MiMGMA 2015 Third Party Payer Day Mt. Pleasant, MI

Transcription

1 MiMGMA 2015 Third Party Payer Day Mt. Pleasant, MI Presented By: Angie Lewis Hearing Facilitator Dept. of Licensing & Regulatory Affairs Workers Compensation Agency Kathryn Witchell Hearing Facilitator Department of Licensing & Regulatory Affairs Worker s Compensation Agency Kris Kloc, RN, BSN Medical Claims Analyst Dept. of Licensing & Regulatory Affairs Workers Compensation Agency 1 What is Workers Compensation? Wage loss benefits, reasonable & necessary medical care and treatment, and potential vocational rehabilitation. Benefits paid by employer either directly or through insurance carrier. Considered exclusive remedy against employer 2 1

2 The role of the Workers Compensation Agency Workers Disability Compensation Act- first adopted in Mission of the Agency is to efficiently administer the Act and provide prompt, courteous and impartial service to all customers Laws are changed by the Legislature and constantly interpreted by the Courts 3 Resolution, Rehabilitation, & Rules Division Facilitate resolution of disputes between injured worker and employer/carrier via alternative dispute resolution hearings Regulate the statutory provision of vocational rehabilitation including evaluation, retraining, and job placement Facilitate billing/payment disputes between payer/provider via alternative dispute resolution hearings Responsible for rule promulgation process and health care services (HCS) fee schedule and rules Publish & update HCS manual listing procedure codes and maximum allowable payments (MAP) Resource for information/questions pertaining to fee schedule Review and certify a Carrier s professional & technical review methodology Facilitate annual HCS seminars for providers/payers/billers Resource for injured workers , option #1 4 2

3 Employer and Employee Responsibilities Employer Have process in place for reporting and treatment of work related injury Promptly submit 1 st report of injury to insurance carrier or service company for handling Directs medical care for the first 28 days of treatment Furnishes all necessary and reasonable medical care and treatment for an employee receiving an injury in the course of employment File Employer s Basic Report of Injury (WC-100) with the WCA reporting cases when the injury results in seven or more days of disability, specific loss or death The insured employer must inform the provider of the name and address of its insurer or the designated agent of the insurer to whom the health care bills should be sent. Employee Report injury to employer, supervisor, and/or HR as soon as possible following company s reporting procedure Request direction of medical care from employer Promptly report injury within 90 days. The law does say, failure to give notice of an accident or injury within 90 days may result in loss of rights to compensation May file claim on own behalf by completing WC-117, Employee s Report of Claim, if employer does not report injury. 5 Legal Requirements for Compensability 1) Is the employer subject to the Workers Compensation Act? 2) Was the injured person an employee? 3) Did the injury arise out of and in the course of employment? 4) Health Care providers obtain history, diagnose, and treat, but do not determine compensability 5) Is the history received accurate? The initial medical history obtained is the most important information that will be reviewed by the adjuster and magistrates. It is imperative that the medical histories taken be accurate 6 3

4 How does a claim begin and how is it processed? 1. Employer submits 1 st report of injury to carrier or service company for handling 2. If employer will not file claim with carrier on behalf of the injured worker, then injured worker has ability to file claim on their own behalf by completing the Employee Report of Injury (WC-117) form and submitting to the Workers Compensation Agency 3. Carrier/Service Company will establish a claim file and do claims investigation, including if necessary: a. Interview of injured worker b. Request injured worker sign release of information to obtain medical records pertaining to the work related injury 4. The State of Michigan does not investigate or pay claims 7 Possible outcomes 8 o o o o o After investigation completed, employer/carrier may dispute or accept the claim If the claim is accepted, reasonable and necessary medical care and treatment directly or causally related to the injury, mileage for medical care/treatment, and wage loss benefits, if applicable, would be paid by the employer/carrier If claim involves medical care only, the State of Michigan would not receive notification from the employer/carrier unless the claim involved a dispute, wage loss, specific loss or death If claim is disputed, the injured worker has the right to file for an application for mediation or hearing with the Agency (Form WC-104A) The form is available on the Agency website at or the employee may call the Agency for assistance at Difference between a disputed case and a litigated case 4

5 Commonly utilized forms Notice of Dispute (WC-107) Application for Mediation or Hearing (WC-104A)

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7 Employee application for mediation and hearing Alternative dispute resolution The following case types will be scheduled for phone facilitation: -Unrepresented claimants -Medical only claims -No record of insurance coverage If no resolution, injured worker may choose to withdraw application or request the file to be transferred to a magistrate for a formal hearing 13 Medical Care-What s covered and how is it reimbursed? Employer direction of care for first 28 days of treatment Michigan s Workers Disability Compensation Act does not mandate managed care or prior authorization for reimbursement of medical services The carrier is required to review the medical services provided to ensure that the services are reasonable and related to the work injury or illness Medical treatment must be directly or causally related to the injury and must be reasonable and necessary The Workers Disability Compensation Act requires the Agency to establish maximum fees for medical services Health Care Services Rules include guidelines for billing and methodologies for determining fees 14 7

8 HCS Rules vs HCS manual HCS Rules Section 315 of Workers Disability Compensation Act (WDCA) of 1969, as amended, requires the agency to establish maximum fees for medical services. Enacted into law through administrative rules process. Include guidelines for practitioner and facility billing, methodologies for determining fees, and rules for carrier reimbursement of medical services. Maximum Allowable Payment (MAP) amounts for medical services are provided by the agency in a separate fee schedule. Rules do not override information contained in the WDCA. HCS Manual Acts as a guide for implementation of the rules. Generally only updated when HCS Rules are updated. Exception to this is when updates are not tied to rule language. Ex: CMS /12 version. If any conflicts between the language of the manual and the HCS Rules, the language of the rules shall control. Any reference in the manual to MCL 418 relates to the Michigan Workers Disability Compensation Act Statutory language. 15 What s new with the Rules since the 2012 Rule set?? Hospital cost to charge ratios now updated every July New rules on reimbursement for opioid treatment for chronic, non-cancer pain (2014) New rules on reimbursement for custom compound medications (2014) Changes to rules on multiple procedure payment reductions (MPPR) for radiology (2014) Rule changes allowing Certified Anesthesiologist Assistants to be reimbursed for anesthesia services within their scope of practice (2015) Changes to rules on reimbursement for biologicals, DME, and supplies (2014) 16 8

9 Opioid Reimbursement (R , a, and b) Rules apply to chronic, non-cancer pain In relation to these rules, chronic, non-cancer pain is pain that is unrelated to cancer, and persists beyond 90 days following the onset of the pain, such as after an acute injury or surgical episode Effective date of opioid rules depend on date of injury Date of injury prior to 6/26/15, rule applicable date 12/26/15, initial physician report due 3/26/16 Date of injury on or after 6/26/15, rule applicable date 6/26/15, initial physician report due 9/26/ Opioid Reimbursement In order to receive reimbursement for opioid treatment beyond 90 days following the onset of pain, the physician seeking reimbursement shall submit a written report to the payer. The written report must be submitted no later than 90 days after the initial opioid prescription fill for chronic pain and every 90 days thereafter. The written report must include the following: Review of prior relevant medical history and/or treatment, including any consultations obtained or review of data from an automated prescription drug monitoring program in the treating jurisdiction, such as the Michigan Automated Prescription System (MAPS). Summary of conservative care provided which focused on increased function and return to work, including a statement on why prior conservative measures were ineffective or contraindicated. A statement that the attending physician has considered results from an appropriate industry accepted screening tool to detect an increased risk of abuse or adverse outcomes to opioid therapy. A treatment plan, which must include overall treatment goals and functional progress, periodic urine drug screens, an effort to reduce pain through the use of non-opioid medications and/or alternative nonpharmaceutical strategies, consideration of weaning from opioid use, and an opioid treatment agreement. The opioid treatment agreement shall be signed by the attending physician and the worker and shall be reviewed, updated, and renewed every 6 months 9

10 Opioid Reimbursement FAQs Q: Can the physician use their own forms for this written report? A: Yes. A physician may elect to use a format of their choice as long as all required information is included. However, the Agency will provide sample forms for ease of physician use on their website at The forms need not be sent to the Agency unless required by the Funds Administration. Q: Does the physician receive reimbursement for the time required to complete the required documentation? A: Yes. The provider may bill CPT code for the office visit, the highest level patient E & M code, to account for the additional time involved with completing the initial 90 day evaluation report. This same code can be used for all subsequent follow-up evaluation reports at 90 day intervals, as required for compliance with these rules. All required information must be present as per Rule 1008a. Also, the Michigan workers compensation specific code, MPS01, may be billed for accessing MAPS, or other automated prescription drug monitoring program in the treating jurisdiction, and reimbursed at $ Opioid Reimbursement FAQs Q: What if the physician elects not to submit the required documentation? A: Physicians may not be reimbursed for opioid treatment if the required documentation is not submitted. Q: Will the injured worker be cut off with no warning? When can denial of reimbursement for prescribing and dispensing opioid medications occur? A: The rules do not provide for sudden cut off from opioid medications. Denial of reimbursement can occur only after a reasonable period of time is provided for the weaning of the injured worker from opioid medications, and alternative means of pain management have been offered. Q: What is a reasonable period of time as referenced in Rule 1008b? A: Reasonable time will vary from individual to individual based on a multitude of factors, including, but not limited to type of opioid, dosage, and length of treatment. The prescribing physician should have extensive input into determining a safe and effective timeframe, and should consider consulting industry accepted and evidence-based guidelines when implementing a weaning protocol. The overall health and safety of the injured worker is the central component of this decision. 10

11 Opioid resource information and frequently asked questions 21 Opioid resource information and frequently asked questions 22 11

12 Custom Compounds Custom compound definition: a customized topical medication prescribed or ordered by a duly licensed prescriber for the specific patient that is prepared in a pharmacy by a licensed pharmacist in response to a licensed practitioner s prescription or order, by combining, mixing, or altering of ingredients, but not reconstituting, to meet the unique needs of an individual patient Custom Compounds R : Custom Compounds shall be reimbursed only when the compound meets all of the following standards: (a) There is no readily available commercially manufactured equivalent product. (b) No other FDA approved alternative drug is appropriate for the patient. (c) The active ingredients of the compound each have an NDC number and are components of drugs approved by the United States Food and Drug Administration (FDA). (d) The drug has not been withdrawn or removed from the market for safety reasons. (e) The prescriber is able to demonstrate to the payer that the compound medication is clinically appropriate for the intended use. (2) Topical compound drugs or medications shall be billed using the specific amount of each component drug and its original manufacturers NDC number included in the compound. Reimbursement shall be based on a maximum reimbursement of the AWP minus 10% based upon the original manufacturer s NDC number, as published by Red Book or Medi-Span, and pro-rated for each component amount used. Components without NDC numbers shall not be reimbursed. A single dispensing fee for a compound prescription shall be $12.50 for a non-sterile compound. The dispensing fee for a compound prescription shall be billed with code WC 700-C. The provider shall dispense a 30-day supply per prescription. (3) Reimbursement for a custom compounded drug is limited to a maximum of $ Any charges exceeding this amount must be accompanied by the original component manufacturers invoice pro-rated for each component amount used, for review by the carrier. 12

13 Biologics Definition: include drugs or other products that are derived from life forms. Biologics are biology-based products used to prevent, diagnose, treat, or cure disease or other conditions in humans and animals. Biologics generally include products such as vaccines, blood, blood components, allergenics, somatic cells, genes, proteins, DNA, tissues, skin substitutes, recombinant therapeutic proteins, microorganisms, antibodies, immunoglobins, and others, including, but not limited to, those that are produced using biotechnology and are made from proteins, genes, antibodies, and nucleic acids. Rule b (1) The carrier shall reimburse durable medical equipment (DME), supplies, and biologicals at Medicare plus 5%. The health care services division shall provide the maximum allowable payments for DME, supplies, and biologicals separate from these rules on the agency website, Biologicals that have NDC numbers shall be billed and reimbursed under R Rule : Changes to MPPR for radiology (1) A multiple procedure payment reduction shall apply to specified radiology procedures when performed in a freestanding radiology office, a non-hospital facility, or a physician's office or clinic. The primary procedure, identified by the code with the highest relative value, shall be paid at 100% of the maximum allowable payment. If the provider's charge is less than the maximum allowable payment, then the service shall be paid at 100% of the provider's charge. (2) The multiple procedure payment reduction shall apply when multiple radiological diagnostic imaging procedures are furnished to the same patient, on the same day, in the same session, by the same physician or group practice that has the same national provider identifier. The agency shall publish in a manual separate from these rules a table listing the diagnostic imaging CPT codes subject to the multiple procedure payment reduction. When more than 1 procedure from the table is furnished to the same patient, on the same day, in the same session, by the same physician or group practice, the procedure with the highest relative value is paid at 100% of the maximum allowable payment. Each additional procedure shall have modifier -51 appended and the technical component shall be reduced to 50% of the maximum allowable payment, or the provider's charge, whichever is less, and the professional component shall be reduced to 75% of the maximum allowable payment, or the provider s charge, whichever is less. 13

14 HCS Rules-where to find 1. Click on Health Care Services tab on left side of screen 2. Under Health Care Services Rules heading, click on HCS Rules, Manual, & Fees 3. Scroll to the bottom to read and accept the AMA licensure information 4. Click on most recent rules: 2014 Rules, Manual, and Fees 5. Rules and Manual in separate blue boxes at the top of the page 6. Blue box entitled, 2014 CMS Physician Fee Schedule is link to full CMS Physicians Fee Schedule 7. Fee schedule broken down into 6 different categories: Ambulatory Surgical Center, Anesthesiology, Clinical lab, HCPCS level II, hospital ratios, RBRVS (Evaluation & Management codes, Medicine, Physical Medicine, Pathology, Radiology, and Surgery) 8. Within each category are 2 boxes, labeled worksheet and methodology 9. Worksheet box will open excel spreadsheet where appropriate HCPCS or CPT code is entered into the specific shaded box. Upon entering, the worksheet will calculate a fee for the code 10. Each worksheet provides a link to the CMS specific fee schedule which serves as the data source for the worksheet 11. Methodology box will present user with more detailed explanation of how the payment amount is calculated and fee schedule derived

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17 Fee schedule Maximum allowable payments (MAP) based upon the CMS Resource-based Relative Value Scale (RBRVS). Relative values are based on the physician work, practice expense, and professional liability insurance involved in providing each service, and applying specific geographical indices, (GPCI), to determine the RVU. Michigan workers compensation is applying the following GPCI resulting from a meld using 60% of the Detroit area GPCI and 40% of the rest of the state s GPCI: Work Malpractice (MP) Practice Expense (PE).9742 The following formula is applied to the information taken from CMS to determine the RVU for the State of Michigan Workers Compensation: Adjusted Work RVU (Work RVU x ) + Adjusted MP RVU (MP RVU x ) + Adjusted PE RVU (PE RVU x.9742) = Michigan Total RVU Most MAP amounts (except anesthesia services) can be determined by multiplying the Michigan Total RVU by the Conversion Factor (currently $47.19) MAP amounts represent the Maximum Allowable Payments that a provider can be paid for rendering services under the State of Michigan Workers Disability Compensation Act. When a provider s charge is lower than the MAP amount, or if a provider has a contractual agreement with the carrier to accept discounts for lower fees, payment is made at the lower amount 33 What if no amount is showing in the fee schedule? Verify that CPT or HCPCS code is consistent with the fee schedule year, i.e. a 2015 CPT code will not populate a value in the 2014 fee schedule Make sure you are in the correct area of the fee schedule When a procedure code does not have an assigned fee or relative value (RVU), the procedure shall be considered by report (BR) unless otherwise specified in the HCS Rules A by report procedure is reimbursed at the provider s usual and customary charge or reasonable amount, as defined in R , whichever is less The following services are by report : Ambulance services, dental services, vision and prosthetic optical services, hearing aid services, home health services 34 17

18 Billing forms/coverage look up If any question regarding correct carrier to bill or to verify coverage, insurance coverage look up is available on the Agency website or call the coverage department at Instructions for completing the CMS 1500 (02/12) located in HCS manual, Chapter 5 CMS 1500 utilized for practitioner billing UB04 utilized by home health agency, hospital, licensed facility (except for freestanding surgical outpatient facility) A facility billing for practitioner services shall bill charges on CMS 1500 claim form ICD-10 vs. ICD-9 35 What do I have to send with the bill? A provider shall furnish the carrier, at no additional charge, with a medical report for the initial visit, all information pertinent to the covered injury or illness if requested at reasonable intervals, and a progress report for every 60 days of continuous treatment for the same covered injury or illness (R ) R (3) A properly submitted bill shall include all of the following documentation: a. Copy of medical report for the initial visit b. Progress report if treatment exceeds 60 days c. Copy of the initial evaluation and a progress report every 30 days of physical treatment (PT/OT, CMT, OMT) d. An operative report or office note (if done in office) for a surgical procedure e. Copy of anesthesia record if billing anesthesia codes f. X-ray report is required when the professional component of an x-ray is billed g. When billing a by report procedure, a description of the service is required h. A copy of the medical report if a modifier is applied to a procedure code to explain unusual billing circumstances 36 18

19 Billing Responsibilities (R ,R ,R ) Provider Promptly bill the correct carrier or the carrier s designated agent after the date of service Submit the bill on the proper claim form, and attach documentation required in part 9 of the HCS Rules If no payment received within 30 days of submitting a bill, then resubmit the bill to the carrier Provider shall bill carrier within one year of the date of service for consideration of payment Carrier Carrier or designated agent shall pay, adjust, or reject a properly submitted bill within 30 days of receipt Shall record payment decisions on a carrier s explanation of benefits form (EOB) using a format approved by the WCA. A copy of the EOB shall be sent to the provider and injured worker A carrier shall not make payment for any service determined inappropriate by their professional review program The carrier shall reimburse the provider a self-assessed 3% late fee if more than 30 calendar days elapse between the carrier s receipt of a properly submitted bill and a carrier s mailing of the payment 37 Are you speaking the same language?? 1. What does Claim mean to you? Health Care Provider: A claim is the bill that is submitted to the carrier for services rendered to an injured worker Carrier: A claim is the file set up to investigate the alleged injury and pay appropriate benefits if owed

20 What do I do if I disagree with payment amount? Health Care Services Rules Part 13- Process for resolving differences between carrier and provider regarding bill When provider is dissatisfied with a payer s reduction or denial of a charge for a work related medical service, the provider may submit to the carrier a written request for reconsideration within 60 days of receipt of the notice of an adjusted or rejected bill or portion of bill Reconsideration form (WC-750) is available on the Agency website, but is not required. Agency does not receive a copy of reconsideration form If provider disagrees with the results of reconsideration, or no response received to reconsideration, provider can file a Health Care Services application for mediation or hearing (WC-104B) with the WCA. A provider shall send its 104B to the agency within 30 days from the date of receipt of a carrier s denial of a provider s request for reconsideration. WC-104B form is found on under health care services tab. WC-104B will be returned if only one billing date completed on form, unless case is in litigation 39How to properly withdraw a WC-104B 40 20

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22 The why/when/how to file a 104B WHY For assistance in resolving payment issues with the carrier To be added as an intervening party if a case is in litigation WHEN When you learn a case is in litigation and there are outstanding balances Have sent 2 properly submitted bills to the carrier and waited a total of 60 days for a case that has not been disputed Request for reconsideration has been submitted to carrier with no resolution or no response Payment was not made in accord with the maximum payments established by the Health Care Services Rules, or the carrier has disputed utilization of the overall services. If the issues are not resolved through the reconsideration process, the provider may file a WC- 104B. HOW Complete form 104B and send copy to the WCA and the carrier along with a copy of reconsideration if available Requires 2 dates of billing unless litigated case Verify correct date of injury, correct employer, correct carrier, and accuracy of total amount billed 43 Additional WC-104B Information WC-104B should not be completed if payment made in accordance with the HCS Rules at fee schedule Maximum Allowable Payment (MAP), but provider not satisfied with MAP amount R (4) If a carrier and a provider have a contractual agreement designed to reduce the cost of workers compensation health care services below what would be the aggregate amount if the fee schedule were applicable, the contractual agreement shall be exempt from the fee schedule 44 22

23 Health Care Services Hearings Telephonic facilitation of provider/carrier disputes Information to have ready for hearing: a. Itemized dates of service and original billed amount b. What services rendered on the date of service c. Date of 1 st billing and 2 nd billing d. Date of reconsideration e. Date & amount of any payment received f. Reason for filing g. Who has contact been made with and their telephone number/extension h. Outcome of contact i. Late Fee: Yes or no 45 Frequently asked questions about the HCS fee schedule Question Answer 1. Can I balance bill an injured worker? 1. No. A provider may not balance bill (refer to R ) when: a. the amount is disputed by utilization review b. that amount exceeds the maximum allowable payment

24 Frequently asked questions about the HCS fee schedule Question Answer 1. Is CPT code (application of hot/cold pack) separately payable? 1. No. Rule (b) states, Procedure is a bundled procedure code and shall not be reimbursed separately. 47 Frequently asked questions about the HCS fee schedule Question 1. Who can I bill if I have a notice of dispute from the carrier? Answer 1. If the provider has received a formal notice of dispute from the carrier and there is no claim in litigation, the provider may bill the injured worker s health insurance or the injured worker 2. If the claim is in litigation, the provider should file a WC-104B with the WCA to become a party to the litigation 48 24

25 Frequently asked questions about the HCS fee schedule Question 1. Do I bill with ICD-9 or ICD-10? Answer 1. Health Care Services Rules mandate use of ICD-10 diagnosis codes in Rules and Rule states a hospital shall use ICD-10 coding on the UB-04 when implemented by CMS. 3. Rule Billing Requirements for other licensed facilities. This rule states that a licensed facility, other than a hospital or freestanding surgical outpatient facility, shall bill the facility services utilizing ICD-10 when ICD-10 is implemented. 4. Rules do not mandate version of ICD for other providers, however, utilizing ICD-9 could potentially lead to reimbursement delays. 49 Frequently asked questions about the HCS fee schedule Question 1. How does a physician bill for medications dispensed from his/her office? Answer (R a & ) 1. Prescription medications reimbursed at AWP minus 10% based on Red Book or Medi-Span 2. Dispensing fee allowed: WC700-G billed for generic drugs $5.50, WC700- B billed for brand name drugs $3.50. No dispense fee shall be billed for OTC medications 3. Dispensing fee can t be paid more than every 10 days for each prescription 4. Repackaged pharmaceuticals reimbursed a maximum of AWP minus 10% based upon the original manufacturer s NDC number, as published by Red Book or Medi-Span 5. When a generic drug exists, the generic drug shall be dispensed 6. OTC drugs dispensed by a provider other than a pharmacy shall be dispensed in 10 day quantities 50 25

26 2016 Advisory Committee Meetings Check for upcoming 2016 dates Meetings to be held at the Workers Compensation Agency address below unless otherwise noted: 2501 Woodlake Circle Okemos, MI Contact Information Angie Lewis, Facilitator, Kathy Witchell, Facilitator, Kris Kloc, RN, Health Care Analyst, David Campbell, Manager, Fax: Insurance Coverage:

27 Questions? 53 27