2013 Hospital Quadrant Meetings

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1 2013 Hospital Quadrant Meetings Blue Cross and Blue Shield of Kansas August 2013 An Independent Licensee of the Blue Cross and Blue Shield Association.

2 Today's Presenters Connie Winkley o Education Coordinator, Institutional Relations, BCBSKS Denny Hartman, CPC o Provider Representative for Southern Kansas, Institutional Relations, BCBSKS Cindy Garrison, CPC o Provider Representative for Northern Kansas, Institutional Relations, BCBSKS BCBSKS Marketing Representative Marie Burdiek o Account Representative, Electronic Data Interchange (EDI), BCBSKS 2

3 Meeting Agenda New BCBSKS Institutional Provider (IR) Staff Availity Web Portal ICD-10 Updates Electronic Inpatient Precertification 2014 Policies and Procedures Hospital Abstracts 2014 Quality- Based Reimbursement Program (QBRP) 3

4 Meeting Agenda Miscellaneous Billing Guidelines Non-contracting Provider Billing Procedures HealthCare Reform (HCR) Products Top 10 Denials New Services/New Procedures Electronic Data Interchange (EDI) Q & A 4

5 Institutional Relations (IR) Org Chart Fred Palenske, Senior VP Provider and Government Affairs Dona Hewes Administrative Coordinator, IR Angie Strecker, Director Institutional Relations Teresa Van Becelaere, Manager Institutional Relations Cindy Garrison, Provider Rep Hospitals in Northern KS Denny Hartman, Provider Rep Hospitals in Southern KS Melanie Moriarty Administrative Assistant (Topeka) Cheryl Carner Administrative Assistant (Wichita) Connie Winkley Education Coordinator Janne Denton Contract Consultant & Specialty Provider Rep Katie Dennison Claims Research Analyst Brent Matile Quality Reimbursement Analyst 5

6 Introducing New BCBSKS Institutional Relations Department Staff Janne Adams-Denton o Contract & Specialty Provider Consultant o Janne.denton@bcbsks.com o

7 Introducing New BCBSKS Institutional Relations Department Staff Katie Dennison o Claims Research Analyst o Katie.dennison@bcbsks.com o

8 Introducing New BCBSKS Institutional Relations Department Staff Brent Matile o Quality Reimbursement Analyst o Brent.matile@bcbsks.com o

9 Availity Web Portal Availity and BCBSKS began their business relationship in 2011 BCBSKS moved their member's eligibility and claim status information for providers to access on the Availity web portal in March BSBSKS has educated providers since March 2012 on Availity through newsletters, workshops and webinars Effective August 19, 2013 providers must log in to Availity to access BCBSKS member's secure information. 9

10 Availity Web Portal BCBSKS Member's eligibility and claims status will only be available on the Availity web portal effective 8/19/13. Other secure member information remains on BlueAccess; however a provider must log on to Availity to get to BlueAccess. Questions on Availity? BCBSKS Provider Rep o Denny Hartman or Cindy Garrison Education Coordinator o Connie Winkley Availity o Availty ( ) o By support@availity.com 10

11 ICD-10 Updates BCBSKS launches ICD-10 Provider Web Page May 2013 o Provider resource in preparation for the U.S. Healthcare industry's change from ICD-9 to ICD-10 for medical diagnosis and inpatient procedure coding. o Provides ICD-10 information through newsletters, training opportunities, web links and FAQs. o Providers can submit questions regarding ICD-10 and BCBSKS will provide answers to the questions through the FAQ link. 11

12 ICD-10 Updates BCBSKS Readiness for ICD-10: o Completed impact analysis and prepared for October 1 deadline o Completed review of Medical Policies and system changes o Working on systems upgrade for review phase o Continue to work on mapping the ICD-9 codes to ICD-10 codes in our claims system. End-to-end testing o Facility submits an ICD-10 coded claim to BCBSKS and BCBSKS will send acknowledgement to provider with the outcome of the claim o If claim is processed as a clean claim, then BCBSKS will produce a remittance advise for the provider. o BCBSKS will track every one of these claims to ensure they make it through the system and let the provider know whether or not they hit any edits. 12

13 ICD-10 Updates Additional ICD-10 Information: o BCBSKS has identified some claims scenarios that we will want to test with providers and likewise, providers should bring specific claim examples to BCBSKS that they want to test during the End-to-End testing period. This will be more of a claim by claim test versus a batch file. o More information on specific processes will be communicated at a later date. o Providers should contact their BCBSKS Institutional Provider Representative if interested in testing for ICD-10. Cindy Garrison Denny Hartman

14 Electronic Inpatient Precertification Electronic Precertification required for inpatient care : o o o Prior to admission The day of admission The first working day following a weekend or holiday Electronic Precertification is a prerequisite to BCBSKS Quality Based Reimbursement Program (QBRP) InterQual upgrade to 2013 version in July o Notice of upgrade sent to providers through enews o Details can be found on the BCBSKS Precert Web Page 14

15 Electronic Inpatient Precertification BCBSKS Electronic Precert Contact Information: Availity Website Access and General Inpatient Precertification and InterQual Information Coding for Inpatient Precertification Coding for Inpatient Precertification Clinical Questions about InterQual and Medical Criteria Problems with BCBSKS Secure Access (BlueAccess) Connie Winkley Education Coordinator Denny Hartman BCBSKS Provider Rep for Southern KS Hospitals Cindy Garrison BCBSKS Provider Rep for Northern KS Hospitals BCBSKS Precertification Department BCBSKS Help Desk Problems with the Availity Web Portal Availity Client Services AVAILITY 15

16 Electronic Inpatient Precertification Electronic Precert Changes coming in 2014 o Implementation of Electronic Provider Access (EPA) on January 1, 2014 which will enable providers to be routed from Host to the member's Home Blue Plan for pre-service review. The Blue Cross and Blue Shield Association will facilitate the routing by providing a web service that will identify the appropriate Home Plan by alpha prefix. o There will be approximately 33 Blue Plans that will have electronic pre-service review for inpatient services available to out-of-area providers. o Note: name change to Pre-service review which includes precertification, pre-authorization and prior approval. o Further information and provider education coming soon. 16

17 2014 Policies & Procedures Replaced the reference to each individual product with all benefit programs, indemnity plans and selfinsured plans Clarified amounts billable to the patient Reworded for ICD-10 claims submission requirements Request for information; Medical Records Request for information; Quality of Care 17

18 2014 Policies & Procedures Amendments to signed Provider Agreement o Providers permitted to disclose PHI for purposes of treatment, payment or operation o Insolvency, Receivership and Liquidation 18

19 Kansas Health Data Systems (KHDS) Hospital Abstracts KHDS is a unique department within Institutional Relations. KHDS is responsible for the processing of Medical Record abstracts and providing facility education to efficiently complete abstracts for all contracting hospitals in Kansas who submit inpatient claims. An abstract is a separate document, which must be present for BCBSKS inpatient claims to process completely Hospital abstracts are designed to confirm the accuracy of the MS-DRG. Paid claim = abstract Audits are done and adjustments are made, as needed 19

20 Kansas Health Data Systems (KHDS) Hospital Abstracts Contractual obligation with BCBSKS Transmitted monthly o 45 days from the end of each month Hospital builds file and submits via: o Vendor o Key in using My Ability or IVANS Option to send BCBSKS only or send for all payers KHDS sends inpatient data to KHA for those submitting all payer abstracts 20

21 Kansas Health Data Systems (KHDS) Hospital Abstracts KHDS Contact Information: odeanna Karle, KHDS Manager, o Todd Colglazier, KHDS Senior Field Representative, KHDS staff: KHDS@BCBSKS.com KHDS website: 21

22 2014 Quality Based Reimbursement Program (QBRP) Mailed end of July First reporting due November 15, 2013 Second reporting due May 15,

23 2014 Quality Based Reimbursement Program (QBRP) Paper copy to CEO s QBRP Web page and Web based form coming soon! Link at top of form to explain each measure and how to calculate Providers won t fill out every section Hover over the numerator/denominator boxes for an explanation IMPORTANT: PRINT SCREEN BEFORE SENDING! Access to web QBRP form will end on the deadline 23

24 General Claims Issues Multiple encounters (2 ER visits) on the same day = 2 claims Multiple services same day Observation (OBS) 24

25 Non-Contracting Provider Billing Procedures Transfers or Referrals o o o o Facility refers or outsources the service to another provider. The contracting facility is required to file for all services rendered and the member is held harmless for the use of a non-contracting provider. The contracting facility would make payment arrangements with the non-contracting provider to be paid for their services. The non-contracting provider should not bill the member or BCBSKS. 25

26 Top 10 Denials 2012 Claim Adjustment Reason Code Remit Remark Code Reason 18 None Duplicate Claim/Service 96 N130 Non-covered service(s)/charge(s) 16 N202 M118 M58 97 MA67 N185 M49 M86 Claim/service lacks information which is needed for adjudication. Additional information/explanation will be sent separately A corrected claim or a claim that needs to be combined with another claim has been received and will adjudicated or benefit for service is included in the payment/allowance for another service/procedure 27 N30 Service(s)/charge(s) incurred after contract terminated 96 N216 Non-covered charge(s) 115 None This claim or line has been cancelled 32 / 35 / 30 N30 The patient was not eligible for benefits at the time of service. B11 None Claim has been forwarded to the local Blue Plan for processing. 23 M43 The Medicare payment is greater than or equal to the maximum allowable payment under the patient's contract. 26

27 Top 10 Denials 2013 TOT CHG CLM LI CT Claim Adjustment Reason Code 147,332, Corrected Claim DS 13,270, The impact of prior payer(s) adjudication including payments and/or adjustments. 73,099, Duplicate claim/service 110,477, Claim specific negotiated discount (Plan 65 Select) 41,810, Claim/service lacks information which is needed for adjudication 2,550, Non-covered charge(s) (Plan 65) 10,284, Expenses incurred after coverage terminated. 7,422, The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. 7,154, Non-covered changes(s) 5,663, Claim/service lacks information which is needed for adjudication. TOTAL CLM LI CT DOS = 1/1/13 7/1/13 27

28 New Services / New Procedures New or Expanded Services o Notify BCBSKS of any new or expanded service(s). The purpose of this notification is to allow BCBSKS to determine if the new or expanded service is covered under the terms of the various member contracts. New Techniques and Technology o o Maximum allowable payment (MAP) for new techniques and technology will be based on existing comparable procedures. Additional allowances will be considered if there is significant improvement in safety or efficacy of patient care. 28

29 Questions? Thank you for attending today's workshop! 29

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