Medicare/Medicaid
Special Report on Medicare
GAFP leaders encourage you to get involved in changing the current payment system for Medicare.
EHR Demonstration Cancelled in Georgia
On April 7, 2009, the Centers for Medicare & Medicaid Services (CMS) announced that it will not implement Phase II of the Electronic Health Record (EHR) Demonstration. Georgia was to be a Phase II participant. On February 17, 2009, President Obama signed into law the American Recovery and Reinvestment Act of 2009 (Recovery Act) which provides approximately $19 billion for the development and adoption of Health Information Technology (HIT). According to James Truesdale, Program Director, Georgia Department of Community Health, Office of Health Information Technology & Transparency (HITT), CMS has determined that Phase II operations are similar to the functions of the Recovery Act. Therefore, to provide funding for the EHR Demonstration Project would duplicate the funding provided by the Recovery Act. For additional information, visit the CMS website: http://www.cms.hhs.gov/DemoProjectsEvalRpts/md/ then select Electronic Health Records Demonstration
Medical Dental Coverage for Medicaid Patients
An overview of Medical Dental Coverage was provided in a recent publication from Healthy Mothers, Healthy Babies Coalition of Georgia. Medicaid program service requirements are highlighted below.
For individuals under the age of 21 who are Medicaid-eligible, dental services are a required component under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. The EPSDT is a mandatory service required to be provided under the state’s Medicaid program. Services must include treatment for relief of pain and infections, restoration of teeth and maintenance of dental health.
Oral screening, as part of a physical exam by a medical doctor, does not substitute a dental examination performed by a dentist. A dental referral is required for every child in accordance with the periodicity schedule set by the state.
EPSDT requires that all services covered under the Medicaid program must be provided if determined to be medically necessary. Under the Medicaid program, the state determines medical necessity. Furthermore, if a condition requiring treatment is discovered during a screening, the state must provide the necessary services to treat that condition, whether or not such services are included in the state’s Medicaid plan.
For individuals age 21 and older, most states, including Georgia, provide at least emergency dental services. Georgia also provides dental coverage for pregnant women with Medicaid. Less than half of the states, however, provide comprehensive dental care. There are no minimal requirements for adult dental coverage.
For more information and dental coverage visit http://www.cms.hhs.gov/MedicaidDentalCoverage/
May 20, 2009
DCH Launches Hotline To Help With CMO Issues
Having trouble attaining a resolution for an issue with a Care Management Organization (CMO)? The Department of Community Health (DCH) has launched a provider’s hotline to assist you with those issues. However, this should not be the first line of communication. Please attempt to resolve the issue with the CMO prior to calling the hotline.
The Georgia Families Hotline number is: (404) 651-8363, or toll-free at (888) 943-5743. You may also submit inquiries to info@atlanticpkg.com.
The Georgia Families program is a partnership between DCH and private CMOs to ensure accessible and quality health care for all Medicaid managed care members. For more information, visit www.georgia-familes.com/en_US/home.htm.
January 19, 2009
What To Do When The Medicare Auditor Calls You
By Jennifer D. Malinovsky, Esq.
Nelson Mullins Riley & Scarborough, LLP
The Recovery Audit Contractor (RAC) program is the latest tool utilized by the Centers for Medicare and Medicaid Services (CMS) for identifying and recouping Medicare overpayments from Medicare providers, including physicians. The RAC program fully implements nationwide by Jan. 1, 2010; Georgia is in the last group slated to come online, in January 2009 or later.
An RAC must identify Medicare claims that contain “improper payments,” which might include:
* incorrect payment amounts;
* non-covered services, including services that are not reasonable and necessary;
* incorrectly coded services;
* duplicate services.
An RAC must have “good cause” to reopen a claim, and it may not reopen a claim paid prior to Oct. 1, 2007. An RAC review may be either automated (claim review utilizing proprietary software) or complex (human reviews of medical records).
How Can You Prepare For An RAC Review?
* Make sure your practice has an effective compliance program in place for billing and coding, reasonable and necessary services, documentation and improper inducements. Self-policing can be critical in preparing for voluntary and involuntary external audits. RAC reviews are focused on “low-hanging” fruit.”
* Incorporate an RAC review policy into your practice’s compliance
program:
* Determine a process for
responding to a medical record
request from a RAC;
* Create an internal system to
track the RAC audit process;
* Educate your staff on the
RAC review process;
* Prepare and plan for appeals.
What Should You Do When An RAC Calls You?
* First: Notify your attorney to discuss the method and manner of response and required response time;
* Second: Assemble your team to organize the response process;
* Third: Compile the requested documentation in an organized manner;
* Fourth: Regroup with your team prior to submitting your response.
While not easy to deal with, the RAC program is likely here to stay. However, your practice can take proactive measures to prepare for a potential RAC review to make the process more manageable while you continue to operate your practice and provide care to your patients.
January 19, 2009
Increase in Medicare Payments and Part IV Credit for ABFM Recertification
Beginning September 2008, ABFM Diplomates may use the Diabetes Module developed specifically for this purpose by the ABFM to collect and submit data to the Registry on a set of either 30 or 15 consecutive patients with either Type 1 or Type 2 Diabetes. Not all patients in these samples must be Medicare patients, but at least two Medicare Part B beneficiaries must be included in the Diplomate’s sample.
For 2008, physicians who meet the criteria for satisfactory submission of quality measures data for 30 consecutive patients will earn an incentive payment of 1.5 percent of their total allowed charges for Physician Fee Schedule (PFS) covered professional services furnished during the reporting period, January 1, 2008 – December 31, 2008 (the 2008 calendar year). Alternatively, those physicians who meet the criteria for satisfactory submission of quality measures data for 15 consecutive patients will earn an incentive payment of 1.5 percent of their total allowed charges for PFS covered professional services furnished during the reporting period, July 1, 2008 – December 31, 2008. CMS approved financial incentives earned for 2008 reporting are scheduled to be paid in mid-2009 from the Federal Supplementary Medical Insurance (Part B) Trust Fund.
This module may be accessed without fee for use in participating in PQRI. However, Diplomates who are participating in MC-FP and elect to complete this module to receive Part IV credit will be required to submit the appropriate MC-FP fee, depending on which payment plan they have chosen. Additional information regarding PQRI and the Diabetes Module can be found on the ABFM website, www.theabfm.org.
November 20, 2008
Medicaid Managed Care Update
Amerigroup Community Care - Member can request re-assignment to a new PCP at any time. Re-assignment will occur on the day of request.
Peach State Health Plan - The member can request re-assignment to a new PCP at any time. The re-assignment will occur on the first day of the following month. However, Peach State will pay for primary care office visits with any network PCP, regardless of assignment.
Wellcare of Georgia - The member can request re-assignment to a new PCP at any time. Requests that occur prior to the 10th day of the month will be made retroactive to the first day of the month. Requests that occur after the 10th day of the month will become effective the first day of the following month. However, Wellcare will pay for primary care office visits with any network PCP, regardless of assignment. Questions and concerns related to CMO credentialing should first be addressed with your CMO provider relations representative. Escalated concerns can be addressed as follows:
Amerigroup - Kiya Harrison at kharri4@amerigroupcorp.com
Peachtree State Health Plan - Credentialing coordinator at (678) 556-2332
Wellcare - contact your regional area director:
* Marla Gould, regional director (SE), (912) 233-2112, ext. 3601;
* Beth Nunnally, regional director (SW), (229) 888-9627;
* Julie Gramoll, regional director (North), (770) 532-6334, ext. 3554;
* Doug Rodgers, regional director (Central), (706) 324-0824, ext. 0824;
* Tracy Smith, provider relations manager (Atlanta), (678) 327-0952;
* James Johnson, provider relations manager (Atlanta), (678) 327-0953.
October 20, 2008
Out-Of-State Medicaid Recipients Might Be Displaced To Georgia
Medicaid recipients from Louisiana and Mississippi may be displaced to Georgia as a result of Hurricane Gustav. However, Georgia Medicaid is not adding them to the state’s eligibility files. In fact, both states have developed abbreviated enrollment forms and processes to get Georgia providers enrolled as Louisiana or Mississippi Medicaid providers as soon as possible.
Louisiana Medicaid: Providers who wish to enroll in Louisiana Medicaid and were not enrolled as a Katrina provider can go to www.dhh.louisiana.gov/offices/?ID=92. and click on “Gustav” (in black font with a circle), then scroll down to “Medicaid Providers” for instructions for enrolling as an entity as well as an individual provider. Providers who were enrolled in Louisiana Medicaid for the Katrina disaster can send an e-mail to jphilli2@dhh.la.gov with their Katrina provider number and NPI number, and Louisiana Medicaid will activate their Katrina provider number.
Mississippi Medicaid: Providers who wish to enroll in Mississippi Medicaid should complete the Emergency Provider Enrollment Form at http://www.medicaid.state.ms.us/. Instructions for completing the form are at the same Web site address.
October 20, 2008
MEDICARE IN CRISIS: KEEP YOUR OFFICE DOOR OPEN!
Dear Colleague:
Unless you take action, your Medicare payments will be cut 10.6% on July 1, 2008 and then an additional 5% cut in 2009. Many primary care physicians, including both of us, will not be able to keep their office doors open for Medicare recipients.
Are you tired of this ‘unfunded mandate' that primary care physicians absorb disproportionately in caring for our nation's poor and elderly? Have you reached the point of ‘doing something' about it?
Then join us in demanding that Congress: 1) Immediately stop the upcoming July 1, 2008 and January 1, 2009 cuts; 2) Declare an 18 month positive payment update and use that time to work on a replacement for the Sustainable Growth Rate which accurately and fairly reflects both the value of primary care medicine and our actual cost of doing business.
We have provided the necessary tools for you to join us in demanding these actions of our members of Congress. All you need to do is:
1) "Speak out". Talk to your patients about the problem and urge them to join you in speaking out.
2) Write letters to your members of Congress.
3) Submit an op-ed article to your local newspaper(s).
4) Urge your patients to sign a petition to Congress to stop the cuts.
5) Urge your patients to write Congress.
6) Place a poster in your office.
Help us stop the cuts so that we can keep your office door open for your patients.
Best regards,
Howard C. McMahan, MD, FAAFP
GA Academy Family Physicians
Jacqueline W. Fincher, MD, FACP
GA Chapter American College of Physicians
P.S. Names and addresses of Georgia's Congressional Delegation: http://capitol.aafp.org/
May 12, 2008
Medicare Carrier Advisory Committee Meeting Review
by Brian Nadolne, MD • GAFP Representative
Please review the highlights of the quarterly Medicare meeting that took place at the end of February. If you have any questions or concerns that you would like me to take to Medicare on behalf of Georgia family physicians, please do not hesitate to contact me at gafp@gafp.org.
* Medicare PQRI • Physician Quality Reporting Initiative is a new program that all family physicians who accept Medicare should be aware of because you could earn an additional increase of 1.5 percent for your Medicare reimbursement. The PQRI manual is quite extensive and must be reviewed to understand the requirements for reimbursement. For more information, visit www.cms.hhs.gov/PQRI.
* Payment for Zostavax • Another issue brought up was the possibility of Medicare paying for Zostavax. This will not happen unless it passes through the proper legislative channels. This same process was necessary for both Influenza and Pneumovax vaccine administration payment.
* Wound Debridement • Another topic discussed was reimbursement for improper coding and documentation upon debridement of wounds. Members need to read the CPT book and make sure they document properly. Medicare is continuing to audit, focusing on debridement.
May 28, 2008
Academy Joins Forces with ACCESS Healthcare Coalition
GAFP has joined the ACCESS Coalition along with several other associations and community groups, including the Georgia Chamber of Commerce, Association of County Commissioners of Georgia, Georgia Hospital Association, American Academy of Pediatrics - Georgia Chapter, American College of Physicians - Georgia Chapter, Georgia Dental Association, Georgia Health Care Association, Georgia OB/GYN Society, Georgia Pharmacy Association and Georgia Coalition of Children’s Hospitals.
The Coalition focuses on how underpayment for Medicaid patients increases prices for everyone as family physicians and other medical groups look to make up for the money they lose on the state program. The Coalition will ask the state to increase its financial commitment to the Georgia Medicaid program.
So far, the program has hosted regular meetings with leaders from these organizations to define objectives for the collaboration. The Coalition has launched a media campaign that has included publishing an informational flier, Atlanta television coverage of a physician greatly affected by accepting Medicaid in his office and a legislative lunch with key representatives.
In addition, The Augusta Chronicle, The Florida Times-Union, the Savannah Morning News and other publications throughout the Southeast recently published an article recognizing the Georgia Academy of Family Physicians as part of the new ACCESS Healthcare Coalition.
The GAFP is encouraging family physicians to speak to the media on the need for increasing reimbursement for physicians.
February 26, 2008
Notice from Vaccines for Children
This article was recently emailed to all GAFP members on December 13, 2007.
As a result of a recent manufacturer-initiated precautionary vaccine recall, Vaccines for Children (VFC) providers are being asked to identify and follow instructions regarding the Merck vaccines listed below.
The lots that are being recalled are:
Product Description Lot # Expiration Date
PedvaxHIB® 0677U 11 January 2010
PedvaxHIB® 0820U 12 January 2010
PedvaxHIB® 0995U 16 January 2010
PedvaxHIB® 1164U 18 January 2010 DISTRIBUTED BY VFC
PedvaxHIB® 0259U 17 October 2009
PedvaxHIB® 0435U 18 October 2009 DISTRIBUTED BY VFC
PedvaxHIB® 0436U 19 October 2009
PedvaxHIB® 0437U 19 October 2009
PedvaxHIB® 0819U 09 January 2010
PedvaxHIB® 1167U 10 January 2010
COMVAX® 0376U 05 January 2010
COMVAX® 0377U 08 January 2010
All inventory matching this description needs to be removed from your refrigerator(s) immediately. There is no need to maintain the cold chain for the recalled lot numbers. Place the vaccine in a bag or box and clearly label “Do Not Use” and include a sheet of paper with the following information: VFC ID #, Inventory details (Lot Number(s), Expiration date, and number of doses). Include the word “RECALL” somewhere on the sheet. Immunization Program Consultants (IPC) will be arranging vaccine pick-ups of recalled vaccine. If you choose, you may also send vaccine back to the warehouse as you would other wasted vaccines.
The recall, initiated by the manufacturer, is precautionary. More information on the recall, including Q & A, is available at: http://www.cdc.gov/vaccines/recs/recalls/hib-recall-faqs-12-12-07.htm Please check this site regularly. Keep yourself and your staff informed so that questions from concerned parents are met with knowledge and compassion. You may also refer questions to the Georgia Immunization Program at (404) 657-3158.
February 11, 2008
Tamper-Resistant Prescription Pads will be required for Fee-For-Service Patients
The Georgia Medicaid Fee-For-Service Outpatient Pharmacy Program will require prescribers to use tamper-resistant prescription pads for any new prescriptions with fill dates on and after March 1, 2008. This requirement applies to hard copy prescription orders for any drug, device or product covered through the Medicaid FFS outpatient pharmacy program, whether legend or over-the-counter.
- Effective March 1, 2008, a prescription pad must contain at least one of the following three characteristics:
- Effective for dates of service on and after March 1, 2008, all prescription pads utilized for Medicaid FFS recipient prescriptions must comply with all three of these characteristics.
- Required tamper-resistant characteristics include one or more industry-recognized features designed to:
- Prevent unauthorized copying of a completed or blank prescription form.
- Prevent erasure or modification of information written on the prescription by the prescriber.
- Prevent the use of counterfeit prescription forms. Access To Care
Examples include but are not limited to:
- High security watermark on reverse side of blank;
- Thermochromic ink technology;
- Copied prescription blanks show the word copy, illegal or void.
- Tamper-resistant background ink shows erasures or attempts to change written information.
- Duplicate or triplicate blanks.
The intent of this program is to reduce forged and altered prescriptions and to deter drug abuse. It is not the intent of the program to inconvenience a person seeking to have a valid prescription filled. The provision of covered outpatient FFS pharmacy products written on a non-tamper-resistant prescription pad is allowed on an emergency basis (as defined by the dispensing pharmacist and in accordance with all applicable Medicaid policies, as well as state and federal laws). However, the dispensing pharmacist must obtain a verbal, faxed, electronic or compliant written prescription within 72 hours of the date the prescription was filled. Failure to secure this verification may result in recoupment of such claims. Note prescriptions filled on an emergency basis because they weren’t written or printed on a non-tamper-resistant prescription pad are not necessarily limited to a 72-hour supply. Exempt from the tamper-resistant requirement are Medicaid prescriptions that are:
- Paid by a Georgia Medicaid Care Management Organization (Amerigroup, WellCare, PeachState);
- Provided in nursing facilities or intermediate care facilities for the mentally retarded (ICF/MR) and the drug is reimbursed as part of a total service and is not reimbursed through the outpatient pharmacy program;
- Provided in any other institutional or clinical settings for which the drug is reimbursed as part of a total service and is not reimbursed through the outpatient pharmacy program;
- e-prescribed, faxed to the pharmacy from the prescriber’s office or telephoned to the pharmacy by the prescriber;
l Refills for which the original prescription was filled before March 1, 2008.
If you have any questions, contact the Division of Medical Assistance Pharmacy Services Unit at (404) 656-4044.
October 8, 2007
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