WELCOME to the OPW EyeCare Benefits INSURANCE OVERVIEW Seminar HOSTED BY OPW & OPW EYECARE BENEFITS COMMITTEE Dr. Glen Owen, Dr. Mark Michael Dr, Ivan

Download WELCOME to the OPW EyeCare Benefits INSURANCE OVERVIEW Seminar HOSTED BY OPW & OPW EYECARE BENEFITS COMMITTEE Dr. Glen Owen, Dr. Mark Michael Dr, Ivan

Post on 22-Dec-2015

212 views

Category:

Documents

0 download

Embed Size (px)

TRANSCRIPT

<ul><li> Slide 1 </li> <li> WELCOME to the OPW EyeCare Benefits INSURANCE OVERVIEW Seminar HOSTED BY OPW &amp; OPW EYECARE BENEFITS COMMITTEE Dr. Glen Owen, Dr. Mark Michael Dr, Ivan Hyde </li> <li> Slide 2 </li> <li> PRESENTERS Dr. Ken White OPW insurance liaison Judy White Billing and coding consultant </li> <li> Slide 3 </li> <li> AUDITS AUDITS AUDITS Because you are being paid doesnt mean you are doing it right? RACS (4.1 Billion recovered 2011) Examples $12000 Overpayment by payor $5000 (DSHS dispensing fees) Recourses available </li> <li> Slide 4 </li> <li> PAYORS CONSIDER THESE ITEMS FRAUD Billing for: Services Not Rendered--- Phantom Billing (or not documented in chart ) Services Performed by Non-Licensed or Non-Payable Practitioners (Staff initialed procedures, but no order from doctor) A More Costly Service than Provided--- Up-Coding (Not medically necessary) </li> <li> Slide 5 </li> <li> PAYORS LIST OF FRAUDULENT ITEMS (Premera) As with all small percent of providers we look at there is potential for up-coding and unbundling Up-coding new and established codes to comprehensive when the documentation does not support this level Unbundling services that are included in a comprehensive examination and billing these in addition. One of the bigger issues we see is practitioners attempting to manipulate the sunglasses exclusion benefit by attempting to pass these off as tinted lenses. Most vision benefits exclude sunglasses and non rx lenses. Billing for services not rendered. Unless there is a chart audit payable codes will go through the system without documentation requirements. Manipulating the diagnosis codes so vision pays under medical when the member has no vision benefit or a richer medical benefit than vision. </li> <li> Slide 6 </li> <li> PAYORS LIST OF FRAUDULENT ITEMS (DSHS) 1.Follow the rules and/or billing instructions: Read them carefully, keep current and follow them. 2.Document, document, document! 3.Make sure that documentation is clear, legible and supports the service billed and remember; If its not documented in the chart, it didnt happen and if it didnt happen, payment will be recouped. </li> <li> Slide 7 </li> <li> MEDICARE 2012 Social Security began in 1937 Elderly National Health Insurance began in 1966 (Prelude to Medicare) Optometry included in Medicare in 1987 CMS is the largest insurance company in the world Estimated by 2015 over 25% of OD billing will be Medicare </li> <li> Slide 8 </li> <li> MEDICARE 2012 65 and older Under 65 with certain disabilities All ages with end stage renal disease </li> <li> Slide 9 </li> <li> MEDICARE 2012 PART A Inpatient care in hospital Skilled nursing facilities Home Health Care </li> <li> Slide 10 </li> <li> MEDICARE 2012 PART B Dr Services, Outpatient Care, DMEPOS and some Preventative Services Subscriber Deductible $140.00/yr Subscriber Premium $99.90/mo Higher Income beneficiaries pay as much as $319.70/mo </li> <li> Slide 11 </li> <li> MEDICARE 2012 PART C Run by Medicare approved private companies Includes Part A, Part B and sometimes Part D Began January 2006, formally called Medicare Choice Plans </li> <li> Slide 12 </li> <li> MEDICARE 2012 PART D Prescription drugs Began January 1 st 2006 Medicare mess!!! </li> <li> Slide 13 </li> <li> MEDICARE 2012 ORIGINAL MEDICARE Run by federal government Covers Part A and Part B Beneficiary can purchase a supplement to cover deductible and 20% Can purchase Part D (Drug coverage) separately </li> <li> Slide 14 </li> <li> MEDICARE 2012 MEDICARE ADVANTAGE PLANS (PART C) Advantage Plans in Washington State 17 plans 2006, (Mostly Fee For Service) 210 plans 2008 157 plans 2010 15 carriers 2012 FFS = 2 PPO = 5 HMO = 13 </li> <li> Slide 15 </li> <li> MEDICARE 2012 MEDICARE ADVANTAGE PLANS (PART C) Private companies approved by Medicare Covers Parts A &amp; B and sometimes D May charge different amounts for items and services Usually charges additional monthly premium Never has supplement Always send claims to plan </li> <li> Slide 16 </li> <li> MEDICARE 2012 MEDICARE ADVANTAGE PLANS (PART C) 5 types of plans PPO (Preferred Provider Organization) IE. Regence HMO (Health Maintenance Organization) IE. Sound Path Health &amp; Spokane Community Care FFS (Fee for Service) IE. Sterling SNP (Special Needs Plan) IE. Molina HMOPOS (Health Maint. Org. Point of Service) IE. Community Health First </li> <li> Slide 17 </li> <li> MEDICARE 2012 Medicare contracting reform New Jurisdiction 10 Western States Jurisdiction F Noridian retains contract </li> <li> Slide 18 </li> <li> DMEPOS Washington is Jurisdiction D (Part B supplies) Includes 17 western states Noridian contract = past 11 years </li> <li> Slide 19 </li> <li> MEDICARE WHAT ARE THE DIFFERENCES? Enrolled 1. Enrolled Has a signed contract with Medicare that physician bills Medicare for beneficiary and accepts their rules for medically necessary ophthalmic goods. Enroll at https://www.noridianmedicare.com/dme/enroll/ https://www.noridianmedicare.com/dme/enroll/ Non-Enrolled 2. Non-Enrolled No DME signed contract with Medicare. Cannot see Medicare patients for medically necessary ophthalmic goods. Opt-Out 3. Opt-Out Signed opt-out affidavit filed with Medicare Signed private contract with each Medicare patient for care Applies to both Part B services and DMEPOS items </li> <li> Slide 20 </li> <li> MEDICARE Two Choices If Enrolled PARTICIPATING 1. PARTICIPATING (accept assignment) Physician sends CMS billing to Medicare Medicare pays physician allowed Medicare fees at 80% NON-PARTICIPATING 2. NON-PARTICIPATING Physician sends CMS billing to Medicare Maximum 115% of allowed Medicare Fees Patient pays physician U&amp;C fees for DMEPOS Medicare pays patient allowed Medicare fees at 80% </li> <li> Slide 21 </li> <li> DMEPOS Enrollment fees $ 523.00 1. New location 2. Additional locations 3. Change of ownership 4. New tax ID # 5. Reactivations 6. Re-validation (Every three years) Fees must be submitted through internet based PECOS system </li> <li> Slide 22 </li> <li> DMEPOS surety bonds 1.Mandatory for DMEPOS enrolled providers that fill outside scripts 2.Effective 05/04/2009 $50,000.00 Bond / location Cost: $1500-2000 / yr 3.Mandatory for participating and non-participating 4.Verify script and make it your own to avoid bond 5.Government approved bond carriers are mandatory www.fms.treas.gov/c570/c570_a-z.html </li> <li> Slide 23 </li> <li> MANDATORY CLAIM FILING Effective September 1 st 1990, Claim Filing Mandatory Social Security Act 1848(g)(4) Law applies to all suppliers providing covered services or items to Medicare beneficiaries regardless of supplier status The fact that the provider has not acquired a Medicare billing number or closed a billing account offers no protection from this requirement Does not apply to non-covered services, due to statutory exclusion unless beneficiary requests submission - IE. refraction </li> <li> Slide 24 </li> <li> MANDATORY CLAIM FILING Law prohibits supplier from charging beneficiary for claim submissions Non-compliance with this law may result in a $2000.00 fine for violation Medicare claims must now be submitted within 12 months </li> <li> Slide 25 </li> <li> All providers must be listed in PECOS to provide some services, post-op care, some screening tests and scripts for post-op glasses To be listed in PECOS provider must have enrolled or submitted changes to Medicare enrollment after Nov 2003 PECOS, whats it all about? </li> <li> Slide 26 </li> <li> To find if you are listed as an enrollee in PECOS, go to the following CMS Website. http://www.cms.gov/MedicareProviderSupEnroll/04 _InternetbasedPECOS.asp#TopOfPage To enroll in the PECOS system go to: https://PECOS.CMS.hhs.govPECOS </li> <li> Slide 27 </li> <li> MEDICARE POST OP BILLING CATARACT AND YAG SURGERY 90 DAY POST OP PERIOD Use modifier 24 with E&amp;M code if seen for totally unrelated problem during post-op Use modifier 79 if treating second eye post op during first eye post op 90 day period IE. 66984-55-79-RT or LT </li> <li> Slide 28 </li> <li> MEDICARE POST OP BILLING Box 17 = Surgeons Name Box 17b = Surgeons NPI Box 19 = Post op care from (date)* to (date)** * Date of transfer on surgeons post op letter ** 90 days from date of surgery (day one is day after surgery) Calculation Website: http://www.medicarenhic.com/providers/billi ng/billing_calc_global_period.html </li> <li> Slide 29 </li> <li> MEDICARE POST OP BILLING Box 21= Must use same ICD-9 code as surgeon uses Box 24a = Date of surgery Box 24d = CPT code must match surgeons Usually 69884 Use modifier 55 &amp; RT or LT for Post Op More complicated surgery will have different codes and higher reimbursement amounts </li> <li> Slide 30 </li> <li> PQRS, Why should I participate? Applies to Medicare only (0.5% Bonus) Must report three measures, 50% of the time Only 3 dxs to think about; AMD, POAG, DIABETES Penalties in 2015 (1.5%) Current Update for ODs Available at: http://www.aoa.org/x17508.xml </li> <li> Slide 31 </li> <li> Slide 32 </li> <li> eRx INFORMATION, WHAT YOU NEED TO KNOW AND WHY Do I have to participate in PQRS to participte in eRx? (No) Separate from and in addition to Physician Quality Reporting (PQRS) Is this a voluntary program? (Yes) (1% bonus2012) What if I dont participate? ( No Penalty for ODs 2012) (2013=?) </li> <li> Slide 33 </li> <li> eRx What if I decide to participate?What if I decide to participate? Applies to Medication; Not glasses rx Rx directly from your computer to pharmacy Helps to Eliminates fraud Do I have to have specific software? (Yes)Do I have to have specific software? (Yes) Qualified System that will generate a complete medication list that incorporates data from pharmacies and provide information on lower cost, and therapeutically appropriate alternatives </li> <li> Slide 34 </li> <li> eRx, GETTING STARTED HOW DO I GET STARTED?HOW DO I GET STARTED? Learn: http://www.aoa.org/x18599.xmlhttp://www.aoa.org/x18599.xml http://www.aoa.org/x18962.xmlhttp://www.aoa.org/x18962.xml Download AOA eRx Webinar; http://www.aoa.org/x18392.xml#erx Get Started http://www.getrxconnected.com/OPTOMETRIC/ site.aspx http://www.getrxconnected.com/OPTOMETRIC/ site.aspx Free Software http://www.nationalerx.com/prescribers.htm </li> <li> Slide 35 </li> <li> 2012 CHANGES PREMERA Corneal Topography (CPT 92025) has been eliminated DSHS Pediatric hardware only ASURIS MED-ADVANTAGE (Regence) VSP FOR routine exams and hardware </li> <li> Slide 36 </li> <li> (OCT) 2012 CHANGES 92132 Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral or bilateral. 92133 Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral, optic nerve. 92134 Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral, retina </li> <li> Slide 37 </li> <li> CPT 92070 has been deleted in 2012 92071 Fitting of contact lens for treatment of ocular surface disease (Per Lens) 92072 Fitting of contact lens for management of keratoconus, initial fitting (Per Lens) Neither code includes supply of lens and may be reported as 99070 (supplies and materials provided by physician over and above those usually included with the office visit or other services rendered or; The appropriate HCPCS material code (V code) or S code (S 0500 (disposable contact lens) Additional care (visits), use appropriate E&amp;M services or general ophthalmological services. </li> <li> Slide 38 </li> <li> ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE New ABN form (03/11) Mandatory after 1-1-12 Replaces old ABN and NEMB Used to inform patients that fees will probably not be covered my Medicare Must be filled out and signed before materials are ordered and rendered No blanket form to every Medicare patient One copy for patient and one in file for 7 years </li> <li> Slide 39 </li> <li> ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE Use GA modifier when ABN is executed Mandatory field of cost estimate for items/services Must be signed and dated by beneficiary or authorized representative Includes beneficiary options -Individual may choose to receive item/service -Pay for it out-of-pocket -No claim submitted to Medicare </li> <li> Slide 40 </li> <li> BILLING DMEPOS Coverage Requirement Medically necessary to restore vision due to surgical removal or congenital absence of organic lens of the eye Covered diagnoses are limited to: Pseudophakia (V43.1) Aphakia (379.31) Congenital Aphakia (743.35) All other diagnosis will deny as non-covered Patient is eligible even if they had surgery prior to Medicare coverage. </li> <li> Slide 41 </li> <li> BILLING DMEPOS Pseudophakia Diagnosis code V43.1 Only one pair of lenses &amp; frames or contacts are allowed after each cataract surgery If patient does not receive glasses or contacts between two separate surgeries, only one pair of lenses and frames or contacts are allowed. Frames are covered only when ordered with lenses Replacements not covered No time limit after surgery to order materials </li> <li> Slide 42 </li> <li> BILLING DMEPOS Aphakia Diagnosis code 379.31 or 743.35 The following combination of frames, lenses or contact lenses are allowed: Bifocal lenses in frame OR Lenses in frames for far vision and lenses in frame for near vision OR Contact lenses worn the same time as eyeglasses and eyeglasses when contacts are removed No limit on replacement except soft lenses </li> <li> Slide 43 </li> <li> BILLING DMEPOS Contact Lenses V2520 -V2523 Allowed fees include professional fitting fees No allowance for solutions Not eligible when used as corneal dressing </li> <li> Slide 44 </li> <li> BILLING DMEPOS Frames V 2020 standard frame Use amount allowed by Medicare. 2012 = $65.42 OR Use your retail (U&amp;C) if less than Medicare allowed amount V2025 delux frame Retail amount over Medicare allowed amount </li> <li> Slide 45 </li> <li> BILLING DMEPOS Frames When billing for delux frame enter standard frame code (V2020) on first claim line On second claim line, enter delux frame code (V2025) and difference in charge between standard and delux frame No ABN form or GA modifier No other modifiers </li> <li> Slide 46 </li> <li> BILLING DMEPOS Medically Necessary Options Following options are covered if ordered by physicians for medically necessary reasons: Photochromatic V2744 ( Glass or Plastic) Tint V2745 Anti Reflective Coating V2750 Oversize lenses V2780 Polycarb lenses V2784 (Must have functional vision in only one eye) Use KX modifier if medically necessary (rare) Must be documented by treating physician and medical record </li> <li> Slide 47 </li> <li> BILLING DMEPOS When the above options are patient preference items, they must be billed on a separate CMS form An ABN form must be executed Use GA EY Modifiers Will be denied as not medically necessary </li> <li> Slide 48 </li> <li> BILLING DMEPOS UV Protection V2755 UV protection reasonable and necessary following cataract extraction. Add...</li></ul>