I, B, Z)Position 4 – numeric values 0 thru 9Position 5 – alphabetic values A thru Z (minus S, L, O, I, B, Z)Position 6 – alpha-numeric values 0 thru 9 and A thru Z

(minus S, L, O, I, B, Z)

Position 7 – numeric values 0 thru 9Position 8 – alphabetic values A thru Z (minus S, L, O, I, B, Z)Position 9 – alphabetic values A thru Z (minus S, L, O, I, B, Z)Position 10 – numeric values 0 thru 9Position 11 – numeric values 0 thru 9

Transition Timeline• Systems ready by 4/1/18

• HICN or MBI used until 12/31/19

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During Transition

• Message on eligibility response when new card sent

• Remittance Advice (RA) will include MBI if HICN was used– Beginning 10/1/18

• Limited use of HICN after transition period– Appeals, adjustments, etc.

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CMS New Medicare Card Web Page• Access at

https://www.cms.gov/medicare/new-medicare-card/nmc-home.html

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Appeal UpdatesThings you need to know…

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Backlog of ALJ Appeals• December 2016 court order

– Clear backlog in 4 years

• HHS appealed December 2016 order– Impossible to comply with 4 year timeline

• August 11, 2017 sent back to lower court– HHS must demonstrate claim of impossibility

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Increase in Duplicate Appeal RequestsThe 60 Day Requirement

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Duplicate Appeal Requests• Occurs when more than one request is

received – For the same provider– Same patient– Same date of service– Same issue

• Regulations allow 60 days to render a decision

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More UpdatesStaying on top of it all…

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CAH 96 Hour Rule

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Physician must certify reasonable expectation of discharge

96 hours

CMS directed review contractors to make 96 hour rule a low priority for medical record review

Reduce burdens on providers CAHs should

not receive request for medical records related to the 96 hour certification requirement

October 1, 2017

Present on Admission (POA)SE 17015• POA information should only be reported on

inpatient claims– POA is being reported on claims for services that

are exclusively incurred in the outpatient hospital setting

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Qualified Medicare Beneficiary (QMB)SE 1128• Providers may not bill

beneficiaries enrolled in the QMB Program for Medicare cost-sharing

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WPS GHA Portal Enhancementswww.wpsgha.com

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Portal Constantly Changing• Web portal consists of two sides

– Public Side– Transactional Side

• Your opinion counts!– Please continue to periodically complete the

ForeSee Website Satisfaction Survey

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Provider Self Service Denial ToolFind the information you need

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Claim Denial Self-Service ToolEnhancing the WPS GHA Portal Experience!

• Instant Information

– Claim denial help any time of day

– Reduce phone calls

– Increase provider convenience

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Claim Denial Self-Service Tool• Compact claim

summary screen– Gray section: claim

information– Blue section: remit

information – Blue “More Info”

button

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More Info Button

Every line of claim has access to line specific information

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Enhanced Information • Information

available

– Provider name & NPI

– Pay codes, if present

– ANSI codes & narrative from RA

• Close window to view next line item

Enhanced Information – Related Claim

Action Script• Explanation of claim

denial• Suggestions for

correcting errors• Potential claim

actions– File new claim– Submit a clerical

error reopening

Special Functions – LCDs

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Special Functions – Eligibility

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Special Functions – Other Insurer Info

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Code Lookup

Code Lookup

Code Lookup

Code LookupPart A Reason Codes

Code Lookup

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Code Lookup – Exact Match

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Code Lookup – Partial Match

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WPS GHA Portal User Manual• Choose link at the

bottom of each portal page to access the WPS GHA Portal User Manual

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Multi Factor Authentication (MFA)Keeping your information safe…

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Multi-Factor Authentication (MFA)• Required by CMS• Passcode sent via phone or email will be valid

for up to four hours

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• Starting July 17, 2017– Mandatory conversion

began weekly according to the last name of the user

Important Go Live DatesInitial Implementation Mandatory Conversion

• March 31 , 2017– MFA use is optional– 3 pieces of

authentication needed starting with date of opt-in

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09/04/2017 H-Hl

09/11/2017 Hm-J

09/18/2017 K

09/25/2017 L

10/02/2017 Ma-Me

10/09/2017 Mf-N

10/16/2017 O-P

Conversion ScheduleDate – First letter of last name Date – First letter of last name

07/17/2017 A-Ba

07/24/2017 Bb-Bo

07/31/2017 Bp-Ca

08/07/2017 Cb-Cz

08/14/2017 D

08/21/2017 E-F

08/28/2017 G

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Conversion ScheduleDate – First letter of last name

10/23/2017 Q-R

10/30/2017 Sa-Si

11/06/2017 Sj-Sz

11/13/2017 T-V

11/20/2017 Wa-Wi

11/27/2017 Wj-Z

11/30/2017 Any other users not included in above schedule

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Login/Register for MFA• On WPS GHA Portal, click on the

“Login/Register” box

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WPS GHA Learning Center (LC)• Located at https://wpsgha.litmos.com• Create/Manage Profile• View Dashboard (Home)

– News– Calendar– Recent achievements

LC Features• View Live Events

– Register

• On-Demand Courses– Includes Questions and Answers developed by

Provider Outreach and Education (POE)

• Training Questions– Specific to LC events (LC issues/logistics/etc.)

• Link to WPS GHA Portal

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Questions?

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Follow-up Survey• Your Opinion Counts!

– Please take five minutes to complete survey to provide feedback on your education experience

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Thank you!