FLORIDA MCA PROVIDER EDUCATION BULLETIN APRIL

Transcription

1 NETWORK NOTES NEW REPORTING REQUIREMENTS Effective 6/1/2010, Coventry's Network directories will look slightly different. On April 12, 2010, the agency sent notice to all MCAs regarding modifications for web-based directories or provider search tools by June 1, Coventry will no longer list provider group names as a stand-alone entry in any medium unless Coventry has the entire group under contract. Instead, we will list individually contracted physicians within the group. The intent of the change is to eliminate confusion in identifying which providers participate in a group or under a group name. Effective 1/12/10, Rule 69L-7.602, F.A.C. for the FL WC medical services, billing, filing and reporting Requirements was adopted. The Rule reflects changes and updates to forms, reference materials, EDI requirements, and billing instructions for providers and insurers. PROVIDER SERVICES NOTES REQUESTS FOR UPFRONT FEES - HELP US TO HELP YOU! There appears to be a lot of noise from our clients and providers about requests for upfront fees in the market. There may be instances when additional reimbursement may be appropriate and necessary; however, these instances are limited. To avoid confusion, Coventry explains its response for these requests. When the request involves additional reimbursement for standard services, Coventry responds that fees for these services are already valued under the fee schedule and our Coventry contract PPO rate remains in force. In this scenario, it is not appropriate to request any further reimbursement for these services. When the request involves additional fees due to complex procedures, Coventry advises the provider that our existing contract defines the compensation for standard services; however, we acknowledge there are other considerations to accommodate additional compensation when the services represent more complex procedures using the applicable CPT billing codes. In these instances, Coventry advises the provider to revise their bill to reflect these correct CPT codes for the more complex procedures and to resubmit their bill to the payor. When a provider requests additional fees for non-standard, non-valued office procedures, these services have no associated CPT codes valued under the fee schedule. This is the limited scenario under which additional fees may be requested; however, the provider should clearly identify which services fall outside the non-valued codes so the payor is aware. The payor has the discretion to accept or deny the provider's fee request and/or redirect the injured worker to another Network provider. E-BILLING Are you connected? Coventry, in conjunction with our partner, Jopari Solutions, supports our stakeholders' ability for bill processing efficiencies, which go beyond green conscientiousness. Advantages include the ability 1

2 to track billing/receivables through the Jopari Portal with self-service functionality, 24 hours a day. Providers may view, download or print information, including elements on EOR/EOBs. In addition, providers may check the payment status of the bill or view the status including received, in process, or in review as well as pending, paid or denied. The Jopari Portal supplies the flexibility and support needed to better manage your financials including the services named above plus appeals and reconsideration services through an automated two way messaging system, which includes electronic document attachment processing, designed to smooth appeal resolution and minimize frictional costs associated with reconsideration processing. If you are not registered with Jopari Solutions to send bills electronically, or are unsure if your ebill Agent or clearinghouse has connectivity, please contact Jopari Customer Service at Jopari representatives will be happy to assist you. PAYMENT PROCESSING Coventry clients use Payment Processing to expand the functionality and synergies of E-Billing. By bundling these two services, clients move from paper checks to electronic fund transactions (EFT) which further expedites funds for providers. Providers will experience additional benefits from the marriage of these two services including aggregate payments for services rendered to multiple claimants minimizing costs associated with managing multiple checks and deposits. BI-ANNUAL CUSTOMER SERVICE SURVEY Coventry conducted its bi-annual "Spring" customer service survey in March The survey is web based and evaluates caller satisfaction with Coventry's Customer Service Department and opportunities for service level improvements. During the survey's two-week period, Coventry's WC Customer Service Centers received ~ 40,000 calls. Callers were asked to participate in the surveys at the end of the call. Those callers who agreed to the survey were then sent an link to the web survey. Billing company representing provider 17% Survey Results: 2,500 callers agreed to accept the survey link 33.83% of the callers who received the link responded to the survey Payor 90% of the respondents were providers or their billing agents 0% Calls from Florida represented the third largest group of callers 60% of the respondents call Coventry daily or weekly 30% of the respondents call Coventry frequently due to a high volume of bills submitted 96% of the respondents were satisfied with Coventry's overall Call Center Services The most common calls received are billing inquiries Insurance adjuster 2% Third party vendor 1% Other 7% Medical provider 73% COVENTRY'S APOLLO PROJECT Coventry's goal is to maintain accurate, demographic provider data integrity. Throughout 2010, providers may receive a call from a Coventry representative to confirm demographic information and continued participation in the WC network. Providers may also initiate changes by contacting Coventry at or viewing information on the Coventry Workers' Compensation Services website at: 2

3 QUALITY IMPROVEMENT NOTES TOP COMPLIANCE FINDINGS - MEDICAL CHART AUDITS Coventry continues to monitor the results of its medical chart audits. The top three errors found during our review of Coventry Providers medical charts include: Medical Chart Audit Results Overall, providers scored higher audit scores in first quarter 2010 compared to first quarter Q10-97% Accuracy 1Q09-93% Accuracy The provider failed to complete the State required status report within the required time frames. The provider failed to note the patient's date of birth, employer name, home and work telephone numbers in the medical charts. The provider failed to document the patient's known allergies or comment that there are no known allergies in the chart. In Coventry's WC medical chart audit process, we randomly select charts to conduct a quality improvement audit. We send notices to providers requesting the medical charts. Once received, our Quality Improvement medical staff audit the charts for compliance. We track the audit outcomes and report our findings to Coventry's FL MCA Quality Improvement Committee and Corporate WC Quality Improvement Committee. We send educational letters to the providers advising them of the missing components. Depending on the severity of the missing component, Coventry may submit the chart to peer review by a medical director. Providers are notified either in writing or telephonically of adverse peer review findings outlining needed corrective action. ACHIEVEMENTS Coventry was recognized as a finalist for the "Case In Point Platinum Awards". Case In Point is the publication produced by the Case Management Society of America. Coventry was recognized in two key areas: General Case Management and Catastrophic Case Management. The formal awards ceremony was held in Washington DC at the National Press Club on April 20 th. The Risk & Insurance Management Society Inc. (RIMS) has selected the exhibitor 'Best of Show' winners for the 2010 Annual Conference and Exhibition. The winners are picked by a group of conference attendees with judges weighing various criteria, including presentation of product, creative use of space, and overall design and layout. This year, Coventry was named the top winner in the large booth category. COVENTRY'S CARE MANAGEMENT NOTES MRI TO USE OR NOT TO USE? 3

4 When is it appropriate to order imaging studies for cervical and lumbar spine injury? A study published in Lancet 2/09 found that there was no benefit in ordering imaging studies of the lumbar spine in the first several weeks following an injury. Most guidelines recommend that MRI of the lumbar or cervical spine not be performed until at lest four to six weeks following the injury unless there is evidence of a red flag that suggests an urgent need for evaluation. Such serious red flags include medical conditions such as infection of the spine, cancer, cauda equina syndrome, spinal fracture, or progressive neurological findings or myelopathy. MRIs are very sensitive in identifying ligamentous injuries and myelopathy [injury to the spinal cord]. Likewise minor disc bulges, discs abutting nerve roots and arthritic changes are often noted that do not correlate with physical exam findings or any symptoms. Many abnormal findings are pre-existing and unrelated to the work injury. Often complaints such as pain are subjective and not associated with correlated neurological dysfunction. Identifying these minor changes on the MRI that are not associated with pain or dysfunction can lead to diagnosis of worker compensation back claims when there has not been a true new injury. This can also lead to aggressive treatment of minor back injuries and unnecessary medical costs and risks to the patient undergoing unnecessary medical testing, procedures and surgery. According to RA Deyo in his 2009 study, in spite of guideline support for limiting imaging studies to only when necessary, the use of lumbar MRI increased by 307% during a recent 12-year interval. He also found that onethird to two-thirds of spinal computed tomography [CT scan] and MRI imaging may be inappropriate. (Deyo, 2009) It is important to use CT scan or MRI early if there is concern about a serious medical problem such as cancer, spinal infection, cervical or lumbar fracture, myelopathy or progressive neurological changes that require urgent intervention. However the majority of lumbar and cervical injuries are strains and sprains that will resolve within the first four weeks with conservative medical care such as physical therapy and medications. References: Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low-back pain: systematic review and metaanalysis. Lancet Feb 7;373(9662): Deyo RA, Mirza SK, Turner JA, Martin BI. Overtreating chronic back pain: time to back off? J Am Board Fam Med Jan-Feb;22(1):62-8. Official Disability Guidelines, WLDI 2010 Neck and Upper Back and Low Back CAUSATION Determining whether an injury or illness is work related can be difficult at times. Details of the mechanism of injury such as the timing of the incident, witnesses and details of the events can be helpful. Austin Bradford Hill was a British epidemiologist and statistician that determined the link between lung cancer and smoking cigarettes. He developed the Bradford Hill criteria to establish a scientific approach to determining causation. The Bradford-Hill criteria are often utilized when deciding if the reported injury is likely to be work related. Bradford-Hill criteria: Temporal Relationship: The onset of the injury has to be at the time of the incident or after and never before. 4

5 Strength: The stronger the association between the work incident and injury, the more likelihood of a causal effect. Dose-Response Relationship: A greater exposure should be associated with greater risk of a causally related injury. Consistency: If the same injury has happened in different settings with similar incidents then it is more likely to be possible that this event is causally related. Plausibility: The current understanding of pathologic processes should support that there is likely to be a relationship between the incident and injury. Consideration of Alternate Explanations: Consider other alternative before deciding that there is a causal relationship between the injury and incident. Experiment: The hypothesis can be tested. Specificity: This is the weakest criteria but is established when a single supposed cause produces a specific effect. Coherence: The association should be consistent with existing theory and knowledge. Review of these criteria, after obtaining detailed facts of the case from the injured worker and employer, witnesses and medical provider, can help determine if the injury is work related. At times it may be necessary to obtain prior medical records to see if there was prior medical treatment for the same or similar medical condition or preexisting factors that predisposed the employee to injury or illness. If the medical provider is reluctant to clarify the pre-existing or non-work related component of the injury or illness then an independent medical examination may be necessary. HELPFUL STATE INFORMATION WHAT'S NEW WITH THE STATE The state offers other helpful topics and information for providers at: including: Contact Information District Office locations Provider Billing Form Instructions Proposed Rule Development Instructions for Online Medical Data Management System (MDMS), 2010 The Minimum/Maximum Compensation Rate Table The FL Medical EDI Implementation Guide (MEIG),