2014 FALL PROVIDER WORKSHOPS Ed Dolly, DHHR Chief Information [PDF]

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WV BUREAU FOR MEDICAL SERVICES 2014 FALL PROVIDER WORKSHOPS

Ed Dolly, DHHR Chief Information Officer Jon Cain, MIS Director of Integrated Systems Management Tanya Cyrus, RN, BMS Director of Policy Administrative Services Meghan Shears, Manager, WV CARES Nicole Becnel, Manager, BerryDunn October 27 - Martinsburg, WV October 28 – Morgantown, WV October 29 – Beckley, WV October 30 – Charleston, WV

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Medicaid Expansion

As of September 20, 2014, approximately 148,611 have enrolled in Medicaid as a result of the expansion:

42% are between 19 and 34 years of age
37% are between 35 and 50 years of age
20% are between 51 and 64 years of age
Less than 1% fall outside of these age ranges

Approximately 54% of the new enrollees are female and 46% are male. Approximately 28% (513,481) of West Virginia’s population is now covered by Medicaid.

About 41% of these individuals are receiving services through

Mountain Health Trust, the State’s Managed Care Program.

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Medicaid Expansion

July 9, 2014 - according to an article in the Charleston Daily Mail WV has seen the biggest drop in adult uninsured rate and has the most new Medicaid enrollees per capita than any other state that expanded Medicaid. WV now has the sixth-lowest uninsured rate in the country. As of April 30, 2014, expenditures for the expansion population were over $225 million. The three highest expenditure categories were:

Outpatient Hospital Services $35.3 million
Prescription Drugs $47.4 million
Inpatient Hospital $38.6 million

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Medically Frail Update

Definition (42CFR §440.315):

Individual having a chronic substance use disorder, serious and

complex medical condition, or a physical, behavioral, intellectual, or developmental disorder that requires additional care.

A member can self-identify at any time during their eligibility

period.

Claims Reprocessing Update

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Enhanced Primary Care Payments

Provision under the Affordable Care Act (42 CFR 447.400(a))
Required that Medicaid reimburse eligible primary care

providers at parity with Medicare rates in 2013 and 2014 for certain evaluation and management (E&M) and vaccination codes beginning with January 1, 2013 dates of service

Enhanced payments expire on December 31, 2014.
There will be a second review required of provider compliance

during CY 2015, which will examine provider participation in CY 2014.

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Hospital Based Presumptive Eligibility (HBPE)

Currently, 37 hospitals participate in the HBPE program. Hospitals must meet two performance measures in order to continue participation in the program:

75% of the individuals who are determined presumptively

eligible must complete a full Medicaid application and

Of those who complete a full Medicaid application, 50% of

them must be approved for Medicaid coverage. September 12, 2014 - 5,384 people have been determined presumptively eligible for Medicaid and 2,246 of them have become fully eligible for Medicaid. To keep informed about the progress of Medicaid expansion check the Medicaid expansion section at http://www.dhhr.wv.gov/bms/Pages/MedicaidExpansion.aspx

n the BMS website.

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BMS Policy and Program Updates

Drug Screening Policy

Coverage changes delayed until 2015 CPT codes evaluated

Take Me Home, WV

Expanding network of Transition Navigator provider agencies
ADW and TBI agencies
For more information, go to program’s website at

http://www.dhhr.wv.gov/bms/MFP/ Home and Community Based Waivers

Renewal applications to be submitted to CMS December 2014

Quality Program

CMS Adult Quality Measures
Medical Record Requests Delayed - Pending CMS Response

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BMS Health Homes Program

WV Health Homes

Launched July 1, 2014
Medicaid members with bipolar disease who have or are at risk
f having Hepatitis B or C
Must be receiving services from provider in
Cabell, Kanawha, Mercer, Putnam, Raleigh or Wayne

counties

Health Home Providers must offer team approach to assist

member with

Managing medical conditions and medications
Understanding medical tests and results
Remembering medical appointments
Other health care needs

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SLIDE 9

BMS Health Homes Program

Currently eight (8) BMS-approved Health Home Providers:

Cabin Creek Health Systems
FMRS Health Systems
Marshall Health
Prestera Center for Mental Health
Process Strategies
Southern Highlands Community Health Center
WV Health Right
WomenCare, Inc. (FamilyCare)
Additional Health Home Program information is available on the

Bureau for Medical Services website: www.dhhr.wv.gov/bms/ or the APS Healthcare-WV website: www.apshealthcare.com/wv

Questions/concerns contact APS Healthcare at 304-343-9663 or

1-800-461-0655.

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New Hospice Rule

BMS will follow new Federal Rule, effective October 1, 2014

Final Rule
Implements changes to coding guidelines for diagnosis reporting on

Hospice claims

Specifies that Alzheimer’s, Dementia, and “adult failure to thrive”

diagnoses cannot serve as the sole/primary determinant for Hospice services

Located in August 22, 2014, Federal Register page 50498, item #4:

“Coding Guidelines for Hospice Claims Reporting” http://www.gpo.gov/fdsys/pkg/FR-2014-08-22/pdf/2014-18506.pdf

APS has attached message to all Hospice submissions with a sole/primary

diagnosis of Alzheimer’s/Dementia or adult failure to thrive indicating that an additional primary diagnosis for prior authorization of Hospice services is required.

Some providers have begun submitting the additional information on

their submissions and are now compliant with the new rule.

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ICD-10

Compliance Date – October 1, 2015

Changes to MMIS completed
BMS Policy Remediation to be completed by January 1, 2015
Policies to be released using current process
Draft policy posted to BMS website
30-day Public Comment Period
Internal testing – CMS Level I is 90% Completed
External testing - to begin 1st Quarter 2015
Provider Readiness Surveys will continue
For more information:
Molina’s website under “ICD-10 Transition” link
Molina Biweekly Webinars
www.cms.gov/icd10

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ICD-10 Policy Remediation

New Format for BMS Policy

NOTE: This is a sample of the new policy format that BMS will be using when existing

policy is remediated for ICD-10 . This is not an actual policy.

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519.6 CARDIAC REHABILITATION POLICY METADATA Policy ID = 519.6 Policy Author = Professional Services Policy Status = Pending Creation Date = 4/1/2013 Initial Approval Date = 4/1/2013 Initial Effective Date = 4/1/2013 Last Revised Date = 10/14/2014 Revision Approval Date = TBD Next Review Date = Date. BACKGROUND Cardiac rehabilitation is a comprehensive outpatient program of medical evaluation, prescribed exercise, cardiac risk factor modification, and education and counseling that is designed to restore members with heart disease to active, productive lives. The central component of cardiac rehabilitation is a prescribed regimen of physical exercises intended to improve functional work capacity and to improve the member’s well-being. POLICY Cardiac rehabilitation programs are regulated exercise programs which are effective in the physiological and psychological rehabilitation of many members with cardiac conditions. The program consists of a series of supervised exercise sessions with continuous electrocardiograph monitoring. Cardiac rehabilitation can be performed in a specialized, freestanding physician-directed clinic or in an outpatient hospital department. Members who use tobacco must be referred to the tobacco cessation program. Please see 519.21, Tobacco Cessation Services. The goals of cardiac rehabilitation are to:  Increase exercise tolerance  Reduce symptoms of chest pain and shortness of breath  Improve blood cholesterol levels  Improve psychosocial well-being  Reduce mortality These services are considered medically necessary for selected members when they are individually prescribed by a physician within a 24 week (6 month) window after any of the following:  Acute myocardial infarction  Other acute and subacute forms of ischemic heart disease  Old myocardial infarction  Angina pectoris  Other forms of chronic ischemic heart disease  Other diseases of endocardium (e.g. valve disorders, mitral, aortic, tricuspid, pulmonary, endocarditis) 519.6 CARDIAC REHABILITATION

Cardiac dysrhythmias  Heart Failure  Cardiomegaly  Functional disturbances following cardiac surgery  Complications of transplanted organ, heart  Organ or tissue replaced by other means; heart  Organ or tissue replaced by other means; heart valve  Other post procedural states; unspecified cardiac device  Other post procedural states; automatic implantable cardiac defibrillator  Other post procedural states; percutaneous transluminal coronary angioplasty status  Personal history of other cardiorespiratory problems; exercise intolerance with pain: at rest, with less than ordinary activity, with ordinary activity.

519.6.1 FREQUENCY AND DURATION

The medically necessary frequency and duration of cardiac rehabilitation is determined by the member’s level of cardiac risk stratification. High risk members who have any one of the following are eligible for cardiac rehabilitation:  Exercise test limited to less than or equal to 5 metabolic equivalents (METS)  Marked exercise-induced ischemia, as indicated by either angina pain or 2 mm or more ST depression by ECG  Severely depressed left ventricular function (ejection fraction less them 30%)  Resting complex ventricular arrhythmia  Ventricular arrhythmia appearing or increasing with exercise or occurring in the recovery phase of stress testing  Decrease in systolic blood pressure of 15 mm HG or more with exercise  Recent myocardial infarction (less than 6 months) which was complicated by serious ventricular arrhythmia, cardiogenic shock or congestive heart failure  Survivor of sudden cardiac arrest.

519.6.2 PROGRAM DESCRIPTION FOR HIGH RISK MEMBERS

The cardiac rehabilitation program is composed of:  36 sessions (e.g., 3x/week for 12 weeks) of supervised exercise. For members of the expansion population under the alternative benefits plan service limits include both rehabilitative and habilitative services. Please see Chapter 400, Member Eligibility for additional information.  Educational program for risk factor/stress reduction  Creation of an individual outpatient exercise program that can be self-monitored and maintained  If no clinically significant arrhythmia is documented during the first three weeks of the program, the provider may have the member complete the remaining portion without telemetry monitoring.  Following the initial evaluation, services provided in conjunction with a cardiac rehabilitation program may be considered reasonable for up to 36 sessions, usually 3 sessions per week, for a 12 week period.

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NCCI Edits

Upcoming Changes

New “X” modifiers
To be used in place of Modifer-59, if appropriate
Date of Service MUEs
Currently in Medicare NCCI edits
A date-of-service MUE sums the submitted units of service

for a given HCPCS / CPT code on all lines of the presenting claim and all paid claim lines on claims in history billed by the same provider for the same member for the same DOS.

CMS current plan is to phase in DOS MUEs over several

quarters

Target date to begin implementation is after April 1, 2015

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SLIDE 14

Ordering/Referring/Prescribing (ORP) Providers

Do not bill WV Medicaid directly
If ORP not enrolled in WV Medicaid, then servicing provider

claim will not be paid

Initially, edits will be implemented with warning message and

claim will not deny

After short period, edit will be set to deny claim
July 1, 2014 - both ORP edits implemented as warning
September 2014 - edit revised to look only for required ORP

information

December 2014 - edit for ORP information will be fully

implemented to deny AND edit for ORP enrollment status will be implemented as warning

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SLIDE 15

Provider Revalidation Payholds & Termination

All Providers must be revalidated by February 15, 2015

Notices for last phase (Phase 10) mailed last week
Phases 1 through 4 on payhold
WV Medicaid participation will be terminated 11/14/14
Phases 5 through 7 to be placed on payhold in November
Provider names, NPI and address will be posted on Molina and BMS

website for 2 weeks

After 2 weeks, payhold for 120 days
After 120 days on payhold – Participation with WV Medicaid will be

terminated

Partial Revalidation for Groups
Applies when outreach efforts to obtain missing information on rendering

and/or ordering/referring/prescribing providers are exhausted

Providers with complete information will be validated
Providers with missing information will have group affiliation terminated
Group will receive notification

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SLIDE 16

BMS Program Integrity

Several reviews:

Payment Error Rate Measurement (PERM) 2013
Completed but final error rate for WV not released yet
Only 2 of 284 providers reviewed had error in documentation

resulting in recoupment

Medicaid Integrity Group (MIG) Audits
Draft reports from onsite hospice review being developed by CMS
Recovery Audit Contractor (RAC)
Electronic Health Record (EHR) Audit
Questionnaire to Select Providers, followed by Reports to

Document Compliance with Meaningful Use Requirements

Enhanced Payments to Primary Care
Annual audit underway
Medicare-Medicaid Data Match

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Reminders

Claims, coding, etc.

Assistant surgeon or assistant at surgery
Operative record required for certain surgical procedures
Procedures identified on BMS RBRVS Fee Schedule with “D”

under “ASST SURG” Column

Modifier –AS for Advanced Practice RN or Physician Assistant
Modifiers -80, -81 and -82 for assistant surgeon

DME Claims

Cost invoice required for certain DME and for “not otherwise

specified” HCPCS Codes, such as L5999

BMS DME Fee schedules for 2012, 2013 and 2014 at

http://www.dhhr.wv.gov/bms/Pages/Durable-Medical- Equipment-(DME)-Fee-Schedule.aspx

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Choosing Wisely in WV

National Initiative of American Board of Internal Medicine Foundation

Goal is to promote patients and health care providers working

together and having meaningful discussions on the appropriate and wise use of health care to improve the quality of health care and contain cost.

Over 60 physician specialty groups and health care organizations

involved

Each identified at least five (5) tests, procedures or drugs in their area
f expertise that have questionable value.
250 low-value procedures have been identified, such as:
Using antibiotics for a viral infection
Imaging for uncomplicated low-back pain
Thirty-one two-page summaries available for providers to print and

give to patients on these low-value services, plus other helpful discussion guides for consumers

To print summaries/guides go to

http://consumerhealthchoices.org/choosing-wisely-west-virginia/

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WV CARES

WV Clearance for Access: Registry & Employment Screening (WV CARES)

Provision under Affordable Care Act of 2010
All direct access employees are required to undergo a

comprehensive fingerprint-based background check.

Required Registry Checks
Criminal Background Checks
Legislation to be introduced in the 2015 Legislative Session
Will authorize the WV CARES staff to receive criminal

background check results.

WV CARES staff will perform fitness determination for

prospective new long-term care employees.

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WV CARES System

Web-based system to be implemented in 2 phases
Phase 1 - Allows employers to conduct required registry checks
Current employee upload function
Conducts monthly required registry rechecks
Initial provider pilot testing – November 2014
Phase-In Process for all long term care providers – December

2014

Phase 2 – Fitness determination based on Fingerprint-based

Background Check

Dependent on Passage of Legislation

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