June 30, 2016
Welcome to the Wesgram Online! 

This is the second edition of the Wesgram in June 2016. There is important information about the Special Enrollment period that PEIA will have between July 1-15, 2016, as well as other important payor news. You'll also find information about upcoming classes and educational events.
The staff of the WVSMA wishes you a Happy and Safe July 4th!

story1ICD-10 Latest News
Coding Updates 

ICD-10 went into effect October 1, 2015, with a CMS-approved one year grace period for providers to transition to the required levels of specificity. For the first 12 months, Medicare claims have not been denied solely on the specificity of the diagnosis codes, provided the submitted code was from an appropriate family of ICD-10 codes.
October 1, 2016, marks the end of the "breathing room" period, and the beginning of an expected increase in claims rejections for practices submitting unspecified ICD-10 codes. With increased rejections will come payor requests for medical records and clinical documentation. This has the potential to become a nightmare for those who have not taken the time to get it right with the new codes.
This is also the time to begin taking steps toward becoming a more data driven practice. Moving forward, good data and metrics will drive the new payment models in healthcare. Quality-based measurements are no longer optional. Under MIPS, practices will be reimbursed in 2019 based on quality metrics reporting in 2017. Act now to prepare your practice and set the stage for future financial success.
The WVSMA will be providing educational events to prepare for MACRA, MIPS, ICD-10 and CPT coding updates and changes. Watch for dates and topics to be announced soon!

Palmetto GBA News
(information from Palmetto GBA)

Additional Documentation Requests

If you have received an Additional Documentation Request (ADR) for one or more claims, you will have 45 days from the date of the letter to submit supporting records. As a best practice, Palmetto suggests that providers set a goal of submitting their documentation by day 30 to help prevent any delay in receipt of records. If we do not receive your records timely, on day 46 the Medicare claims system will automatically deny the claim.

CERT Decisions May be Appealed

A CERT decision may be appealed. If the provider disagrees with the CERT's decision, you may appeal by submitting the appropriate form, which can be located under the 'Forms' Link on the home page www.palmettogba.com

E/M Tip: Hospital Discharge and Nursing Facility Admission on the Same Date of Service

The hospital discharge code and the nursing facility admission code may be billed by the same physician with the same date of service.

E/M Tip: Documentation Provided By Students

Any contribution and participation of a student to the performance of a billable service (other than the review of systems and/or past family/social history which are not separately billable, but are taken as part of an E/M service) must be performed in the physical presence of a teaching physician or physical presence of a resident in a service meeting the requirements set forth for teaching physician billing.

On July 18, 2016, new provisions go into effect for the new nondiscrimination in health programs and activities law. The new rule, called Section 1557, was released May 13, and appeared in the Federal Register (Volume 81, No. 96) on Wednesday, May 18. The rule, which originated in the Affordable Care Act, extends civil rights protection to patients based on their gender identity, boosts protections for limited English proficiency patients and addresses the obligation that physicians take reasonable step to provide meaningful access without discrimination.

All Medicare participating providers are covered entities under this rule. In addition, participation in an Advantage Plan, Medicaid and SCHIP, means that you must meet these guidelines in your practice.

The Office of Civil Rights has given health plans a little longer to prepare for compliance. Provisions that require a change to health insurance or to a group health plan will apply on the first plan or policy year after January 1, 2017.  
Payor News and Other News 
PEIA Update---The Latest on Special Enrollment 2017 
(information from WV PEIA)
With the adoption of a state budget with funding for PEIA, there are substantial changes in the benefits for State agencies, colleges, universities and county boards of education, as well as non-Medicare retirees, so PEIA will be holding a Special Enrollment period from July 1 - 15, 2016. All changes will be retroactive to July 1, 2016.

This Special Enrollment period is NOT an extension of the 2017 Healthy Tomorrows deadline that passed in May.

PEIA will conduct a reconciliation in August to true-up premiums, deductibles, out-of-pocket maximums and copays resulting from retroactive plan changes.

The WVSMA asked for clarification regarding PEIA claim processing during this re-enrollment period and was advised that HealthSmart will continue to process claims July 1 per the Plan the member selected during the regular Open Enrollment. If the member changes Plans during this enrollment period, HealthSmart will process the adjustment. You may want to make your billing department aware of this potential reprocessing.

The following benefit changes take effect July 1, 2016:

Urgent Care copay increases to $50 for PEIA PPB Plans A, B and D.

For Comprehensive Care Partnership (CCP) Program members, ANY non-CCP office visit now requires the $40 specialist office visit copay.

The Face-2-Face Diabetes Program will be limited to two years. Current F2F members will be permitted two more years of services starting July 1, 2016, as long as they continue to meet the other requirements of the plan.

Out-of-state, non-network services are no longer covered in any of the PEIA PPB Plans. Patients will be responsible for 100% of billed charges from non-network providers outside West Virginia, except in a medical emergency or when approved in advance by HealthSmart. PEIA PPB Plan members who reside more than one county outside of West Virginia may use in-network providers where they live without prior approval from HealthSmart, as long as PEIA has been notified of the member's residential address.

Facility- fee limits for select facility-based services/procedures. If the member chooses an out-of-state facility that charges more than the PEIA facility fee limit, the member will be responsible for the difference between PEIA's payment and the facility's charge.

  • Additional emergency room copay of $500 for high-risk behaviors, such as:
  • Accidents while driving motorcycle or UTV/ATV without a helmet
  • DUI/DWI or drug -related accidents
  • Failure to wear seatbelt(s)

Opioid pain medications will have a quantity limit (QL) for all medications in the opioid class. Additional quantities require Prior Authorization.

Highmark West Virginia News
In March, physicians were sent a communication from Highmark regarding a change in reimbursement for their ACA product. This change affects about 45,000 covered lives who participate via the ACA plans.   Highmark West Virginia advised physicians that they were taking a measured approach to managing ACA fees with an aggregate adjustment (reduction) of 0.6 percent for ACA direct-pay products.
Effective May 1, 2016, Highmark began to adjust the provider fee schedule to implement new fees for their ACA individual (direct-pay) products. Current fees are available in NaviNetĀ®. These fees are not published on the public Provider Resource Center and questions regarding the new fees should be addressed to Highmark's Provider Resource Center.
The Highmark mailing also included an addendum to memorialize the fee changes and other agreements relevant to Highmark West Virginia's ACA network and products. Physicians should retain this document with their contract records. Remember, your contract is your source for all your legal information regarding participation with insurers.
Highmark West Virginia has also announced that the plan is doing business differently in 2016. Physicians no longer have an assigned Provider Relations representative, but are instead encouraged to utilize the plan's self-service options. Highmark encourages you to take advantage of the online and telephonic tools that the plan offers.
NaviNet should be utilized as the primary resource for inquiries related to West Virginia Family Health members. Questions that cannot be resolved through NaviNet functionality for these members should be directed to West Virginia Family Health Provider Services at 1-855-412-8002.
story6Other News
WVSMA to Offer CMIS Certification in August

The WVSMA will offer the CMIS (Certified Medical Insurance Specialist) course beginning on Thursday, August 4, 2016. This PMI (Practice Management Institute) nationally recognized certification class explores the current landscape of third party reimbursement. Detailed lectures, course materials and examples will teach participants how to effectively expedite claims, secure timely, correct reimbursement, and protect the financial interest of the practice.
The CMIS (Certified Medical Insurance Specialist) class has a recently added benefit!   A new incentive, The Coding Basics Package, is designed to help those who lack coding experience or want to gain foundational knowledge prior to taking the class.
The FREE package consists of four pre-recorded webinar courses that can be downloaded and reviewed at your convenience. Each presentation includes a 90-minute lecture, presentation PDF, and a quiz that will help participants better prepare for the class. You will receive the Coding Basics Package when you register for the CMIS class.  
This class has not been offered in West Virginia since 2014 and will not be offered again in 2016.
Register now at the WVSMA's website, www.wvsma.org.   
The WVSMA is the exclusive WV partner with PMI. 

Practice Administrator of the Year Award

Nominations are now being accepted for the WVSMA's annual Practice Administrator/Manager of the Year. 

The award is presented to an individual recognized as a dynamic medical practice leader and advocate for patient care. The nominee must meet the following criteria:
  • Must be from a WVSMA Member's practice and nominated by a physician member of WVSMA.
  • A dynamic leader is someone who inspires others to be their best, to think about solutions, and can adapt to changing situations and environments.
  • A strong advocate who thinks about the needs of the patient and the patient experience and consistently works to build cohesion among practice staff and the patients they serve. 
The recipient will be recognized at the 2016 WVSMA Healthcare Summit during the Friday evening, August 26 Inaugural Celebration and Gala Dinner at The Greenbrier
Nomination deadline is July 31, 2016. To nominate your Practice Manager today click   here and return the completed form to 4307 MacCorkle Avenue SE, Charleston, WV 25304 (attn: Karie Sharp) or fax to (304) 925-0345. 
Questions: Contact Barbara Good  or  Karie Sharp.  

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