Third Party Newsletter

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1 September 2003 Volume 3 Issue 9 CMS IMPLEMENTS CONTINGENCY PLAN COMPULSORY HIPAA EDI COMPLIANCE POSTPONED NEBRASKA OPTOMETRIC ASSOCIATION Third Party Newsletter Compliant Electronic Transactions Will Not Be Required by October 16 The Centers for Medicare & Medicaid Services (CMS) announced that it will implement a contingency plan to accept non-compliant electronic transactions after the October 16, 2003 compliance deadline. This plan will ensure continued processing of claims from thousands of providers who will not be able to meet the deadline and otherwise would have had their Medicare claims rejected. "Implementing this contingency plan moves us toward the dual goals of achieving HIPAA compliance while not disrupting providers' cash flow and operations, so that beneficiaries can continue to get the health care services they need," said CMS Administrator Tom Scully. CMS made the decision to implement its contingency plan after reviewing statistics showing unacceptably low numbers of compliant claims being submitted. "Medicare is able to process HIPAAcompliant transactions," said Tom Grissom, director of CMS' Center for Medicare Management, "but we need to work with our trading partners to increase the percentage of claims in production." The contingency plan permits CMS to Inside this issue: Compliance: Misleading Statements & Kickbacks 2 ProPar Clearinghouse for Medicare 3 Medicare Coding Classes for Beginners 4 Trauma Edits 5 Dr. Quack 6 continue to accept and process claims in the electronic formats now in use, giving providers additional time to complete the testing process. CMS will regularly reassess the readiness of its trading partners to determine how long the contingency plan will remain in effect. The authority to implement a contingency plan was provided by guidance issued by HHS on July 24. CMS recognized that transactions often require the participation of two covered entities and that non-compliance by one covered entity may put the second covered entity in a difficult position. The guidance stated that covered entities that make a good faith effort to comply with HIPAA transactions and code set standards may implement contingencies to maintain operations and cash flow. CMS announced its contingency plan on September 11, but at that time had not made a decision on whether the plan would be implemented. Today's announcement means the CMS plan will be implemented on October 16, "We encourage other plans to assess the readiness of their trading partners and implement contingency plans if appropriate," Grissom said. Abstracts of All Newsletter Articles Are Found at the Top of Page Six.

2 Compliance: Misleading Statements; Kickbacks The following information was recently published in the Federal Register and entitled Compliance Program Guidance for Individual and Small Group Physician Practices. It directly impacts optometrists. A lengthy document, it has been distilled here for readability, and will be presented as a series of articles in this publication. Continued from last month False Statements and Representations It is a crime to knowingly and willfully: Make, or cause to be made, false statements or representations in applying or benefits or payments under all Federal health care programs; Make, or cause to be made, any false statement or representation for use in determining rights to such benefit or payment; Conceal any event affecting an individual's initial or continued right to receive a benefit or payment with the intent to fraudulently receive the benefit or payment either in an amount or quantity greater than that which is due or authorized; Convert a benefit or payment to a use other than for the use and benefit of the person for whom it was intended; Present, or cause to be presented, a claim for a physician s service when the service was not furnished by a licensed physician; For a fee, counsel an individual to dispose of assets in order to become eligible for medical assistance under a State health program, if disposing of the assets results in the imposition of an ineligibility period for the individual. Anti-Kickback Statute It is a crime to knowingly and willfully solicit, receive, offer, or pay remuneration of any kind (e.g., money, goods, services): For the referral of an individual to another for the purpose of supplying items or services that are covered by a Federal health care program; or For purchasing, leasing, ordering, or arranging for any good, facility, service, or item that is covered by a Federal health care program. There are a number of limited exceptions to the law, also known as ``safe harbors,'' which provide immunity from criminal prosecution and which are described in greater detail in the statute and related regulations. Current safe harbors include: Investment interests; Space rental; Equipment rental; Personal services and management contracts; Sale of practice; Referral services; Warranties; Discounts; Employment relationships; Waiver of Part A co-insurance and deductible amounts; Group purchasing organizations; Increased coverage or reduced cost sharing under a risk-basis or prepaid plan; and Charge reduction agreements with health plans. Penalty for Unlawful Conduct The penalty may include the imposition of a fine of up to $25,000, imprisonment of up to 5 years, or both. In addition, the provider can be excluded from participation in Federal health care programs. The regulations defining the aggravating and mitigating circumstances that must be reviewed by the OIG in making an exclusion determination are set forth in 42 CFR Part Examples 1. Dr. X accepted payments to sign Certificates of Medical Necessity for durable medical equipment for patients she never examined. 2. Home Health Agency disguises referral fees as salaries by paying referring physician Dr. X for services Dr. X never rendered to Medicare beneficiaries or by paying Dr. X a sum in excess of fair market value for the services he rendered to Medicare beneficiaries. Page 2 THIRD PARTY NEWSLETTER

3 ProPar BCBS of Nebraska s Health Care Clearinghouse In researching Medicare B and HIPAA EDI Dr. Quack found the following information at the Medicare B website which stated: To get started with electronic transactions and additional services [contact]: Pamela Black Blue Cross and Blue Shield of Nebraska 7261 Mercy Road Omaha, Nebraska (402) We contacted Pamela, who was helpful in explaining that she worked with ProPar, which is a clearinghouse that Blue Cross-Blue Shield of Nebraska has created. We then researched the ProPar Web Site (address and found the following information: About ProPar Who are we? ProPar Services, Inc. is a Nebraska based company. We are dedicated to the development of cost effective e-commerce solutions that fulfill the business requirements of health care business associates in Nebraska. What's in a name? Our name, ProPar, reflects our approach to e- commerce: Provider Partnerships We strive to make lasting partnerships with our business associates by providing them with quality products and services for increased value and productivity. ProPar e-commerce solutions One of the e-commerce business solutions available through ProPar is a Health Care Claims Clearinghouse. A health care claims clearinghouse facilitates the exchange of data between two parties, and can translate standard or non-standard data in accordance with the needs of the sender and receiver. Why choose a health care clearinghouse? Your selection of a health care clearinghouse is vital to your business. Take a look at some of the advantages of ProPar. ProPar Clearinghouse Advantages The following services are provided at no cost: Blue Cross Blue Shield of Nebraska, Medicare Part A and Part B claims submission echo Health desktop claim edit and submission software Provider set-up and health care insurance e- commerce consultation Dedicated, experienced, knowledgeable, and friendly support staff Pricing information The ProPar health care clearinghouse routes both commercial and Nebraska Medicaid claims to all major payers at a low cost to the customer. Pricing information will be available on this web site soon. Moving forward ProPar Services, Inc. offers all-payer solutions through echo Health, a desktop edit and transmission software, as well as through claims clearinghouse services. ProPar 's business plan is being developed with input from Nebraska providers gathered in a Spring, 2001 survey. Dr. Quack found this information interesting and thought it would be helpful to our NOA members since ProPar appears to be recommended by our Medicare B Carrier. However, this is not an endorsement of ProPar by Dr. Quack nor by the NOA. However, if time is drawing nigh and you have an EDI crisis, this resource might be helpful. VOLUME 3 ISSUE 6 Page 3

4 Medicare B Education Medicare Coding for the New Beginner: Back to Basics Workshops The Medicare Part B New Beginner Provider workshop is designed to give individuals a general overview on how to bill Medicare. Currently, Medicare Part B New Beginner Workshops, which are offered by the carrier, are free-of-charge. These workshops are offered on a first come, first served basis. However, registration is required due to occupancy capacity of the rooms. Reservations are accepted via Internet or US Postal Mail Service only. The deadline date for receipt of reservations is 5 days prior to the workshop date. Registration is easy. Individuals may elect to register on-line at NE_NEWPROVIDER.HTM. If mailing registration forms, send to: Medicare Part B, Department 346D2, P.O. Box 3543, Topeka, Kansas Attend a New Provider Workshop only if you need the most basic education on filing claims or need a refresher course. New Provider Workshops Agenda BENEFITS AND EXCLUSIONS BILLING INSTRUCTIONS SERVICES INCIDENT TO A PHYSICIAN'S PROFESSIONAL SERVICE ADVANCED BENEFICIARY NOTICE (ABN) REMITTANCE ADVICE APPEALS LOCAL MEDICAL REVIEW POLICIES / NA- TIONAL COVERAGE DETERMINATIONS FRAUD AND ABUSE WEB SITE INFORMATION QUESTIONS AND ANSWERS Date and Corresponding Workshop Number October 16, 2003 #VW3303N (Occupancy = 30) November 10, 2003 #VW3403N (Occupancy = 30) December 11, 2003 #VW3503N (Occupancy = 50) Event Location Memorial Health Center Rooms "A" and "B" 2116 West Faidley Avenue Grand Island, Nebraska Bryan West Hospital Cheyenne Room 2600 South 16th Street Lincoln, Nebraska Midlands Hospital Ogram Room South 84th Street Papillion, Nebraska Scheduled Time 1:00 P.M. to 4:30 P.M. 1:00 P.M. to 4:30 P.M. 8:30 A.M. to 12:00 P.M. Page 4 THIRD PARTY NEWSLETTER

5 Dr. Quentin Quack s Queries and Questionable Quotes ~~~~~~~~~~~~~~~~~~~~~~~~~~ Third Party Questions from NOA Doctors and Staff ~~~~~~~~~~~~~~~~~~~~~~~~~~ TRAUMA CODE EDITS Dr. Quentin Quack Dr. Quack received a question in September regarding electronic claims, trauma codes, and when to check the accident box yes. After stumbling around and getting mud on his bill, Dr. Quack (with the help of the inquirer) found the following information at the BCBS web site (exact address is listed below.) This information should be helpful to those starting out with electronic billing. There are just two rules to follow when it comes to trauma codes: 1. When a claim record includes a primary diagnosis code from the trauma code range for a payer, you must enter an accident date and an accident indicator. 2. When the claim record contains an accident date and indicator, you must enter a primary diagnosis code from the trauma range for that payer. BCBS Nebraska Trauma Codes MEDICARE PART B TRAUMA CODES effective 2/ V015 V V045 V V155 V V V V VOLUME 3 ISSUE 9 Page 5

6 NEBRASKA OPTOMETRIC ASSOCIATION 201 N. 8TH Street, Suite 400 P.O. Box Lincoln, NE ABSTRACTS OF THIS MONTH S ISSUE COMPLIANT HIPAA ELECTRONIC TRANSACTIONS WILL NOT BE REQUIRED BY OCTOBER 16 The Centers for Medicare & Medicaid Services (CMS) announced that it will implement a contingency plan to accept non-compliant electronic transactions after the October 16, 2003 compliance deadline. Page 1. COMPLIANCE: MISLEADING STATEMENTS; KICKBACKS False Statements and Representations It is a crime to knowingly and willfully make, or cause to be made, false statements or representations in applying or benefits or payments under all Federal health care programs.. Anti-Kickback Statute It is a crime to knowingly and willfully solicit, receive, offer, or pay remuneration of any kind (e. g., money, goods, services) Page 2. PROPAR CLIEARINGHOUSE In researching Medicare B and HIPAA EDI Dr. Quack found the following information at the Medicare B website regarding the ProPar Clearinghouse. Dr. Quack thought this information might be helpful to our NOA members since ProPar appears to be recommended by our Medicare B Carrier. However, this is not an endorsement of ProPar by Dr. Quack nor by the NOA. However, if time is drawing nigh and you have an EDI crisis, this resource might be helpful. The following services are provided at no cost: Blue Cross Blue Shield of Nebraska, Medicare Part A and Part B claims submission echo Health desktop claim edit and submission software Provider set-up and health care insurance e-commerce consultation. Page 3. MEDICARE CODING FOR THE NEW BEGINNER: BACK TO BASICS WORKSHOPS A Medicare Part B New Beginner Provider workshop is being provided to give individuals a general overview on how to bill Medicare. Currently, Medicare Part B New Beginner Workshops, which are offered by the carrier, are free-of-charge. Page 4. TRAUMA CODE EDITS Medicare and BCBSNE have trauma code edits that are based on diagnosis codes. This list is an excellent resource to use to resolve those edits. Page 5. Dr. Quentin Quack s Queries...continued O ccasionally Dr. Quack s fax machine or contains a question or story that is interesting, but may not pertain directly to third party care. Dr. Quack feels that he should share some of these humorous thoughts. Five surgeons were discussing who made the best patients on the operating table. The first surgeon said, "I like to see accountants on my operating table because you open them up, everything inside is numbered." The second responded, "Yeah, but you should try electricians! Everything inside them is color coded." The third surgeon said, "No, I really think librarians are the best... Everything inside them is in alphabetical order." The fourth surgeon chimed in, "You know, I like construction workers. Those guys always understand when you have a few parts left over at the end." BUT...the fifth surgeon shut them all up when he observed, "You're all wrong... Politicians are the easiest to operate on... no guts, no heart, and no spine, plus their skull and colon are interchangeable." The NOA Third Party Newsletter is published monthly by the Nebraska Optometric Association with the assistance of Ed Schneider, O.D., Third Party Consultant. To reach Ed (aka Dr. Quack): Fax & Voic Address: SchneiderEd@msn.com To reach the NOA: Nebraska Optometric Association 201 North Eighth Street, Suite 400 P.O. Box (68501) Lincoln, Nebraska Phone: Fax: VOLUME 3 ISSUE 9 Page 6