August 28th, 2016
Horizon NJ Health
- Claims billed to Horizon NJ Health still have processing issues and hospitals are realizing increased receivables. One hospital reported that they were told by TriZetto that their systems will not be fully updated until August 2016. To date, there does not seem to be material improvement. Issues include but are not limited to:
- Claims are priced incorrectly.
- Claims are returned if not completed on the red and white form. This includes some, but not all claims sent electronically.
- Phone contacts take up to 45 minutes.
- Claims deny for no authorization though the authorizations were obtained.
- NJHA asked the Department of Business and Insurance to monitor. Providers who need assistance should contact Gregory Papazian via email at firstname.lastname@example.org. Mr. Papazian is responsible for all provider relations areas. You are encouraged to send this as a special request and NOT as a routine project list. If it is a routine “project” many hospitals noted it can take months to resolve.
- The August 30, 2016 “Open Claims Issues” is attached with the dates for the scheduled fixes.
- Medicare Change Requests:
- MM9603 will be implemented on January 3, 2017. Medicare is imposing the use of the JW modifier for any claims associated with discarded drug or biologicals not administered to any patient. This must also be documented in the patient’s medical record. (See Attachment)
- SE1615 informs providers that Medicare will cover Zika Virus testing. (See Attachment)
- MM9740 will be implemented on January 3, 2017. The Common Working File (CWF) is adding an auto-search capability that will eliminate the need to go through multiple hosts to obtain eligibility information.HFMA Update
Federal Issues: The Fiscal Year (FY) 2017 Proposed Hospital Outpatient Prospective Payment System (OPPS) Rule was released Wednesday, July 6, 2016. Comments are due to CMS September 6, 2016.
- Payment Update: CMS proposes to utilize the 2.8% hospital market basket increase for OPPS. Reductions will be taken as mandated by the Affordable Care Act (ACA):
- 0.5% adjustment for multi-factor productivity and
- an additional 0.75% adjustment.
- this results in a net market basket of 1.55%.
- ASC service payments are updated for inflation by the percentage increase in the Consumer Price Index for urban consumers (CPI-U), which is proposed at 1.7% for calendar year (CY) 2017. In addition, there is a 0.5% multifactor productivity adjustment resulting in a net CPI-U update factor for CY 2017 of 1.2%.
- Section 603 of the Bi-Partisan Budget Act:
- CMS included information in the rule regarding implementation of Section 603 of the Bipartisan Budget Act of 2015. Section 603 states that services furnished in off-campus provider based departments (PBD), (excluding dedicated emergency department services that began billing on or after November 2, 2015) will no longer be paid under the OPPS and will be paid under Part B payment systems beginning January 1, 2017.
- Beginning in 2017, the rule proposes the payment be based on the physician fee schedule for site-neutral rates for most services furnished in a new off-campus PBD. The payment, which would be at the “non-facility” PFS rate, is for physicians only; CMS proposes no payment be made directly to the hospital by Medicare.
- Existing off-campus PBD (before November 2, 2015) that expand their clinical services are subject to the site-neutral rate as would any facility that relocates after November 2, 2015. An off-campus PBD that existed prior to November 2, 2015 and undergoes a change of ownership after that date will be exempt from the site-neutral rate only if the new owner accepts the existing Medicare provider agreement from the prior owner.
- Electronic Health Record (EHR) Incentive Program:
- In the rule, CMS recommends a 90-day reporting period for 2016, versus the full year.
- They also propose to reduce the requirement for patients to view, download and transmit their information from the current 5% obligation down to a minimum of one patient.
State Issues The State Fiscal Year (SFY) 2017 Budget was finalized June 30, 2016:
- Charity Care
- The final SFY 2017 budget contains $200 million less for charity care, reducing in the pool from $502 million to $302 million. This is the result of a $150 million reduction in the Governor’s proposed budget and an additional $50 million cut that Governor Christie put forward as revenues lagged.
- The Legislature stood with NJHA in rejecting this additional $50 million cut, but Governor Christie used the line-item veto to implement the reduction.
- The charity care distribution formula uses the 2004 statute, pro-rating down to account for the reduced amount of charity care funding in the SFY 2017 budget. The distribution formula is the same as the one released in the Governor’s proposed budget in February.
- The state is reimbursing hospitals with the highest relative charity care burden at 96% of what Medicaid would have paid for those patients (96 cents on the dollar) based on calendar year 2014 documented charity care. The formula removes any upward cap over the prior year that would have limited any charity care subsidy increase to hospitals.
- Graduate Medical Education (GME) will see an increase of $60.7 million, raising that pool from $127.3 million to $188 million for the state’s 42 teaching hospitals.
- The $188 million FY 2017 GME funding will be distributed using 2014 CMS Medicaid cost reports.
- This year’s formula requires facilities receiving GME funding to report to the Commissioner of Health the number of physicians who plan to remain in New Jersey.
- The Delivery System Reform Incentive Payment (DSRIP) fund will remain at last year’s level of $166.6 million.
- The Mental Health Subsidy Fund will hold at the same level as last year at $24.7 million.