2017 Blue's Tour Presented by: Blue Cross and Blue Shield of Kansas - - PowerPoint PPT Presentation

2017 Blue's Tour

Presented by: Blue Cross and Blue Shield of Kansas

Presenters Include:

Sally Stevens

Institutional Provider Consultant, Southern Kansas

Cindy Garrison

Institutional Provider Consultant, Northern Kansas

Jessica Moore

Institutional Education and Communication Coordinator

Marie Burdiek

EDI Account Representative

Agenda

• BCBSKS Institutional Policy and Procedure Changes
• Quality-Based Reimbursement Program (QBRP) Updates
• Updates and Reminders
• Top Denials
• Self Service Tools
• EDI Updates

Presented by: Sally Stevens Institutional Provider Consultant

2018 Summary of Changes

• The following is a summary of the changes to the BCBSKS

Institutional Policies and Procedures for 2018. Deleted wording is noted in brackets [italicized].

• New verbiage is identified in bold. Language moved within the

document is noted as underlined.

• With the redesign of our Policies and Procedures for 2018, two

new sections have been added (Claims and Credentialing). Sections and provisions are also rearranged for readability, however no content / language has changed unless outlined within this summary document.

2018 Summary of Changes

Page 6: Updated language to better clarify the intent of this provision. 1.6 Wholly Owned Subsidiaries Any entity which provides and/or bills members and/or BCBSKS for health care services, which advertises or represents itself to the general public as being owned/owning, controlled/controlling, managed/managing, affiliated with, or operated by a Contracting Provider, must also be contracting with BCBSKS, unless

• therwise permitted by BCBSKS. Failure of such providers to contract with

BCBSKS shall be considered cause for termination of the Agreement in accordance with Section V, paragraph 2 of the Agreement. This provision is applicable to entities serving members in the same general locale as those served by the Contracting Provider.

2018 Summary of Changes

DEFINITIONS

Page 7: Added the definition "For Cause." 2.6 For Cause Includes, but is not limited to any of the following (1) breach of contract; (2) a civil case ruling, settlement in a civil or criminal matter, a verdict or plea of nolo contendre and/or any other instance determined by BCBSKS as moral turpitude; and/or (3) any act of defamation, slander, and libel toward BCBSKS and it's subsidiaries (as determined by BCBSKS).

2018 Summary of Changes

CLAIMS

Page 9: Added verbiage as notification that employee groups may impose alternate timely filing requirements.

3.4 Timely Filing Initial billings must be submitted to BCBSKS within one year, three months (15 months) from the date of discharge or the date of outpatient services. In the event initial billings for covered services are not submitted timely, deductibles, coinsurance and shared payments may be recovered from the member [when approved by BCBSKS]. The [all other balances as it relates to these initial billings will be a write-off to the] Contracting Provider must write off all other balances. When BCBSKS becomes aware, BCBSKS will notify Contracting Providers when employee groups impose alternate timely filing requirements. [Notification will be provided when employee groups impose alternate timely filing and claim assessment requirements. Failure to meet those requirements will result in claim denial.]

2018 Summary of Changes

Page 10: Clarified existing language specific to remittance advice.

3.8 Remittance Advice BCBSKS sends to the Contracting Provider notification regarding claim payment and claim denials via the remittance advice. The remittance advice will indicate whether the charges for denied services may be billed to the Member or if the Contracting Provider must write off the charges. Charges for services excluded from coverage by the Member's contract may be billed to the Member. Charges for services that are deemed to be not medically necessary or experimental / investigational by BCBSKS may not be billed to the Member unless the patient was given advance notice and signed a Limited Patient Waiver prior to the service. More information regarding coverage of services can be found in the BCBSKS Medical Policies, BCBSKS newsletters and in the Institutional Provider Manual. [The Contracting Provider will be informed through the remittance advice of services not included as covered benefits under the various member contracts. BCBSKS will also identify the amounts for these services which can be billed directly to the member. All such charges shall be included in the total charges billable to BCBSKS. Services that are not covered benefits and either billable or non- billable to the member and claim submission procedures for those services are identified in the BCBSKS Institutional Provider Manual or BCBSKS newsletters.]

2018 Summary of Changes

GENERAL CONDITIONS

Page 13: Updated language for clarity. 5.1 Audit Requirements Post-Pay Audits: BCBSKS conducts periodic post-payment audits of patient records and adjudicated claims to verify congruence with BCBSKS medical and payment policies, including medical necessity and established standards of care. Post-payment audits are performed after the service(s) is billed to BCBSKS and payment(s) has been received by the provider. Post-payment audits can range from a basic audit to determine if the level of care is accurately billed, to a complete audit which thoroughly examines all aspects of the medical record. [BCBSKS cannot go back further than 15 months following the date of claim adjudication to initiate an audit.] BCBSKS will not initiate audits more than 15 months following the date of claim adjudication. Post-payment audits being performed to resolve an allegation of fraud or abuse are not subject to the 15 month limitation.

2018 Summary of Changes

MEDICAL AND UTILIZATION REVIEW

Page 16: Added language regarding the use of alternative waivers. 6.2 Medical Necessity …The Contracting Provider shall not bill members for services which have been determined medically unnecessary, experimental/investigational, have been denied due to Utilization Review, and/or are patient demanded services unless the member has been given written notification in advance of services being provided, that specific services will be the member's

• responsibility. Contracting Providers are strongly encouraged to use the Limited Patient Waiver

(LPW). However, if the Contracting Provider wishes to use an alternate waiver, the Contracting Provider must obtain prior approval from BCBSKS. Generic or all- encompassing notifications without advanced written authorization by BCBSKS shall not be deemed to meet the specific notification requirement mentioned above. In instances where medical necessity is questionable, the Contracting Provider may contact BCBSKS medical review department for a predetermination of coverage. This provision applies to inpatient,

• utpatient and partial-day services.

2018 Summary of Changes

Page 16: Added language regarding the use of alternative waivers. Continued: [All claims for services for which the member has been given a LPW shall be submitted on a paper claim form with the LPW form attached. Charges shall be billed as non-covered.] If a [the] member does not want a [the] claim to be filed, obtain this instruction in writing from the member and keep it on file with the LPW. For additional information and a copy of the LPW form, refer to the BCBSKS Institutional Provider Manual.

2018 Summary of Changes

Page 19-20: Removed redundant language from this provision. 6.9 Inpatient Claim Reviews Reviews may be conducted to determine medical necessity, which may include but not be limited to the following:

• 1. Patterns of practice within the hospital's medical staff that deviate from the norms as seen

in other Kansas hospitals

• 2. Re-admission frequencies
• 3. Assignment and reporting of principal diagnosis, procedures and other criteria used in

assigning the MS-DRG for payment

• 4. [Mental and substance use disorder MS-DRG MAPs are limited to the inlier MAP where

the number of covered days is less than the high trim point, regardless of the patient's actual length of stay. In the event that the number of covered days exceeds the high trim point, the

• utlier MAP will be limited to the number of covered days, even though the patient may have

stayed longer. Charges for services provided on days where no coverage exists may be billed to the Member.]

2018 Summary of Changes

REQUESTS FOR INFORMATION

Page 20: Added language describing claim adjudication when requested medical records are not received.

7.2 Medical Records The Contracting Provider must provide or make available complete medical records at no charge in a format which can be utilized by BCBSKS or an entity acting on behalf of BCBSKS. When medical records are requested to substantiate a claim for services, each patient record must contain adequate documentation to justify the course of treatment provided and reflect the patient's status and progress during the course of treatment. Medical records shall include all versions, whether handwritten or Electronic Medical Record (EMR) generated. Any applicable audit log documentation must be provided if requested by BCBSKS. In most instances, BCBSKS will allow 30 calendar days for the production of the requested records. Failure to send the requested documentation

• r providing insufficient documentation to determine medical necessity may result in a claim

denial and accordingly a provider write off.

2018 Summary of Changes

DISPUTES/APPEALS/ARBITRATION

Page 22: Re-worded language in Section 8.5 and 8.6. The intent of the provision has not changed. 8.5 Member Appeals [Claims Denials After Limited Patient Waiver is Given] If the patient has signed a LPW, the [when] claim[s are] will be denied as member responsibility,. The Contracting Provider may assist the member with an appeal as the member's authorized

• representative. In such circumstances, the Contracting Provider must follow the guidelines

established by the Employee Retirement Income Security Act of 1974 (ERISA) and/or the benefit plan documents applicable to the member. The provider appeal process described herein does not apply.

2018 Summary of Changes

Page 22: Re-worded language in Section 8.5 and 8.6. The intent of the provision has not changed.

Continued: 8.6 Provider Appeals for Experimental/Investigational or Not Medically Necessary Services When BCBSKS denies claims as experimental and investigational or not medically necessary, unless the patient has signed a LPW, the Contracting Provider shall not bill the member for the denied charges. [Claim Denial When Limited Patient Waiver Is Not Given. The guidelines in this section apply when services have been denied and a Limited Patient Waiver (LPW) has not been signed by the patient. When this occurs, the Contracting Provider may not bill the member for the denied charges. This would be true if the service is determined to be not medically necessary of if the service is experimental/investigational.]

2018 Summary of Changes

AMENDMENTS TO SIGNED PROVIDER AGREEMENT

Page 27: Updated language to reflect the current law. 9.6 Acknowledgement of K.S.A. 44-1030 [Kansas Act Against Discrimination]

[The Contracting Provider shall observe the provisions of the Kansas Act Against Discrimination, to the extent applicable to the Contracting Provider given the nature of the Contracting Provider's activities within the State of Kansas, and shall not, in any event, discriminate against any person in the performance of work under the contract between Contracting Provider and BCBSKS because of race, color, religion, sex, physical handicap unrelated to such person's ability to engage in the particular work, national origin, or ancestry. In all solicitations or advertisements for employees, the Contracting Provider shall include the phrase "Equal Employment Opportunity Employer," or a similar phrase as approved by the Kansas Commission of Civil

• Rights. If the reporting obligations of K.S.A. 44-1031 apply to the Contracting Provider and if the Contracting

Provider fails to report to the Kansas Commission on Civil Rights in accordance with the provisions of such statute upon request, the Contracting Provider shall be deemed to have breached this Agreement and this Agreement may be cancelled, terminated or suspended, in whole or in part, by BCBSKS. If the Contracting Provider is found guilty of a violation of the Kansas Act Against Discrimination under a decision or order of the Kansas Commission on Civil Rights which has become final, the Contracting Provider shall be deemed to have breached this Agreement and it may be cancelled, terminated or suspended, in whole or in part, by BCBSKS.]

2018 Summary of Changes

Page 27: Updated language to reflect the current law.

Continued: As a provider of services to the State of Kansas and to counties, municipalities and other state governmental units, BCBSKS is required by K.S.A. 44-1030 to observe the provisions of the Kansas Act Against Discrimination, not to discriminate against any person in the performance of work because of race, religion, color, sex, disability, national origin or ancestry, to include the phrase "equal opportunity employer" or a similar phrase in advertisements for employees, and to require in any contracts BCBSKS has with others that such others shall also abide by such provisions, and that if such contractors are found guilty of a violation of the Kansas Act Against Discrimination, such contractors shall be deemed to have breached their contracts with BCBSKS and the contract may be canceled, terminated or suspended in whole or in part. The contracting provider agrees that is shall abide by the 18 foregoing provisions. As a provider of services for qualified health plans, any entity that operates a health program or activity, any part that receives Federal financial assistance is required by Section 1557 of the Patient Protection and Affordable Care Act, and its implementing regulations published by the Office of Civil Rights, to not discriminate against any person on the basis of race, color, national origin, sex, gender identity, age, or disability, to accommodate individuals with limited English proficiency. Any entities that are found to have discriminated in violation of Section 1557, and its implementing regulations, can be subject to a private right of action. The contracting provider agrees that it shall abide by the foregoing provisions.

2018 Summary of Changes

PAYMENT ATTACHMENT

Page 3: Provision re-worded for clarity. 1.3 Reimbursement for Quality Transparency and Quality Reporting [In addition to, or in lieu of, the3 maximum allowable payment (MAP) as referenced elsewhere in any BCBSKS Policy & Procedure,] BCBSKS may establish reimbursement criteria based on quality components. Such components may be used to monitor performance and reward providers for meeting quality benchmarks. BCBSKS will communicate quality criteria and corresponding reimbursement changes to Contracting Providers in advance of the effective date. BCBSKS may publish the Contracting Providers' performance of the quality metrics [to reward providers for meeting specified performance levels, or quality initiatives and programs to monitor and report performance results of participating providers, and make available such results in web-based and/or written form} to the general public, enrolled employer groups, and/or members via web- based and/or written communication. [Such criteria and corresponding reimbursement changes will be communicated in advance of the effective date.]

2018 Summary of Changes

PAYMENT ATTACHMENT

Page 4: Removed obsolete language related to the hierarchy of outliers. 1.6 Day Outliers [Length of Stay Below the Low Trim Point – Charges will be recognized for medically necessary services up to the maximum allowable payment (MAP) for the specific Medicare Severity Diagnostic Related Group (MS-DRG).] [Length of Stay Above the High Trim Point – ] Charges will be recognized for medically necessary services up to the MAP for the specific MS-DRG. In addition, a per diem consisting of the MAP for the specific MS-DRG divided by the high Trim Point for that MS- DRG will be allowed for each medically necessary day beyond the high Trim Point. MAP high Trim Point x patient length of stay = MAP for day outliers. [Outlier Due to Transfers of Patients Leaving Against Medical Advice-Charges will be recognized for medically necessary services up to the MS-DRG MAP. Claims for admissions involving more than one outlier will be paid using the MAP for the most significant outlier. The hierarchy of outliers is:

2018 Summary of Changes

PAYMENT ATTACHMENT

Page 4: Removed obsolete language related to the hierarchy of outliers. Continued: Claims for admissions involving more than one outlier will be paid using the MAP for the most significant outlier. The hierarchy of outliers is:

• 1. Length of stay above or below specified trim point - Reimbursement will be charges up to

MAP plus the daily per diem for each day beyond the high trim point. For days below the trim point, reimbursement will be charges up to the MAP.

• 2. Transfers of patients to other hospitals - Reimbursement will be charges up to the MAP.
• 3. Patients leaving against medical advice - Reimbursement will be charges up to the MAP.
• 4. Patients having unrelated conditions treated during hospitalization –Reimbursement will be

charges up to the MAP.

• 5. Patient becomes deceased – Reimbursement will be charges up to the MAP.]

2018 Summary of Changes

PAYMENT ATTACHMENT

Page 5: Provision re-named for clarity. 1.8 Exhaustion of Medicare Benefits [Medigap Allowable Payment] Upon exhaustion of the Medicare hospital inpatient coverage including the lifetime reserve days, coverage of the Medicare Part A eligible expenses for hospitalization is paid at the approved BCBSKS inpatient payment rates less any Medicare payment amounts subject to a lifetime maximum benefit of an additional 365 days.

2018 Summary of Changes

PAYMENT ATTACHMENT

Page 7: Paragraph moved from Inpatient Claims provision to Rehabilitation and Psychiatric Units provision as language belongs in the latter provision. There was no change in the language. 1.11 Rehabilitation and Psychiatric Units Acute care hospitals that have obtained separate National Provider Identifier(s) (NPIs) for their Medicare-certified rehabilitation or psychiatric units will submit separate claims for these inpatient admissions. Reimbursement will be a per diem for each covered day. Hospitals that have not obtained separate NPIs for their Medicare-certified rehabilitation or psychiatric units or when this type of care is provided in the acute hospital area instead of the certified unit, will submit claims for inpatient admissions using the acute hospital NPI. For inpatient claims reflecting charges for both medical and rehabilitation admissions, a daily allowance will apply for each day that a patient resides in that rehabilitation unit. This allowance applies when the initial MS-DRG is other than 945 or 946.

2018 Summary of Changes

PAYMENT ATTACHMENT

Page 11: Language reworded to clarify that while the claim level reimbursement MAP will not be used to price the entire claim. Line level pricing may include MAPs for the services billed. 1.31 Outpatient Claim Level Reimbursement Payment for outpatient claim level procedures will be reimbursed at an all-inclusive rate based on the MAP for the procedure

• billed. When multiple procedures are performed during the same encounter, the all-inclusive

rate is based on the highest MAP'd claim level code. All services provided during an

• utpatient encounter will be reimbursed at the aforementioned all-inclusive rate and must

be billed on the same claim. Outpatient services resulting from an accidental injury that occurred on the same day may not be subject to claim level reimbursement. [will be reimbursed at the contracted charges less discount and will not be subject to the claim level MAP.]

QBRP UPDATES

Estimated QBRP paid to facilities in 2016

• QBRP amount paid Inpatient $ 12,712,676.28
• QBRP amount paid Outpatient $ 22,621,155.29
• Total QBRP paid to facilities $ 35,333,831.57

QBRP UPDATES

New/Updated Measures

Surviving Sepsis Campaign

• Based on Kansas Health Collaborative Hospital Improvement Innovation Network

3-hour bundle

• Detailed information on this measure is found on the QBRP portal

Low Volume Incentive

• Tiered levels
• 4% for each event up to 20% for 1,000 and fewer days
• 3% for each event up to 15% for 1,001 to 1,300 days
• 2% for each event up to 10% for 1,301 to 1,500 days
• 1% for each event up to 5% for 1,501 to 1,700 days

QBRP UPDATES

Precertification/ Continued Stay Review

• Period 1- May 1- October 31, 2017
• Period 2- November 1- April 30, 2018

Period 1 Data Reporting

• Close of business - November 5, 2017
• Effective date - January 1, 2018

Period 2 Data Reporting

• Close of Business - May 5, 2018
• Effective date - July 1, 2018

QBRP UPDATES

BIG CHANGE FOR 2018

• QBRP will be applied to Lab services when Lab MAP applies
• MAP does not apply
• Rev 450/762
• Claim level pricing- labs not "add-on"

Telemedicine vs Telehealth

Telemedicine

• Two-way, real time interactive communication
• Between the patient and the physician or practitioner
• Equipment that includes, at a minimum, audio and video equipment.
• Approved by BCBSKS
• Distant site: Site at which the physician or other licensed practitioner delivering the service

is located at the time the service is provided via telecommunications system.

• Professional provider bills services on CMS 1500 form
• TIN and NPI must be different than the originating site
• Originating site: Location (Revenue Center of the hospital) of the patient at the time the

service being furnished via a telecommunications system occurs.

• Facility bills for use of room on UB04
• TIN and NPI must be different than the distant site

Telemedicine vs Telehealth

Billing BCBSKS for Telemedicine Services

• Specialty not otherwise available in the community
• including services by Mid-level Practitioner
• Primary care service are not covered
• Billable only on outpatient claims.
• Revenue code either:
• 0780 (telemedicine general classification or revenue)
• Revenue code that identifies where the services was performed (i.e. 0450 – emergency room;

0510 – clinic)

• Report HCPCS Q3014,
• Additional services (e.g. laboratory, x-rays, etc.) are separately billable.

Telemedicine vs Telehealth

Telehealth

• Virtual medical services
• Anytime, anywhere
• Currently only certain employer groups with BCBSKS have access
• Services contracted through American Well
• Telehealth services are not billable to BCBSKS

Air Ambulance

Participating Air Ambulance Providers

• LifeStar of Kansas
• LifeTeam
• AMR Air Ambulance
• Alacura

Air Ambulance Map

Presented by: Cindy Garrison Institutional Provider Consultant

Preventive Services

• Preventive Services

▫ PPACA members have no cost share ▫ Availity will show the benefit

Preventive Services (cont.)

• Preventive Service Guide on the Web
• Change implemented 7/16/17
• We do not need multiple claims
• Preventive diagnosis MUST be in the primary position
• IPM Updated

Exclusive Provider Organization Network (EPO)

Effective January 1, 2018

• XSN – Individual On Exchange
• XSZ – Individual Off Exchange
• XSY – Small Group SHOP
• KSA – Small Group Off SHOP

Records Request Letters

• Fewer Letters
• Request on the RA
• CARC= A1
• Washington Publishing Company (WPC)

Records Request (Examples)

Records Request (Examples) cont.

Observation Services

• Physician ordered
• Medically necessary
• Be unscheduled
• Billed with revenue code 762 and valid observation HCPCS/CPT code
• No hourly limitation
• Reimbursement
• Payment limited to one average semi-private room rate or the charge whichever is less.

Observation Services Added to Inpatient Claim

• FL 6- Statement Covers Period (FROM/THROUGH)
• FL 12- Admit Date
• Bundling Rule
• Outpatient services provided before midnight of the following day

preceding the admission.

Observation Services Added to Inpatient Claim (example)

Room Rate Filing

• Updated annually
• When bed counts change
• When rates change
• Available on the Web – www.bcbsks.com

• Submit form
• Print form
• Confirmation email
• Effective first of the month following notification

Billing for Inpatient Room

• First line is the Room and Board
• Private room only
• Value code 002
• Newsletter: BC-14-3

1 Claim vs 2 Claims

• Series Bill
• Reimbursement

1 Claim vs. 2 Claims (example)

Corrected Claims

• Definition
• BCBSKS =A request made from a Contracting Provider to change a claim

(e.g., changing information on the service line, diagnosis correction, etc.) that has previously processed.

• What's not a corrected claim
• TOB XX5 vs. XX7
• One claim
• Impacts Reimbursement

Off-Site Services

• Definition
• Merriam-Webster: away from the place of business or activity.

Printing of our manual is done off-site.

• BCBSKS: Services provided off-site of the physical presence of the

main hospital campus.

Split Claim

• Baby covered for the first 5 days
• Inpatient stay expands Benefit Period
• Coverage terminated
• Inpatient stay is => 60 days
• Use status code 30

Statewide Top Denials

$0.00 $20,000,000.00 $40,000,000.00 $60,000,000.00 $80,000,000.00 $100,000,000.00 $120,000,000.00 Corrected claim Record request ICD-10 laterality Canceled claim Claim/Service denied. Exact duplicate claim/service Non-covered charge(s). Our records indicate that this dependent is not an eligible dependent as defined. Non-covered charge(s). Bluecard Expenses incurred after coverage terminated. Information requested from the patient/insured/responsible party was not provided or was insufficient/incomplete. 2016 2017

Presented by: Jessica Moore Education and Communication Coordinator

Self Service Tools Demonstration

• Web Resources
• Bcbsks.com
• Availity
• E-News
• Newsletters
• Workshops
• BCBSKS Medical Policies
• Precertification
• FEP Medical Policies

QUESTIONS?