August 5th, 2016
- The July 20, 2016 “Open Claims Issues” is attached with the dates for the scheduled fixes.
- MLN Matters article SE1604 summarizes available Medicare coverage for substance abuse services. (See Attachment)
- April 2016: MM9533 informs providers about the Comprehensive Care for Joint Replacement (CJR) education. The new CJR model is established to promote quality and financial accountability for episodes of care surrounding Lower-Extremity Joint Replacement (LEJR) or reattachment. Joint replacement procedures are currently paid under DRG 469 or 470. Under the new guidelines, the episode will include the LEJR procedure, inpatient stay and all related care under Medicare Parts A and B within the 90 days after discharge.
- Medicaid released a newsletter advising providers that on or about July 1, 2016, DMAHS will terminate enrollment of NJ Family Care fee for service providers who have not completed a re-enrollment application.
- May 2016: Permedion audits are enforcing the regulation that the admit order must be the same day of admission. This causes denials when a baby is born on one day and the pediatrician does not write the admit order until the next day.
- Maternity claims for the mothers are overpaid as they are grouping them into a surgical DRG. Medicaid is advising hospitals to “hold” them until the recap occurs. There is no timeframe for these recoupments.
Aetna Better Health
Several hospitals have reported discrepancies with Aetna Better Health payments. Primary accounts are not paying at the contracted rates and secondary accounts have been erroneously declined as having no authorizations.
HFMA Patient Financial Services: Pertinent Info
- Long Term Acute Care (LTAC) Payment Rules
- LTAC patient claims must be filed by acute hospitals within a specific time frame. On October 1, 2016 there will be a payment policy change. The new rule changes may negatively impact payments. LTAC’s may receive the lower IPPS rate instead of the LTAC PPS rate.
- Two Midnight Rule Audit Pause
- There is detail on the CMS website noting CMS found inconsistencies in the audit process.
- Review all denied claims since October 2015 to ensure decisions are in line with the current policy. Re-review these accounts before you appeal.
- Communicate with Livanta BEFORE you appeal to determine where your hospital stands.
- Education has been provided to some hospitals, but not all. The algorithm of how to proceed is on Livanta’s website.
- RAC: On June 2, 2016 a new timeline in the active procurement process was received.
- May 16, 2016: the last day an auditor can send an ADR
- July 29, 2016: the last day you can be notified of an improper payment
- August 28, 2016: the last day for discussion
- October 1, 2016: the last day the RAC can send claim adjustment files to the MAC’s.
- If the RAC does not meet one of the deadlines, the account review “should be” closed, however this is not yet certain.
- HNJH TriZetto Trading Partner Systems issues continue:
- Claims are still not processing correctly. When the roll out began in April 2016, over 13,000 claims incorrectly denied for missing the primary payer EOB. Some still remain unprocessed.
- In May, approximately 45,000 claims were received at HNJH’s office after being forwarded there from their former, London, KY office. These accounts are said to be processed, but follow up is needed at many facilities.
- Their systems will not be fully updated until August.
- Claims are not accepted and are returned if not submitted on a red and white UB04. Most hospitals can easily create a black and white UB04 for submission, but preparing a red and white UB04 is inefficient for many.
- Phone calls take up to 45 minutes to answer.
- Claims deny for no authorization, despite a valid authorization obtained and on file.
- Locals processing through Horizon Blue Cross are recapping payments stating patients were not covered on the dates of service, even though Hospitals verified benefits upon admission. NY Medicaid
February 2016: The Affordable Care Act mandates that all Medicaid providers must be revalidated every 5 years. Revalidation is to be completed by March 2016. (See Attachment)
Property Tax/Not-for-Profit Tax Status
March 2016: During the lame duck session, the Hospital Community Service Contribution Bill was passed through both the Senate and the Assembly.
- Non-Profit Hospitals with For-Profit operations would have to make Community Service Contributions directly to their municipalities. The payment formula is set at $2.50 per day for each acute care hospital bed and $250 per day for each facility providing Satellite Emergency Care. It would generate roughly $20 million in revenue per year.
- Municipal payments would be dedicated to property tax relief and public safety (police, fire and emergency services). Five percent of the payments would be sent to the county where the hospital is located.
- Voluntary contributions by the hospitals would be deducted from the community service payments and any hospital that is losing money could apply for an exemption from the payments.
- Not-for-Profit hospitals would retain their tax-exempt status.
On January 19, 2016, Governor Chris Christie used a pocket veto to stop the bill, effectively vetoing the Hospital Community Service Contribution Bill. There was no opportunity for an overriding vote.
- A new bill will now have to be reintroduced in the regular legislative session and pass through the Senate and Assembly again.
- NJHA is in contact with the Governor’s office to determine the reasoning behind the pocket veto in case modifications need to be made to a future version of a bill.
Veteran’s Administration Claims
The Department of Veteran Affairs continues to have a material backlog processing claims, now stated to be eight months. Emergency care is covered, but no additional services are. Once patients are stabilized, they should be transferred.