North Carolina Health Insurance Institute October 10-11

Transcription

North Carolina Health
Insurance Institute
October 10-11, 2013
Greensboro, NC
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Proprietary information of MedCost, LLC. Do not distribute or reproduce without express permission of MedCost.
What’s New With MedCost?
We are celebrating 30 years of being in business.
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A New Web Site and Logo
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Enhanced Information on the Web Site
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MedCost Initiatives – What We Are Doing Regarding
The Changing Landscape In Healthcare
• Improving Member and Provider Experience
• Managing Cost of Total Care
• Improving the Health of Populations
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• We are serving in a role as a trusted advisor on health care
reform legislation and changes.
• Commitment to exceptional and local customer service.
• Exploring ways to collaborate with providers to meet their needs
as we move from pay for volume (Fee for Service) to pay for
value.
• We are working with our partners to ensure compliance for the
October 1, 2014 go live for ICD-10.
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• MedCost is moving to an integrated delivery model and
exploring options with providers to accommodate the changing
landscape. Since January 1, 2013 we have been piloting a
Patient-Centered Medical Home model (PCMH) with another
health system in Southeastern NC to help reduce readmits and
ER visits.
• Expected trend is that with healthcare reform employers will be
looking at self-funded options.
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We are working with HealtheReports as a pricing Transparency tool to allow
patients to compare pricing, quality of care, and see feedback of other members
regarding their experience with providers they are considering. An example is
shown below for a common procedure for four providers.
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Top 5 Reasons Claims Are Denied By Payer
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Incorrect member/group information
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Use information on ID Card.
File group # and alternate member # as shown on ID Card.
Claims filed on paper rather than EDI
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Standard practice to file electronically.
Many systems require electronic claims for receipt of payment thereby forcing the translation paper to EDI.
To validate the integrity of the data, providers should file to MedCost in a standard EDI format through their
clearinghouse or practice manager.
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Claims filed that require additional information
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Prompt response from provider is expected when a request for additional information is made.
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Providers should check EOBs to validate they documented the difference between a denial and a request
for information.
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Claims filed with invalid or incorrect diagnosis code or CPT codes
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Use the most appropriate dx code and CPT code per detail line.
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Routine wellness visits present challenges and issues could be minimized if appropriate codes are filed.
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Many dx codes in the V ranges are designed to be a secondary dx and could result in a denial if billed as
the primary dx code.
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Update of patient information for other coverage.
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Ensure other COB information is included in the electronic claim filing to MedCost.
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ICD-10 Key Facts & MedCost Readiness
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The October 1st ICD-10 implementation will accommodate new procedures
and diagnosis unaccounted for in the ICD-9 code set and allow for greater
specificity of diagnosis-related groups and preventative services.
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MedCost is prepared for the transition to ICD-10 and will only accept claims
for services rendered on or after the implementation date that are coded
using ICD-10 codes. MedCost will not accept ICD-10 before the
compliance date. Claims are processed based off of the discharge date.
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MedCost will follow CMS guidelines regarding any claims with dates of
service through 9/30/14 being filed with ICD-9 codes. All ICD-10 codes
need to be placed on a separate claim with dates of services 10/1/14 and
after.
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ICD-10 – Getting Ready for ICD-10:
MedCost Resources for Providers
MedCost ICD-10 Webinar
MedCost offers a pre-recorded ICD-10 Webinar for you to view at your convenience.
To access, go to our website at www.medcost.com, click Providers portal, select
Provider Education, and click on ICD-10 CM Webinar. Highlights include:
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An overview of the major differences between ICD-10 and ICD-9.
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How the transition will impact your practice.
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The history of ICD-10 and why the industry is moving in this direction.
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Comparison of present and future coding changes specific to the 122,809
new codes.
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New formatting and fracture coding features, changes specific to body
systems and physician documentation, and the deletion of V-codes.
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Electronic Communications
MedCost will continue to update providers via our website and Provider
Connection Newsletter
If you would like to sign up for electronic communications or provide
feedback, please e-mail us at [email protected].
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Inclusive Health Updates
Purpose
Established the North Carolina Health Insurance Risk Pool in 2007 to provide affordable, individual health
insurance coverage to North Carolinians who do not have access to an employer health plan and face
higher premiums or who have been denied coverage due to a pre-existing medical condition.
Inclusive Health – State Option in North Carolina
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Inclusive Health will end coverage for all State Option Plan members at midnight on December 31, 2013.
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Inclusive Health will continue to process all claims with a date of service prior to January 1, 2014, that are
submitted on or before March 31, 2014.
Inclusive Health – Federal Option in North Carolina
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As of July 1, 2013, Inclusive Health no longer administers the Federal PCIP (Pre-existing Condition
Insurance Plan). Members of the Inclusive Health Federal Option Plan were required to change their
coverage to a federally administered PCIP plan to continue their risk pool coverage for the remainder of
2013.
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For additional questions or concerns regarding this change, please visit the Inclusive Health website at
www.inclusivehealth.org or call 1-866-665-2117.
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Legislative Updates
Health Benefit Exchanges
Online insurance marketplace available to individuals & small employers
• Open Enrollment: Open enrollment began on October 1, 2013 and runs through March
31, 2014 (shorter open enrollment in future years)
• NC/SC/VA/TN – Federally Facilitated Exchange
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Legislative Updates
NC Transparency Legislation – HB 834
What Does the Legislation Do?
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Requires providers and DHHS to make available to the public information about the cost of health care.
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Goal: Improve transparency in health care costs by reporting cost information to the public.
What information be submitted to DHHS?
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Must disclose the following pricing arrangements:
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Full charges billed to uninsured patients
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Average negotiated rates with uninsured patients
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Medicaid reimbursement
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Medicare reimbursements
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5 largest health insurers providing payments on behalf of insureds [NAME OF INSURER WILL BE
REDACTED]
Applies to the following admissions/procedures:
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100 most frequently reported admissions by DRG (identified by DHHS)
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20 most frequent imaging/surgical procedures.
Who must submit this information?
• Hospitals & ambulatory surgical facilities
When?
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100 most frequent admissions – by June 30, 2014
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20 most frequent imaging/surgical procedures – by September 30, 2014
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Hospitals will be listed separately and by category.
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Hospital outpatient & ambulatory surgical facilities listed separately.
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DHHS tasked with coming up with rules & framework for how this information would be disclosed.
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Transparency in Health Care Costs.
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Will not be payer specific.
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Legislative Updates
NC Transparency Legislation – Other Provisions of HB 834
Charity Policy & Costs (Hospitals & Ambulatory Facilities)
• Hospitals/facilities must report financial assistance policy & costs
• Publically available on DHHS website
New debt collection requirements – examples:
• Right to request itemized bill
• Provider must refund undisputed overpayments within 45 days of notice
• Cannot bill patient for amounts denied by insurance because of untimely filing
• Tight restrictions on collections activities
• Must give accurate information regarding network status.
Health Information Exchange
• Established to collect patient demographic and clinical data on all services paid for with
Medicaid funds
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Legislative Updates
HIPAA Final Omnibus Rule
Key Provisions – Effective September 23, 2013
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Privacy & security rules directly apply to business associates & subcontractors
Expands patient right to request/receive copies of PHI
Greater ability to restrict sharing of PHI with insurance plans (after payment in full)
Modification of breach notification rules
• “Low probability” standard
• New risk assessment
New notice of privacy practices requirements
New requirements for Business Associate Agreements
New limitations on use of PHI in marketing/fundraising
New enforcement mechanisms & penalties
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Questions?
Thank you for your time today
and being a part of MedCost!
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North Carolina Health Insurance Institute October 10-11

Transcription

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