Provider Compliance Programs Required for Medicaid Re-enrollment

The ACA applicant or re-enrolling provider must certify that it has a compliance program containing the core elements as established by the Secretary of Health and Human Services referenced in Section 1866(j)(8) of the Social Security Act (42 U.S.C. Sections 1395cc(j)(8), as applicable.
• Conducting internal monitoring and practice standard
• Implementing compliance and practice standards
• Designating a compliance officer or contact
• Conducting appropriate training and education
• Respond appropriately to detected offenses/ develop corrective actions
• Developing open lines of communication
• Enforcing disciplinary standards through well-publicized guidelines

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ACA Webinar Update and Important Information

The webinar will be conducted by TMHP via a virtual classroom, hosted on the TMHP Learning Management System (LMS), and delivered as a presentation of information, with limited participant interaction. The webinar is tentatively scheduled to occur the week of March 20th, 2013.

TMHP will communicate ACA Webinar Invitation to the professional organizations via email. The communication will include information about the webinar, a high level agenda, instructions for registering as an LMS user, webinar registration information, and participation limits. Participation in the webinar is limited to 100 participants. The intent is to present information to the provider community. Participation by non-provider entities, to include the associations may be limited to no more than 30 seats.

The event will last 1 hour, with 35 minutes allotted for presentation of content, 20 minutes for question/answer (Q&A), and 5 minutes for discussing resources.

Questions from participants will be received via the “chat” function in the virtual classroom. These questions will be sorted and categorized, and some will be selected to be answered during the allotted Q&A time.

Questions not addressed or answered during the webinar will be compiled and answered after the webinar, and be incorporated into the existing “ACA FAQ” document.

A hyperlink to the ACA webpage and the complete ACA FAQ document will be added to the TMHP LMS upon completion and HHSC approval

The webinar will be recorded, and posted to the TMHP LMS no later than 10 business days after the webinar (tentatively the week of April 3rd, 2013).

A provider notification regarding the posting of the recorded webinar will be published via traditional methods (a web article and banner message) on the TMHP website.

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Affordable Care Act Enrollment

Effective January 1, 2013, Texas Medicaid is complying with the provisions of section 6401 of the Affordable Care Act of 2010 (ACA) affecting the enrollment of Texas Medicaid providers. All Medicaid providers will be required to re-enroll in Texas Medicaid and to do so every three to five years per the risk category from Texas Medicaid. There will be an application fee at initial enrollment and re-enrollment unless that fee has already been paid for an application with their Medicare enrollment. All institutional providers are required to pay the application fee.

There is no application fee for: a group practice; physician, non-physician practitioner; and outpatient physical therapy/occupational therapy/speech pathology service providers that enroll via the CMS-855B.

Providers are categorized by their risk level of fraud, waste and abuse which determines their required screening elements. CMS and HHSC are responsible for the risk category assigned to a provider:

These providers are assigned as Limited Risk providers: physicians, non-physician practitioners; medical groups and clinics; ambulatory surgical centers (ASCs); audiologists; federally qualified health centers (FQHCs); hospitals, including critical access hospitals; end stage renal disease facilities; occupational therapists enrolling as individuals or as group practices; pharmacies; radiation therapy centers, rural health clinics (RHCs); skilled nursing facilities; and speech language pathologists.

The limited risk category required screening elements are verification of provider-specific requirements, including but not limited to the following:
• License Verification
• National Provider Identifier (NPI) verification
• Federal and state database checks
• Ownership/controlling interest information verification

Beginning January 1, 2013, all providers must re-enroll at least every five years. Suppliers of durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) are required to re-enroll at least every three years. HHSC may require certain providers to re-enroll more frequently.

HHSC, through correspondence from TMHP, will notify providers when they are to submit their re-enrollment applications. Do not submit anything until they tell you to.

HHSC says they will work through health care professional associations, the providers themselves, and through the managed care Medicaid HMOs to notify providers as to when each provider will need to submit their Texas Medicaid re-enrollment applications

The Texas Health and Human Services Commission (HHSC) has posted a Frequently Asked Questions (FAQ) to the TMHP website.

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Texas Register Texas Medical Board Employment of Physicians

A recent decision overturning a legislative rule was made by the Texas Medical Board that has significant impact for RHC Physician Assistant and Nurse Practitioner owners. Previously the Texas Legislature during its last session had approved a bill that said effective in January 2012, a PA or NP could not own the majority interest in a RHC. Only PA and NP owners of current existing RHCs were grandfathered. This requirement has now been overturned by the Medical Board after a number of non-physician providers obtained legal advice and court support to overrule that requirement. Below is a section from the current Texas Register that overturns the rule.

“The Texas Medical Board (Board) has adopted the amendments to Section 177.17, concerning Exceptions to Corporate Practice of Medicine Doctrine , without changes to the proposed text as published in the July 27, 2012,issue of the Texas Register (37 TexReg 5539) and will not be republished.

The amendments to Section 177.17 to provide exception to doctrine for rural health clinics that meet the requirements of 42 CFR 491.8. The Board sought stakeholder input through Stakeholder Groups which made comments on the suggested changes to the rule in a meeting held on July 20, 2012. The comments were incorporated into the proposed rules.

The Board received comments regarding Section 177.17 from the Texas Medical Association (TMA).

TMA commented that the proposed rule exceeds the Texas Medical Board’s statutory authority that prohibits the corporate practice of medicine under the Medical Practice Act, including Section 164.052(a) (17) that prohibits physicians from aiding and abetting the practice of medicine by unlicensed persons.

The Board disagrees with this comment. Under federal law, specifically, 42 CFR 491.8, it provides that in relation to federally qualified health centers and rural health clinics, “The physician assistant, nurse practitioner, nurse-midwife, clinical social worker, or clinical psychologist member of the staff may be the owner or an employee of the clinic or center, or may furnish services under contract to the center.” < clinic means Rural Health Clinic RHC and center means a Federally Qualified Health Center FQHC> The Board has made the determination that as federal law has granted physician assistants the authority to own rural health clinics, that Board rules may recognize that authority and not penalize physician assistants for exercising their rights. Further, the Board supports the intent of the federal law which is to improve access to primary health care in rural, underserved communities and promote a collaborative model of health care delivery.”

Source: The Secretary of State John Steen

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New Rule Protects Patient Privacy, Secures Health Information

The U.S. Department of Health and Human Services (HHS) has announced a new rule to strengthen the privacy and security protections for health information established under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The rule replaces the harm threshold form the interim rule on breach notification with a more objective standard. It also requires business associates to comply with specific HIPAA privacy and security requirements, and imposes direct liability for their noncompliance with these regulatory standards. In addition, the rule incorporates the increased and tiered civil money penalty structure provided by eth HITECH Act; makes changes to the use of and disclosure of protected health information in certain circumstances; and prohibits most health plans from using or disclosing genetic information for underwriting purposes, as required by the Genetic Information Nondiscrimination Act.

Individual rights are expanded in important ways. Patients can ask for a copy of their electronic medical record in an electronic form. (The state has already addressed this electronic health record request from a patient in Texas House Bill 300, which went into effect on September 1, 2012, with requirements to furnish electronic records within 15 days of a patient written request instead of the HIPAA requirement of within 30 days.)

The new rule allows for when individuals pay by cash they can instruct their provider not to share information about their treatment with their health plan. You might want to discuss this with your insurance network provider representatives to make sure everyone is straight on that new wrinkle. I know from dealing with my network contracts they don’t like it when their members do such actions like this off line and don’t tell the health plan when they have medical procedures done and appear to be hiding medical conditions from their insurance payer.

The final omnibus rule sets new limits on how information is used and disclosed for marketing and fund raising purposes, and prohibits the sale of an individual’s health information without their permission. The final rule takes effect March 26; however covered entities and their business associates generally will have until September 23 to comply with most of the rule’s provisions .The 563-page HIPPA Privacy, Security, Enforcement and Breach Notification Rules, FR Document 2013-01073 may be viewed in PDF form in the Federal Register in the Health and Human Services Department section.

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Texas Primary Care Provider Fee-For-Service Rate Increase Delayed

Texas will be increasing Medicaid primary care fee–for-service rates, those for certain physician visits and vaccine administration, as quickly as possible. However the state did not receive final federal regulations on the increase until November 1, 2012. This was too late to allow the state to meet the January 1, 2013 date authorized in the Affordable care Act. Once the state increases primary care rates, the Medicaid Managed Care Organizations (MCOs) should be making retroactive payments for increase for fee-for-service providers and services that qualify under the federal regulations. This fee increase does not apply to the RHC encounter rate. RHCs are reimbursed on a facility cost basis and this fee-for-service increase does not apply to RHC encounter rates. However, the Medicaid RHC encounter rate will increase in the beginning months of 2013 due to the annual adjustment that is done every year. When you receive your TMHP Medicaid RHC encounter 2013 rate increase letter, don’t forget to send a copy to the MCOs that you are contracted with in order to be paid correctly.

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December RHC Technical Assistance Call

The next Rural Health Clinics Technical Assistance (RHC TA) call has been set for Wednesday, December 19 at 1:00pm (Central). We are pleased that Anne Ferrero, the program coordinator for the Small Health Care Provider Quality Improvement (Rural Quality) Grant Program is available to talk about this important initiative.

Rural Health Clinics are eligible to receive Rural Quality Improvement grant funds and are specifically named in the law as one of the target audiences. All RHCs — for-profit and non-profit — are eligible to participate in this initiative. Applicants may propose funding for up to three (3) years from September 1, 2013 to August 31, 2016. The maximum award is $150,000 per year. The Federal Office of Rural Health Policy (ORHP) expects to provide financial support for approximately 40 projects. The purpose of the Rural Quality Improvement project is to provide support to rural primary care providers for implementation of quality improvement activities. Organizations participating in the program are required to use health information technology (HIT) to collect and report data. It is expected that organizations will have implemented an HIT system by the time of award.

If you would like to learn more about this program and how Rural Health Clinics and other providers can apply for a grant, the call-in information is as follows:

Toll-free Number: 800-857-9747; Participant Passcode: 1914329

Anne will provide details on: how to apply for a grant; where to submit your grant application; the types of projects ORHP is interested in supporting; and, she will be available to answer any questions you might have. Several Rural Health Clinics have been funded during previous cycles and there is every reason to believe that RHC projects will be competitive this time around. The deadline to submit an application is January 30, 2013. ORHP strongly recommends that applicants submit their applications prior to the due date to avoid any technological problems.

We look forward to your participation on this important RHC Technical Assistance call.

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Texas Medicaid Wellness Program PCMH Webinar – Join Us to Learn What PCMH Can Do For You

You’re invited to attend a Texas Medicaid Wellness Program Webinar on Tuesday, January 15th, 12:00-1:00 p.m. (Central Time), to learn more about how the Patient Centered Medical Home (PCMH) can help you and your practice.

In this webinar, we will be discussing the purpose and background of the TX Medicaid Wellness Program, as well as PCMH and its impact on your practice. If you would like to learn more about PCMH and how it can benefit your practice, please join us for this webinar!

Please take a moment to register.

Other Helpful Resources:
The National Academy for State Health Policy has information regarding Medicaid paying for the patient centered medical home (PCMH). Since most rural health clinics have a substantial number of Medicaid patients it is important to determine if the State Medicaid plan is paying for Patient Centered Medical Home and if rural health clinic status will impact those payments. Here are some places to begin your search:

1. National Academy for State Health Policy Medical Home & Patient-Centered Care Map: (click on your state to see what is happening regarding Patient Centered Medical Home)
2. National Academy for State Health Policy Aligning Reimbursement & Purchasing: (this is a listing of all states and the Medicaid activity regarding patient centered medical home in that state)
3. National Academy for State Health Policy Aligning Health Information Technology and Delivery System Transformation Efforts
4. SuccessEHS (Electronic Health Record company in Birmingham, Alabama) has a white paper on patient centered medical homes.
5. NCQA ’s Patient-Centered Medical Home (PCMH)
6. TransforMED is how primary care practices become high-performing Patient-Centered Medical Homes (PCMH). The key from the financial side is to identify payers (either insurance or Medicaid and Medicare in the future) that will partner and pay for the transformation that will be needed in your practice to become certified. Of course, if you have electronic health records in your clinic, the transition will be much, much less difficult.
7. There were two NARHC hosted Rural Health Clinic Technical Assistance calls on this topic in 2011. You can access both the transcript and recording for these calls here. Scroll down to the presentations done on August 19, 2011 (Becoming a Patient Centered Medical Home) and November 29, 2011 (Becoming a Primary Care Medical Home: Why Should RHCs Take This Next Step?). The August presentation is an overview of the general value of PCMH status. The November presentation was by an RHC Administrator (Pine Medical Group in Michigan) who has gone through the process and been designated as a PCMH and she talks about the process and value to the RHC.

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Transitional Codes

The National Association of Rural Health Clinics (NARHC) after some discussion with the Centers for Medicare & Medicaid Services (CMS) has been informed that RHCs will be able to bill for the new care transition/coordination codes. Originally, there was some concern that this would not be the case because the proposed policy did not mandate physician/PA/NP involvement. However, in the final rule, CMS included a face-to-face encounter with one of the above providers for a medically necessary service therefore making the service a billable RHC encounter.

The two new codes are below along with the elements that will be necessary to bill for either of these codes. These will be billable as RHC encounters and the clinic will receive the RHC payment rate for these services.

99495 – Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and /or caregiver within 2 business days of discharge. Medical decision making of at least moderate complexity during the service period. Face-to-face visit, within 14 calendar days of discharge.

99496 – Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with eth patient and/or caregiver within 2 business days of discharge. Medical decision making of high complexity during the service period. Face-to-face visit, within 7 calendar days of discharge.

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TrailBlazer Medicare Contractor Coverage Ends Soon

Effective November 19, 2012, the Jurisdiction 4 (J4) Part B workload will transition to Novitas Solutions, Inc. (Novitas Solutions) as part of the JH implementation. The Trailblazer Part B toll –free numbers and IVR will no longer be in service after 4:00pm Central Time, November 16, 2012. Novitas will observe a “dark day” on November 19th to complete the cutover transition activities and offers a toll-free customer service line to be effective November 20, 2012.

The TrailBlazer J4 Medicare Administrator Contract (MAC) web site will no longer be available after 4:00 pm November 16, 2012.

Providers will need to access the Novitas Solutions web site https://www.novitas-solutions.com to obtain all Medicare information.

Reminder – contact Novitas at (855) 252-8782 for all Part A –related Medicare questions or visit the Novitas web site.

RHC Medicare (Part A) billing through TrailBlazer stopped at the end of October.

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