Archive for Medicaid

CMS Releases Physician Fee Schedule Final Rule

CMS Releases Physician Fee Schedule Final Rule

The Centers for Medicare and Medicaid Services (CMS) released its final rule for the CY 2020 Physician Fee Schedule. The Medical Association and the AMA will continue to review the rule and analyze these policies in the coming weeks. Attached is a summary of some of the policies CMS finalized in the rule.

Some of the highlights of the final rule are:

  1. E/M Coding: Finalizes new E/M coding policy effective January 1, 2021. E/M codes for new patients will be 4 levels (CPT codes 99202-205) and for established patients, there will be 5 levels (CPT Codes 99211-99215)
  2. Conversion factor: $36.09 resulting in a .14% increase in fees
  3. Scope of Practice-Physician Supervision Requirements for Physician Assistants (PAs). CMS finalized its revisions to regulations on physician supervision for physician assistant services. The current policy requires general physician supervision for PA services, however, CMS’ revisions provide that the statutory physician supervision requirement for PA services is met when a PA furnishes their services in accordance with state law and state scope of practice rules for PAs in the state in which the services are furnished.
  4. Physician Enrollment CMS finalized new authority to deny or revoke a physician’s enrollment if he or she has been subject to prior action from a state oversight board, federal or state health care program, Independent Review Organization (IRO) determination(s), or any other equivalent governmental body or program that oversees, regulates, or administers the provision of health care with underlying facts reflecting improper physician or other eligible professional conduct that led to patient harm

For a full summary of the physician payment rule, click here.

Posted in: CMS, Medicaid, Medicare

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Changes Coming to AKS, Stark and CMP Laws

Changes Coming to AKS, Stark and CMP Laws

On October 9, 2019, the Office of Inspector General (“OIG”) and the Centers for Medicare and Medicaid Services (“CMS”) published proposed rules to revise the Stark Law, Anti-Kickback Statute and Civil Monetary Penalty Statute.  These statutes create criminal and civil penalties for certain financial arrangements involving providers. According to OIG and CMS, the goal of the proposed rules is to address barriers created by the rules that interfere with care coordination.  The additional safe harbors were necessary to allow for coordination of patient care among providers because of the increased focus on value-based care. Value-based programs reward healthcare providers with incentive payments for quality of care. Examples of these programs include Hospital Value-Based Purchasing, Hospital Readmission Reduction Program and Hospital Acquired Conditions Reduction Program.

Anti-Kickback 

The proposed changes in the published rule include three new safe harbors for certain remuneration exchanged between or among participants in a value-based arrangement intended to foster better coordinated patient care.  These include:

  1. Care Coordination Arrangements to Improve Quality Health Outcomes and Efficiency,
  2. Value-Based Arrangements with Substantial Downside Financial Risk, and
  3. Value-Based Arrangements with Full Financial Risk.

The proposed rule also offers a new safe harbor for certain tools and support furnished to patients to improve health quality outcomes and efficiency, such as health-related technology or patient health-related monitoring tools.  Additionally, a new safe harbor is proposed for remuneration provided in connection with a CMS sponsored innovation model, which is intended to reduce the need for separate and distinct fraud and abuse waivers.

There is a proposed safe harbor for donations of cybersecurity technology and services as well as modifications to the existing safe harbor for electronic health records and services to add protections for certain related cybersecurity technology, to update provisions regarding intra-operability, and to remove the sunset date that previously existed.

The rule proposes a positive change to the Personal Services and Management Contracts safe harbor, by eliminating the requirement that periodic or part-time services be on a specific schedule or interval. Additionally, the safe harbor adds a provision for “outcome-based payments.”  Outcome-based payments are those payments that reward the provider for improving patient or population health by achieving one or more outcome measures or that reduce payor costs while improving or maintaining the improved quality of care for patients.

Another existing provision related to warranties is updated to revise the definition of warranty and provide protection for bundled warranties for one or more items of related services.  Local transportation is covered by an existing safe harbor, but the proposed change expands and modifies mileage limits for rural areas and for transportation for patients discharged from inpatient facilities.

Lastly, the Accountable Care Organization Incentive Program is added to the exception of the definition of “remuneration.”

Stark Law

The physician self-referral law, known as the Stark Law, has not been significantly updated since its enactment in 1989.  The proposed changes seek to reduce the burden on physicians and allow for coordination of care.

Like the new safe harbors under the AKS, the proposed changes to the Stark Law include value-based arrangements.  A value-based arrangement is defined as an arrangement for the provision of at least one value-based activity for a target patient population between or among the value-based enterprise (“VBE”) and one or more VBE participants or VBE participants in the same value-based activity.

Another update to the Stark Law includes a proposed change clarifying the existing provision that allows a physician in a group practice to be paid a share of the overall profits of the group that is indirectly related to the volume or value of the physician’s referrals.  Additionally, there are changes to how the law treats productivity bonuses for physicians.

According to CMS, the intent of the proposed changes is to alleviate the fear physicians may have in entering into legitimate relationships to coordinate and improve care of patients.

CMP

There is only one proposed change for the Civil Monetary Penalty statute, and it adds a new statutory exception to the prohibition on beneficiary inducements for telehealth technologies furnished to certain in-home dialysis patients.

For all the proposed rules, OIG and CMS are seeking public comments, which are due December 31, 2019.  For more information on the proposed rules visit https://oig.hhs.gov/compliance/safe-harbor-regulations/index.asp and https://www.cms.gov/newsroom/fact-sheets/modernizing-and-clarifying-physician-self-referral-regulations-proposed-rule.


Article contributed by Angie C. Smith, Esq. with Burr Forman.

Posted in: Legal Watch, Medicaid, Medicare

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CMS Is Expanding Its Enforcement Ability

CMS Is Expanding Its Enforcement Ability

Pursuant to a new rule, entitled Program Integrity Enhancements to the Provider Enrollment Process, the Centers for Medicare & Medicaid Services (“CMS”) is expanding its ability to combat fraud and abuse within the healthcare industry.

Under the new rule, CMS will be able to identify individuals and entities that pose a fraud and abuse risk solely based on “affiliations” with other entities that have been sanctioned by CMS. CMS can then take steps to prevent such identified individuals and entities from participating in the Medicare program. At the request of CMS, enrolling providers will disclose
any current or previous “affiliation” with an organization that has uncollected debt (regardless of amount and regardless of appeal status), experienced a payment suspension, been excluded, or had its billing privileges denied or rescinded (regardless of the basis). As used within the new rule, “affiliation” would include, among other things, an individual with 5% or greater indirect or direct ownership interest, officer, director, individual with operational or managerial control, or any reassignment relationship.

The provider community has expressed a number of concerns with this new rule, as the new rule gives a large amount of discretion to CMS without comparable notice or remedy to the provider. Consequently, in light of this new rule, Medicare providers and suppliers need to carefully and thoroughly examine any individual with whom it has an “affiliation” relationship to
avoid negative consequences.

The rule takes effect on November 4, 2019.

Kelli Fleming is a Partner at Burr & Forman LLP practicing exclusively in the firm’s healthcare industry group.

Posted in: Legal Watch, Medicaid, Medicare, Members

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Get Text Updates from Alabama Medicaid

Get Text Updates from Alabama Medicaid

Providers and recipients now have a new way to receive important information from the Alabama Medicaid Agency. The Text Messaging Service provides immediate and/or important communication directly to you. Examples of information shared with providers includes:  approaching deadlines, new program announcements, required provider agreements, Medicaid meetings and training, office closures, or other vital information which may impact your practice.

We hope you will take advantage of this service to stay up to date. Subscribing is quite simple. Text ALPROVIDERS to 888777 to receive provider notifications. You can opt-out at any time. Please note that recipients have a separate keyword and text messaging list to subscribe to in order to receive important recipient information from the Agency.

The Agency will continue to provide regular communication through the Provider Insider newsletter, the Medicaid website, the subscription-based electronic mailing list and Alerts. For additional information about the Text Messaging Service for Medicaid, please visit www.Medicaid.Alabama.gov or call (334) 353-9363.

 

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Alabama’s ACHNs Go Live Oct. 1

Alabama’s ACHNs Go Live Oct. 1

The end date for the Patient 1st Program is approaching, and providers will be required to have completed agreements with both Medicaid and the ACHN. Primary Care Physicians (PCPs) will no longer receive Patient 1st capitation payments beginning in October 2019. The ACHN program will be implemented on October 1, 2019, and providers will need to complete ACHN agreements as soon as possible and before July 1, 2019, to avoid any delay in receiving bonus and participation payments.

Providers can visit the following link to download the PCP Enrollment Agreement with Medicaid or obtain information about the ACHNs: 
https://www.medicaid.alabama.gov/content/2.0_Newsroom/2.7_Special_Initiatives/2.7.6_ACHN.aspx

To obtain a copy of the PCP and DHCP agreement with the ACHN, contact the ACHN in your region.  Providers can visit the following link for ACHN contacts: https://www.medicaid.alabama.gov/documents/2.0_Newsroom/2.7_Special_Initiatives/2.7.6_ACHN/2.7.6_ACHN_Regional_Map_Contacts.pdf

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Alabama Medicaid Updates: Don’t Miss This Information!

Alabama Medicaid Updates: Don’t Miss This Information!

Promoting Interoperability with Prescription Drug Monitoring Program (PDMP)

The Alabama Department of Public Health Meaningful Use team recently added new functionality where Eligible Providers who are currently participating in the PI Program can access the PDMP registry and run reports to show that they are actively engaged with this Specialized Registry during the reporting period. This documentation is required to meet the Public Health objectives and measures and can be submitted with the EP’s application for the Program Year for which they are attesting.

If you have technical issues with accessing and generating this report, please contact ADPH Helpdesk at 1-855-925-4767, Option 1.

Complete Your ACHN Agreements Before July 1

Primary Care Physicians (PCPs) will not be receiving a capitated payment in October 2019. The Alabama Coordinated Health Network (ACHN) program will be implemented on October 1, 2019, and providers will need to complete ACHN agreements as soon as possible before July 1, 2019, in order to receive bonus and participation payments. The end date for the Patient 1st Program is approaching, and providers will be required to have completed agreements with both Medicaid and the ACHN.

Providers can visit this link to download the PCP Enrollment Agreement with Medicaid or to obtain information about the ACHNs. To obtain a copy of the PCP and DHCP agreement with the ACHN, contact the ACHN in your region. Providers can visit this link for ACHN contacts.

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Alabama Medicaid Cumulative MME Edit Coming Early 2019

Alabama Medicaid Cumulative MME Edit Coming Early 2019

UPDATE April 26, 2019: Effective May 1, 2019 the Alabama Medicaid Agency will begin implementing cumulative daily MME edits for opioid experienced recipients.

Higher doses of opioids are associated with higher risk of overdose and death – even relatively low dosages (20-50 MME per day) may increase risk.1 Therefore, Alabama Medicaid will limit the amount of cumulative MME allowed per day on opioid claims. The edit will begin at 250 cumulative MME per day and will gradually decrease over time. The final cumulative MME target is scheduled to be 90 MME per day.  This edit is different, and in addition to, the short-acting opioid naïve edit implemented on November 1, 2018.

Phase-In Period:
Beginning May 1, 2019, Alabama Medicaid will begin with a “phase-in” period for 3 months. Claims that exceed the cumulative daily MME limit of 250 MME will be denied at the pharmacy Point of Sale (POS).  The dispensing pharmacist will be provided a universal prior authorization (PA) number on the rejection screen and may enter this universal PA number on the claim to allow it to be paid. Pharmacists are urged to notify the affected patient/prescriber to develop a plan to decrease the patient’s total daily MME.

Hard Edit Implementation:
Beginning August 1, 2019, opioid claims that exceed the cumulative MME edit of 250 MME/day will be denied.  The universal PA will no longer be valid to bypass the 250 MME edit.  Pharmacy override requests for quantities exceeding the MME limit may be submitted to Health Information Designs (HID) and will be reviewed for medical necessity. See link below for override form.

Edit Details:

  • The universal PA number to override the 250 MME edit will be 0009996321
  • The universal PA number will be provided on each cumulative MME rejection screen for the pharmacist   convenience
  • Additional edits such as therapeutic duplication, maximum quantity limitations, early refill, non-preferred edits will still apply
  • Claims prescribed by oncologists will bypass the edit
  • Long term care and hospice recipients are excluded
  • Children are included in the edit
  • A Recipient Information Sheet for prescribers and pharmacists to provide to recipients can be found at http://www.medicaid.alabama.gov/content/4.0_Programs/4.3_Pharmacy-DME.aspx.

Anticipated Phase Down:
The Agency anticipates gradually decreasing the daily cumulative MME limit every 4 months. The first decrease to 200 MME/day will be implemented on December 1, 2019.  Prior to each decrease, a new universal PA number will be assigned to override claims that exceed the new threshold.  Providers will be notified via an ALERT prior to each decrease.  Again, pharmacists are urged to notify the affected patient/prescriber to develop a plan to decrease the patient’s total daily MME.

Examples of MME calculations/day include:

  • 10 tablets per day of hydrocodone/acetaminophen 5/325 = 50 MME/day
  • 6 tablets per day of hydrocodone/acetaminophen 7.5/325 = 45 MME/day
  • 5 tablets per day of hydrocodone/acetaminophen 10/325 = 50 MME/day
  • 2 tablets per day of oxycodone 15 mg = 45 MME/day
  • 3 tablets per day of oxycodone 10 mg = 45 MME/day
  • 10 tablets per day of tramadol 50 mg = 50 MME/day
  • 1 patch per 3 days of fentanyl 25mcg/hr = 60 MME/day

A link with more information regarding MME calculations is https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf.

IMPORTANT: Only if the override is denied, then the excess quantity above the maximum unit limit is deemed a non-covered service, and the recipient can be charged as a cash recipient for that amount in excess of the limit.  A prescriber must not write separate prescriptions, one to be paid by Medicaid and one to be paid as cash, to circumvent the override process.  FAILURE TO ABIDE BY MEDICAID POLICY MAY RESULT IN RECOUPMENTS AND/OR ADMINISTRATIVE SANCTIONS.  Source: Provider Billing Manual 27.2.3

1 https://www.cdc.gov/drugoverdose/prescribing/guideline.html

Override Requests:
Once the hard edit is implemented, the MME Override Request Form will be used by the prescriber when requesting an override. The form will be found at: http://medicaid.alabama.gov/content/9.0_Resources/9.4_Forms_Library/9.4.13_Pharmacy_Forms.aspx.

Any policy questions concerning this provider ALERT should be directed to the Pharmacy Program at (334) 242-5050.

The Agency has developed a consumer-friendly handout to explain the new edit to recipients. A copy is attached to this email and may also be found at http://www.medicaid.alabama.gov/documents/9.0_Resources/9.4_Forms_Library/9.4.13_Pharmacy_Services/9.4.13_Opioid_Edit_Recipient_Handout.pdf


ORIGINAL ARTICLE April 2019: In addition to the opioid naïve 5 and 7-day limits, the Alabama Medicaid Agency is working toward implementing cumulative Morphine Milligram Equivalent (MME) edits in early 2019.

Higher doses of opioids are associated with a higher risk of overdose and death; even relatively low dosages (20-50 MME per day) may increase risk.1 Alabama has led the nation for the past six years in the opioid prescribing rate per 100 population (121 in 2016; 107.2 in 2017) and had nearly three times more opioid prescriptions per 100 population than New York.2

The Alabama Medicaid Agency previously executed many programs to address opioid use such as monthly maximum unit limits, therapeutic duplication edits, Drug Utilization Review (DUR) letters, academic detailing report cards and face to face visits, prior authorization, and other educational efforts. Most recently, Medicaid implemented limits for opioid naïve patients to limit first-time use to five days for children and seven days for adults, limiting daily use to 50 MME. Overrides are available for medical necessity.

In an effort to continue combating the opioid crisis, beginning May 1, 2019*, Alabama Medicaid will limit the amount of cumulative MMEs allowed per day on claims for opioid experienced recipients. The edit will begin at 250 cumulative MME per day and will gradually decrease over time. The final MME target is 90 MME per day.

Claims for opioids that exceed the maximum daily cumulative MME limit will be denied. Claims prescribed by oncologists will be excluded from the edit. Long term care and hospice patients will also be excluded; however, children will be included. Overrides for quantities exceeding the MME limit for medical necessity may be submitted to Health Information Designs (HID). Information regarding override requirements and MME examples will be made available on the Alabama Medicaid Agency website closer to the implementation of the new limitations.

The Agency will implement a robust educational program to include academic detailing visits to the prescribers and pharmacies of the first round of affected patients, extensive training, and notifications to the impacted providers through a provider ALERT closer to implementation. Please check the Alabama Medicaid Pharmacy webpage for additional information: http://www.medicaid.alabama.gov/content/4.0_Programs/4.3_Pharmacy-DME.aspx

*At the time of article submission, the implementation date is May 1, 2019, for a ‘phase in’ for 250MME/day. During the phase-in period, a universal prior authorization number will be provided on the pharmacy claim rejection, with an explanation to notify the affected patient/prescriber. Hard stops/edits will begin after the phase-in period.

  1. “Calculating Total Daily Dose of Opioids for Safer Dosage”. CDC. https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf. Accessed 2/1/2019.
  2. “Understanding the Epidemic”. Centers for Disease Control and Prevention. https://www.cdc.gov/drugoverdose/epidemic/index.html. Accessed 2/1/2019.

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SAME Act Could Give Alabama Second Chance at Medicaid Expansion

SAME Act Could Give Alabama Second Chance at Medicaid Expansion

Alabama Sen. Doug Jones introduced legislation this week to give a second chance to expand Medicaid to those states that have not yet expanded their programs. The States Achieve Medicaid Expansion (SAME) Act would also give these states another opportunity to receive the same levels of federal funding that was offered in 2010.

“Alabama made a mistake by not expanding Medicaid. If I can give them an opportunity to rectify that, I’d like to do it,” Jones said in an interview with the Montgomery Advertiser. “I think it’s important for us to expand Medicaid in the state to help save our rural hospitals, get better health outcomes in those rural areas and to provide an economic boost in the state. Let’s finish this job and move forward, instead of languishing and letting our Medicaid dollars that we already pay go to other states.”

Originally in 2010, there would have been federal funds to cover the full cost of expansion for three years for those states that expanded their Medicaid program, at which time federal coverage would drop to 90 percent and states would cover the rest. Should the SAME Act pass, full funding would be offered for three years before decreasing to 95 percent funding in the fourth year, 94 percent in the fifth and 93 percent in the sixth. Federal coverage would stand at 90 percent every year thereafter.

The Medical Association remains an advocate for not only fully funding Alabama’s Medicaid program but also agrees with expansion of the program. Medicaid is a state-run program providing health coverage for about 23,000 low-income residents. To qualify for current Medicaid coverage, families with children must have a household income at or below 18 percent of the poverty level. Expanding the program would take that threshold up to 138 of percent the poverty level, offering access to as many as 325,000 Alabamians.

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New Requirements for Fee-For-Service Delivery Claims

New Requirements for Fee-For-Service Delivery Claims

Effective for dates of services on or after Feb. 1, 2018, fee-for-service delivery claims for recipients who reside in a county not served by an Alabama Medicaid (Medicaid) Maternity Care Program must contain the date of last menstrual period and the date of first prenatal visit. This information is not required for hospital claims.

Counties not included in a Medicaid Maternity Care Program:

District 10:  Autauga, Bullock, Butler, Crenshaw, Elmore, Lowndes, Montgomery and Pike
District 12: Baldwin, Clarke, Conecuh, Covington, Escambia, Monroe and Washington

Soft Denial:
Claims without the date of last menstrual period and the date of the first prenatal visit will receive a “soft” denial.  This means the claim will process, but the provider will receive an alert to remind them to include the information.

Hard Denial:
On Feb. 1, 2019, claims that do not include the date of last menstrual period and the date of the first prenatal visit will be denied.

Some examples of what a provider can expect to see on the denied claim include:
Edit 330 – DTP SEGMENT DATE IS INVALID
Edit 331 – DATE LAST MENSTRUAL PERIOD MISSING OR IN FUTURE

Edit 332 – DATE FIRST PRENATAL VISIT MISSING OR IN FUTURE

Claims with the procedure codes below must include the date of last menstrual period and date of the first prenatal visit:

  • 59400-59410     Vaginal delivery
  • 59510-59515      Cesarean delivery
  • 59610-59622     Delivery after previous cesarean delivery

How can a fee for service provider submit a claim?

  • For claims submitted through 5010 X12 837P:
    1. Enter the date of the patient’s last menstrual period in a DTP segment in loop 2300 with a qualifier of 484
    2. Enter the date of the patient’s first prenatal visit in a DTP segment in loop 2300 with a qualifier of 454
  • For claims submitted on the Medicaid Interactive Web Portal:
    1. Enter the date of the patient’s last menstrual period in the field labeled “last menstrual period date”
    2. Enter the date of the patient’s first prenatal visit in the field labeled “first prenatal visit date”
  • For paper claims submitted on a CMS form 1500:
    1. Enter the patients last menstrual period in block 14
    2. Enter QUAL the value “484” to identify the information in block 14 as the date of the last menstrual period.
    3. Enter QUAL the value “454,” which identifies the information entered as the date of the first prenatal visit in block 15
    4. Enter the date of the patient’s first prenatal visit in block 15
    5. If no prenatal care was received, the date entered in block should be the date of the first contact during the pregnancy.

*Reminder:  Medicaid requires all claims be filed electronically unless they are required to be submitted on paper.

  • PES does not currently allow claims to be submitted with this information, but a software upgrade will be available prior to claims denying for not containing the information.

Note:
Providers within the Maternity Care Program must continue to follow guidelines outlined in the April 13, 2017 ALERT. Please visit http://medicaid.alabama.gov/alert_detail.aspx?ID=12209 for a copy of the ALERT.

Please direct questions to the Fiscal Agent, Provider Assistance Center at (800) 688-7989.

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Medicaid to Host Regional Meetings With Primary Care Providers

Medicaid to Host Regional Meetings With Primary Care Providers

Patient First primary medical providers and other primary care providers are invited to attend one of seven upcoming meetings to learn more about Medicaid’s proposed Alabama Coordinated Health Networks (ACHNs).

ACHNs are designed to create a single care coordination delivery system that effectively links patients, providers and community resources within each of seven regions. In coordination with ACHN, there will be a new way of paying primary care providers which will be discussed at these regional meetings. If ACHN is approved by the federal government, the networks are expected to be implemented on October 1, 2019.

All meetings will be from 5:30 p.m. to 6:30 p.m.  An online session will be scheduled in February.

Muscle Shoals
Thursday, January 24
NW Shoals Community College – Hospitality Center
800 George Wallace Blvd, Muscle Shoals, AL 35674

Mobile
Tuesday, January 29
Ben May Main Library – Bernheim Hall
701 Government Street, Mobile, AL 36602

Birmingham
Thursday, January 31
Hoover Public Library – Fitzgerald Room
200 Municipal Drive, Hoover, AL 35216

Montgomery
Tuesday, February 5
Vaughn Park Church of Christ
3800 Vaughn Road, Montgomery, AL 36106

For more information, go to http://www.medicaid.alabama.gov/content/2.0_Newsroom/2.7_Special_Initiatives/2.7.6_ACHN.aspx.

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