UHIN Dental WG Mini-Clinic. March 14, 2014

Transcription

1 UHIN Dental WG Mini-Clinic March 14, 2014

2 Today s Agenda 2:00: Welcome and Introductions 2:05 2:25: UHIN Dental Work Group presents on CORE EFT and ERA Operating Rules 2:25 2:45: Janet Jenson presents on HIPAA 2:45 3:05: Nancy Askerlund of Utah Insurance Department presents on COB claims 3:05 3:30: Payer Panel/Q&A

3 What Can Operating Rules Do for You? UHIN Dental Work Group Panel

4 UHIN Dental Work Group A collaborative effort of dentists, dental payers, state government and clearinghouses Goal: To make billing easier for Utah dentists and staff by encouraging EDI use Through outreach and education, helped increase EDI use in Utah dental offices from 27% in 2009 to 67% in 2013

5 Who We Are Are

6 What We Do In 2013 we: Created guidelines for dental offices seeking to credential with payers; updated attachment requirements guidelines Assisted payers with an electronic crossreference to J430 paper form Provided input to Davis Applied Technology College for HIT program Continued work on electronic attachments Represented our community at X12 and WEDI meetings to add needed information to data formats

7 Every office counts to make secure, easy EDI Transaction electronic billing Rates the standard! EDI Submission Rates over Time 80% 70% 60% 50% 40% Q Q Q Q Q Q Q Q4 2013

8 Goals In 2014 we plan to: Increase EDI volume by 5% Pilot an electronic claim attachment tool Stay connected with dentists through the UDA Newsletter and CQI meetings Work with X12, WEDI, NDEDIC and other national organizations to make EDI transactions friendlier to dentists

9 CORE Electronic Billing Operating Rules CORE (the Committee on Operating Rules for Information Exchange) Selected by HHS to write standard rules to make electronic healthcare transactions easier for providers and payers to use

10 CORE Electronic Billing Operating Rules Phase III Operating Rule Set covers common trouble spots in the electronic funds transfer (EFT) and electronic remittance advice (ERA or 835): Complicated adjustment codes in the ERA Trouble reassociating EFT and ERA Filling out different EFT/ERA enrollment forms for each payer you bill, all with different information required

11 CORE 350 Health Care Claim Payment/Advice (835) Infrastructure Rule Providers who receive 835s must return 999s to the sending payer for each functional group of 835s To state whether it was accepted, accepted with errors or rejected and Explain each error found

12 CORE 350 Health Care Claim Payment/Advice (835) Infrastructure Rule Payers must be able to accept and process 999s. Payers must continue to send paper remits to a provider while they are testing implementation of the 835 with that provider. Paper remit delivery must continue for at least 31 calendar days from the date implementation begins or until the provider has received at least three payments from the payer. Providers may choose to stop receiving paper remits before the 31-day period is up, or may arrange with the payer to receive paper remits for a longer time if necessary. If a provider cannot process a payer s 835s, the provider may continue to receive paper remits from that payer.

13 CORE 360 Uniform Use of CARCs and RARCs Rule CARC=Claim Adjustment Reason Code RARC=Remittance Advice Remark Code Rule is meant to standardize the codes that payers use to explain why the amount they paid is different from the amount you billed The payment adjustment explanations you get in your 835s should be more standard across payers EHR/EMR software must accurately describe the CARC/RARC codes included in the 835

14 CORE 370 EFT and ERA Reassociation Rule To accurately match an EFT payment with the corresponding 835, providers need to have a way to associate them! Rule requires payers to include data elements required so that EFT to 835 matching is possible Payer must tell provider during EFT enrollment that the provider should contact their bank to set up the CORE-required Minimum CCD+ (EFT) Data Elements that are needed to correctly reassociate the EFT payment with the 835. Payer must send provider the appropriate 835 no more than three business days before and no later than three business days after the EFT goes through. Payer must have written procedures to tell providers how to resolve issues with late or missing EFT payments and/or late or missing 835s.

15 CORE 380 EFT Enrollment Data Rule Establishes a maximum number of data elements that a payer may request when enrolling a provider to receive EFT payments and requires payers to use the standard data element name and description provided by CORE when collecting EFT enrollment data Read the complete list of EFT enrollment data elements here: ERA/EFT_Enrollment_Data_Rule.pdf Requires payers to offer written instructions for providers to follow when enrolling for EFT and when changing or cancelling an existing EFT enrollment Provides standard templates that payers must use for paper EFT enrollment forms and online EFT enrollment Requires payers to offer electronic method for EFT enrollment

16 CORE 382 ERA Enrollment Data Rule Establishes a maximum number of data elements that a payer may request when enrolling a provider to receive 835s and requires payers to use the standard data element name and description provided by CORE when collecting 835 enrollment data. Read the complete list of 835 enrollment data elements here: ERA/ERA_Enrollment_Data_Rule.pdf Requires payers to offer written instructions for providers to follow when enrolling for 835s and when changing or cancelling an existing 835 enrollment. Provides standard templates that payers must use for paper 835 enrollment forms and online 835 enrollment Requires payers to offer electronic method for 835 enrollment

17 What s the Bottom Line? The CORE Operating Rules can: Help your office work with your payers to improve the electronic remits that they send you Make sure that all of your payers 835s consistently and clearly explain any differences between the amount you billed and the amount that the payer paid, and inform you of any upcoming changes to how you will be paid for that particular service Make sure that the EFT payments you receive contain the trace number you need to correctly match the EFT to the corresponding 835 Make sure that your 835s arrive in the same time frame as your corresponding EFTs Standardize the information that payers ask for when you enroll to receive EFTs and 835s and keep the terminology used for that information consistent from payer to payer, so that you always know exactly what you need to enroll for EFT/835s from any payer and can save time and effort on the enrollments

18 Questions?

19 HIPAA OMNIBUS Janet I. Jenson, Attorney at Law Jenson and Guelker, PLLC (801)

20 Janet I. Jenson, Attorney at Law Jenson & Guelker, PLLC (801) / (801) (private) (801) (cell) janet@jandglegal.com J and G Legal)

21 Health Insurance Portability and Accountability Act of 1996 ( HIPAA ) Came in 4 waves: (1) Kennedy-Kassebaum let employees with large group health insurance plans take them to new jobs. (2) Administrative simplification standardize forms and billing. (3) Privacy regulations-protected Health Information ( PHI ), Notice of Privacy Practices, Authorizations, etc. (4) Security computers, etc. Janet I. Jenson, Attorney at Law Jenson & Guelker, PLLC (801)

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25 Health Information Technology for Economic and Clinical Health Act ( HITECH ) which was part of the American Recovery and Reinvestment Act of 2009 ( ARRA ) - Lots of rules about breach notification and enforcement: What is a breach of HIPAA privacy and security? What must providers do when there is a breach? Providers must maintain HIPAA breach log online: Janet I. Jenson, Attorney at Law Jenson & Guelker, PLLC (801)

26 Genetic Information Nondiscrimination Act of 2008 ( GINA ) HIPAA Omnibus Rule published by feds includes GINA and further implementation of HIPAA and HITECH. Effective date of final rule - March 23, 2013 Compliance date for providers - September 23, 2013 Note that HHS/OCR went with this delayed deadline not to be nice to providers, but to give Congress time to meddle. Janet I. Jenson, Attorney at Law Jenson & Guelker, PLLC (801)

27 Final HIPAA Omnibus rule is 500 pages long. If you want to try to do your own compliance and revise your own HIPAA forms, here are your tools: - Official in charge AndraWicks at (202) Final rule published in Federal Register on January 25, 2013 (at page 5566). - Final Rule online at: Go to Click on FDsys (at left side of page) Click on Federal Register (on right side of page) Click on 2013 Click on January Click on Health and Human Services Scroll down to Rules and Regulations (It s the first one) Click on PDF (on right) - FAQ s and other helpful information: Janet I. Jenson, Attorney at Law Jenson & Guelker, PLLC (801)

28 What does the HIPAA Omnibus regulation do? Changes and expands definition of business associate and therefore expands the numbers of types of entities with which providers will need to have a business associate agreement, and expands responsibilities and liability of business associates. Extends the reach of HIPAA privacy and security protections to subcontractors of business associates. Janet I. Jenson, Attorney at Law Jenson & Guelker, PLLC (801)

29 Redefines electronic media to clarify when fax information doesn t come under HIPAA. Makes clear that PHI held in copiers, hard drives, etc. does come under HIPAA. PHI covered by HIPAA now excludes: (1) PHI in educational records; (2) PHI in employment records held by a covered entity as an employer; (3) PHI of any person deceased for more than 50 years. Janet I. Jenson, Attorney at Law Jenson & Guelker, PLLC (801)

30 New rule changes HHS/OCR position from hand-holding and education to enforcement. -- Every complaint must be investigated. -- Any case of willful neglect must proceed with civil money penalties. Janet I. Jenson, Attorney at Law Jenson & Guelker, PLLC (801)

31 ENFORCEMENT GRID: VIOLATION CATEGORY: EACH VIOLATION: MAXIMUM PENALTY:* (A) Did not know $ $ 50,000 $ 1,500,000 (B) Reasonable cause $ 1,000 - $ 50,000 $ 1,500,000 (C)(i) Willful Neglect-Corrected $ 10,000 - $ 50,000 $ 1,500,000 (C))(ii) Willful Neglect-Not Corrected $ 50,000 $ 1,500,000 * For all such violations of an identical provision in a Calendar Year: -- For impermissible uses and disclosures, count number of individuals affected. -- For continuing violations, e.g. lack of safeguards for a period of time, count per day. -- $1.5 million annual cap is per a type of violation and therefore there could be multiple violations that could result in a much higher amount. -- To determine amount of civil money penalty, Secretary of HHS will consider factors, such as degree of culpability, history of prior offenses, number of individuals involved, time period during which violation(s) occurred, reputational harm, and financial condition of the person investigated. Janet I. Jenson, Attorney at Law Jenson & Guelker, PLLC (801)

32 Affirmative defense of did not know is no longer permitted, but instead is a factor to be considered in lowest tier of penalties. Secretary now has ability to waive a penalty in whole or in part where covered entity can show it was not cognizant of the violation but had also been using prudent business practices. Covered entities have 30 days to cure a violation, and clock begins to run on day that entity first acquires actual or constructive knowledge of the violation. Janet I. Jenson, Attorney at Law Jenson & Guelker, PLLC (801)

33 Security rule now applies directly to all business associates and their subcontractors. Janet I. Jenson, Attorney at Law Jenson & Guelker, PLLC (801)

34 Big changes are made to marketing. Marketing is defined as making a communication about a product or service that encourages recipients of the communications to purchase or use the product or service. Where marketing is paid for by a third party, each patient must sign a valid authorization prior to the communication and the authorization number must disclose the fact that the covered entity is receiving financial remuneration from a third party. Where marketing is not subsidized, Notice of Privacy Practices is enough. Janet I. Jenson, Attorney at Law Jenson & Guelker, PLLC (801)

35 HIPAA still permits: -- Communications made face-to-face by the covered entity to the individual (phone, mail or is not face-to-face); -- Gifts of nominal value provided by the covered entity; -- Refill reminders or other communications about a drug or biologic that is currently being prescribed for the patient; -- Case management/care coordination; -- Recommending alternative treatments, therapies, providers or care settings; -- Describing products or services that are within provider network or covered by health plan as a benefit. Janet I. Jenson, Attorney at Law Jenson & Guelker, PLLC (801)

36 The sale of PHI is prohibited. Sale does not include disclosures for: - public health reporting; - research (under certain circumstances); - for treatment or payment purposes; - for due diligence in a merger or acquisition of practice or business; - to a business associate; or - to individual patient who requests his or her own PHI. Janet I. Jenson, Attorney at Law Jenson & Guelker, PLLC (801)

37 PHI about decedents: -- Final rule requires covered entities to comply with the Privacy Rule regarding PHI of deceased individuals for 50 years, after which it is no longer considered PHI. -- Covered entities are now permitted to disclose a decedent s PHI to family members and others who were involved in the care or payment for care of a decedent prior to death (unless covered entity actually knows decedent would not have wanted disclosure). -- Such disclosures are permitted, not required. Covered entity has final decision. Janet I. Jenson, Attorney at Law Jenson & Guelker, PLLC (801)

38 New rule requires changes to the Notice of Privacy Practices: -- Must include a statement about fundraising and patient s right to opt out. -- Must give patients the right to restrict disclosures of PHI to their health plan or health insurer if they pay for a service in full and out-of-pocket. -- Must contain statement of patient s right to be notified of a breach. Janet I. Jenson, Attorney at Law Jenson & Guelker, PLLC (801)

39 New rule makes clear that PHI can be maintained electronically, and patients can requests for PHI. Covered entity must produce a copy of the electronic PHI in the form and format requested by the individual. Redefines PHI to expressly include genetic information of patient and family members, genetic tests, and genetic services. Sets out rules about who can receive genetic information and for what purposes. Janet I. Jenson, Attorney at Law Jenson & Guelker, PLLC (801)

40 Coordination of Benefits Nancy Askerlund Director, Health and Life Division Utah Insurance Department

41 Coordination of Benefits When a patient has more than one health plan that covers their medical expenses, a coordination of benefits divides the responsibility of payment between the health plans so that together they will pay up to 100% of covered charges.

42 Different types of coordination Dual coverage with spouse or children Dual coverage for self Self Funded Plans Medicare Medicaid Automobile no-fault coverage

43 Applicability of Rules These rules apply only to fully insured health insurance, and are consistent throughout 48 states. The rules for plans who employers have self funded their health coverage may be different.

44 The Life of the Overachiever Family Married with one child Father: John Overachiever, date of birth October 4 Mother: Jane Overachiever, date of birth February 12 Daughter: Amy Overachiever, date of birth January 2

45 Health Coverage John has coverage with Insurer A while working for Employer A Jane has coverage with Insurer B while working for Employer B COB process based on the birthday rule : Insurer A Insurer B John (D.O.B. 10/04) Primary Secondary Jane (D.O.B. 02/12) Secondary Primary Amy Secondary Primary

46 The divorce decree assigns responsibility Overachiever Family Divorces The divorce decree states that John is responsible for providing health insurance for Amy. However, Jane also continues her coverage. Insurer A Insurer B John Primary No coverage Jane No coverage Primary Amy Primary Secondary

47 The divorce decree splits insurance responsibility equally The divorce decree assigns both parents equal responsibility for Amy s health care expenses and insurance coverage. The birthday rule is followed for Amy s coverage (same as if parents were married). Insurer A Insurer B John (D.O.B. 10/04) Primary No coverage Jane (D.O.B. 02/12) No coverage Primary Amy Secondary Primary

48 The divorce decree does not address health insurance The divorce decree provides for joint custody but does not address health care expenses or coverage, and Jane has custody of Amy: Insurer A Insurer B John Primary No coverage Jane No coverage Primary Amy Secondary Primary

49 There is no divorce decree Jane has custody of Amy: Insurer A Insurer B John Primary No coverage Jane No coverage Primary Amy Secondary Primary

50 Active / Retiree or Laid-Off Rule John just got laid off from his job for 6 months. John s employer, Employer A, is maintaining his health insurance coverage. John obtains employment with Employer Z, who provides him coverage through Insurer Z. Plans that cover an active employee are primary. The plan that covers a retiree and/or laidoff employee is secondary. Insurer A (laid off) Secondary Insurer Z (active employee) Primary

51 Longer Shorter Rule John works two full-time jobs to make ends meet. John started working with Employer A in John later obtains employment with Employer Z in When two plans cover an active employee, the plan that has covered the person longer is primary. Insurer A (hired 1992) Insurer Z (hired 2009) Primary Secondary

52 SELF- FUNDED HEALTH BENEFITS PLANS If an employee works for a large employer, the health benefit plan may not be underwritten by an insurance company. Federal law exempts self-funded employer plans from state insurance regulation.

53 Assistance with Self- Funded Plans If a health plan (including dental) is selffunded, please contact the employer s Human Resource advisor. If additional help is needed, please have the insured contact the Employee Benefits Security Administration (EBSA) at (415) or toll free (866) between 8:00 a.m. and 4:30 p.m. Pacific Time. EBSA does not take complaints from a third party.

54 We Can Help If you have a complaint involving a Utah insurance company offering a fullyinsured insurance plan, please contact us. Complaint forms are available on the Utah Insurance Department s website at

55 Contact the insurer or administrator of the plan if you have difficulties determining the order of benefits. Contacts Utah Insurance Department Health Insurance Division (801) (800) In-State Toll Free

56 ?? Questions??