Tagged with Provider Contracting and Enrollment

Maryland Owes Millions of Dollars to Mental, Behavioral Health Providers

Mental and behavioral health providers in Maryland are owed millions of dollars for services that have gone unpaid because of a malfunctioning state payment system. The Maryland Health Department has begun sending providers estimated payments totaling about $32 million per week until the system is fixed.

Anthem CT Outpatient Facility Edit Implementation

Beginning with claims processed on and after April 26, 2020, Anthem Connecticut will be enhancing its outpatient facility edits for revenue codes, Current Procedural Terminology (CPT®) codes, Healthcare Common Procedure Coding System (HCPCS) and modifiers.

CMS Issues Quarterly Update to the NCCI PTP Edits

As a guide for physicians, providers, and suppliers billing Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries, CMS has released an update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edits. The agency hopes the update will promote national correct coding methodologies and to control improper coding that can lead to inappropriate payment in Part B claims.

CMS Issues Additional Guidance on D-SNP Integration Requirements

On January 17, CMS issued a memorandum providing additional guidance clarifying Medicare-Medicaid integration requirements for Dual Eligible Special Needs Plans (D-SNPs). The memorandum is intended to clarify distinctions between fully integrated D-SNPs (FIDE SNPs) and highly integrated (HIDE SNPs); permissibility of carve-outs of behavioral health services and long term services and supports (LTSS) for FIDE SNPs and HIDE SNPs; alignment of D-SNP and companion Medicaid plan service areas; and compliance with integration requirements for DSNPs that only enroll partial-benefit dually eligible individuals.

UHC Medical Policy Updates

UnitedHealthcare (UHC) has released its 2020 Summary of Changes to Advance Notification and Prior Authorization Requirements.

CMS Issues Advanced Alternative Payment Model Incentive Payment Advisory

CMS has released a payment advisory alerting certain clinicians who are Qualifying APM participants (QPs) and eligible to receive an Advanced Alternative Payment Model (APM) Incentive Payment for 2019, that the agency does not have the current banking information needed to disburse the payment and provides information on how to update banking information to receive this payment.

Ohio to Transition to Single List of Preferred Medicaid Drugs

Ohio has announced that the state will transition to a single list of preferred Medicaid drugs, effective during the first quarter of 2020, in an attempt to streamline prior authorization and reduce confusion among beneficiaries, providers, and pharmacists.

CMS, HHS Proposes Changes to Stark Law and Anti-Kickback Statute Reforms

On October 9, the Department of Health and Human Services (HHS) announced proposed changes that seek to modernize and clarify the regulations that interpret the Physician Self-Referral Law (the Stark Law) and the Federal Anti-Kickback Statute. The proposed rule has been designed to provide greater certainty for healthcare providers participating in value-based arrangements and providing coordinated care for patients. The proposed changes are intended to ease the compliance burden for healthcare providers across the industry while maintaining strong safeguards to protect patients and programs from fraud and abuse.

ACR Seeks Urgent Action Opposing Cuts to Radiology

The American College of Radiology (ACR) is seeking help in its efforts to urge Congress to stop CMS from implementing proposed changes to the Evaluation and Management (E/M) Codes that could result in severe cuts to radiology.

Humana Releases Latest Claims Payment Policy Updates

Humana has published its latest medical claims payment policy updates, including its reimbursement policy for ambulance transportation, requirements for billing and documentation of observation services, as well as a new policy for obstetric billing, including antepartum, delivery and postpartum care.

New York Health + Hospitals Expands Health Program for the Uninsured

On October 4, New York City’s public hospital system, NYC Health + Hospitals, established a new program to provide health care to New York City’s uninsured, called NYC Care. The program originally launched in August and has a current enrollment of 5,000 people, and will expand into Brooklyn and Staten Island in January 2020.

Texas to Receive Increase in Federal Funds for Uncompensated Care

The Texas Health and Human Services Commission announced, on October 1, that the state will be given $11.6 billion over the next three years to help reimburse health care providers for indigent services and is intended to benefit hospitals, clinics, public ambulance, and dental providers.

Proposed Legislation Aims to Improve Provider Directories Accuracy

Two physician lawmakers have proposed new legislation that aims to improve the accuracy of information in health plan provider directories and protect patients from surprise out-of-network bills. The Improving Provider Directories Act (HR 4575) would require health plans to provide an avenue for people to report errors in provider directories, in a “highly visible way”.

Executive Order Issued to Protect Traditional Medicare and MA Plans

The president, on October 3, signed an executive order directing the Department of Health and Human Services to increase efforts to provide more insurance plan options under Medicare Advantage and to remove regulations that are considered burdensome to health care providers. The order is intended to protect traditional Medicare and private Medicare Advantage while ramping up alternative payment models, time spent with patients, access to innovative technology and reducing the regulatory burdens on providers.

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