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PIPAC Monthly News BriefPublished February 2004On-Line Version -- The following articles are taken from our February 2004 monthly news brief. Click on the headlines below to jump to that story. For More Information Contact: Kimberly
Fullmer - Marketing & Communications Manager PIPAC/RIPAC Embarks on Mission to Explore Our Malpractice Options Check Your CIGNA, First Health EOBs for Correct Allowables HIPAA Standards Put the Kibosh on Grace Periods for Updated Code Sets New Contracts Are on the Horizon with ChoiceCare and CompNet Latest HIPAA Provision Set Forth in Final Rule PIPAC/RIPAC Embarks on Mission to Explore Our Malpractice Options Preferred/Regional Integrated Provider Access Corporation (PIPAC/RIPAC) membership represents a significant amount of malpractice liability premium that is currently spread out among a number of insurers, including NCRIC, Physician’s Mutual and BRIM, with various renewal dates and brokers. Because of this unstable and unpredictable marketplace across the country and especially in West Virginia, the PIPAC/RIPAC boards—and staff—have actively been looking into alternative malpractice solutions—and now we need your help. Taking Matters into Our Own Hands The PIPAC/RIPAC boards have heard from a number of consultants and brokers in recent months and have agreed upon engaging a highly qualified consultant, to serve as a consultant or facilitator in gathering malpractice loss history, premium dollar paid, as well as some information that is also required to credential our members (e.g., board certification). We would like to keep the task of gathering this information as painless as possible for all parties. Our consultant has stated that we will need malpractice claims and premium data for the last 10 years on all PIPAC members. Most of this comprehensive information about malpractice history is actually required on the standard statewide credentialing application. Authorization by the consultant to verify this data directly with each malpractice carrier must be provided by each PIPAC physician. An authorization form will be provided. The consultant has said that the key to success of this initiative lies in the minds and the hands of PIPAC’s physician membership. “If nothing happens, each member can expect to continue to be at the mercy of the insurance markets. At this point,” he adds,” physicians have little, if any, control of this very important business expense.” The Purpose of Aggregating Data By aggregating this data on PIPAC members into a central repository, we will then be able to present the information to other carriers. As a group purchasing organization, we will “sell” our group as a whole to other malpractice liability carriers. This data will indicate from an underwriting perspective whether the group is a good risk or a bad risk. PIPAC CEO John L. Fullmer has stated that the loss ratio among PIPAC members has been quite low. He said, “The problem is that we are grouped with all other physicians in the state for rating purposes. We feel we can do much better if we are underwritten as a group and can also save our members some of their hard-earned money.” Fullmer also adds that all of our members are credentialed according to NCQA/URAC quality standards, which also can be used to our benefit, from an underwriting and risk management perspective. Down the road, it is quite possible that as this data is analyzed in aggregate, that PIPAC/RIPAC physicians may be able to create our own risk retention group or “insurance facility.” That is, we are diligently working on a roadmap to a self-directed medical malpractice program that could potentially contain and redirect our premium dollars. We will continue to update you on the future process of this initiative. If you have any questions, please contact the PIPAC office at (304) 598-0363. For More Information Contact: Kimberly
Fullmer - Marketing & Communications Manager Check Your CIGNA, First Health EOBs for Correct Allowables Preferred/Regional Integrated Provider Access Corporation (PIPAC/RIPAC) has been informed by several member providers that recent explanation of benefits (EOB) from both CIGNA and First Health are not reflecting correct allowables. As you have been made aware, PIPAC members received a fee update (increase) with CIGNA, effective 12/01/03. Because of reports of incorrect allowables and reimbursement from providers, we encourage you to take a close look at this issue. These rates are available to you. If you have not yet obtained a reimbursement CD from the PIPAC office, call TODAY and one will be shipped to you. PIPAC also recently finalized a contract with First Health. The majority of providers opting in became effective 12/01/03 and the last remaining few became effective 01/01/04. If you are unsure of your effective date with First Health, please call Michelle Bolyard at (304) 598-0363. We have also received reports from providers that they too are not receiving correct reimbursement from First Health. Again, you are encouraged to double-check this. These rates are also included on the reimbursement CD. We don’t want to get into the same issue with the above payors that we found ourselves in last summer with Carelink. PIPAC is furnishing you with the information you need to assure you are receiving correct reimbursement. If this is NOT happening, we need to know about it. For More Information Contact:
Michelle Lynn Bolyard – Contracts & Reimbursements Manager HIPAA Standards Put the Kibosh on Grace Periods for Updated Code Sets Although the Centers for Medicare and Medicaid Services (CMS) has permitted providers to have a 90-day grace period after implementation of an updated code set to learn about the new and discontinued codes, the Health Insurance Portability and Accountability Act (HIPAA) has now put an end to this practice. Specifically, the HIPAA transaction and code set rule requires usage of the medical code set that is valid at the time that the service is provided. Since ICD-9-CM diagnosis codes are a medical code set, effective for dates of service on and after October 1, 2004 CMS will no longer provide a 90-day grace period for providers to use in billing discontinued codes on Medicare claims. Claims containing a discontinued ICD-9-CM code will be returned as unprocessable. Therefore, CMS issued two memoranda —one for HCPCS updates and the other for ICD-9-CM updates—on February 6, 2004, that instructs Medicare carriers and fiscal intermediaries to eliminate the 90-day grace period effective October 1, 2004 for discontinued ICD-9-CM codes and January 1, 2005 for discontinued HCPCS codes. For the 2004 HCPCS update, there will remain a grace period for submitting codes and modifiers that were deleted. Claims submitted with codes and modifiers deleted in the 2004 HCPCS update that are received prior to April 1, 2004, for dates of service January 1, 2004 through March 31, 2004, will be paid based on updated 2004 amounts. Claims received after March 31, 2004 with codes that were deleted in the 2003 update will be rejected. Rejected claims must be submitted as new claims with valid 2004 codes and modifiers. For More Information Contact: Kimberly
Fullmer - Health Care Policy Manager New Contracts Are on the Horizon with ChoiceCare and CompNet As you are reading this issue of the newsletter Monthly News Brief, Preferred/Regional Integrated Access Corporation (PIPAC/RIPAC) is in the process of finalizing group Agreements with two payers—ChoiceCare and CompNet. As you are likely aware, ChoiceCare was an affiliate of Private Healthcare Systems (PHCS) until 1999 when the health plan separated and became an independent network. According to our Agreement with PHCS, affiliates separating from PHCS have the right to “take” the existing Agreement and those who have opted into that Agreement with them. This means that any PIPAC providers participating with PHCS in 1999 are now participating with ChoiceCare under that Agreement. Those opting in with PHCS since 1999 are not currently participating with ChoiceCare, but will soon have the opportunity to opt in under a NEW direct Agreement with the payer. Those PIPAC members who are already participating with ChoiceCare under the PHCS umbrella will have the option of switching to this new agreement. Another payer we’re currently working with, CompNet, is a West Virginia Worker’s Compensation Plan that is administered through Acordia. We are in the process of working out the final details of an agreement with them and upon completion you will be receiving notification. We realize the frustrations that go along with Worker’s Compensation and are convinced that because of our affiliation with CompNet this will soon become less “painless.” For More Information Contact:
Michelle Lynn Bolyard – Contracts & Reimbursements Manager Latest HIPAA Provision Set Forth in Final Rule The Centers for Medicare and Medicaid Services (CMS)—formerly the Health Care Financing Administration (HCFA)— announced in late January the adoption of a National Provider Identifier (NPI) as the standard unique identifier for health care providers to use in filing and processing health care claims and other transactions. The standard unique health identifier is mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The NPI is a new number that will be issued through the National Provider System, which is being developed by CMS. The NPI replaces all “legacy” identifiers that are currently being used. All health care providers, whether or not they are covered entities under HIPAA, are eligible to be assigned NPIs. Non-covered providers may obtain NPIs. All covered health care providers must obtain NPIs. Health care providers are covered entities if they transmit any data for which the Secretary of Health and Human Services has adopted a standard. Covered entities must use NPIs in standard transactions no later than the compliance dates. The compliance dates for all but small health plans is May 23, 2007. The compliance date for small health plans is May 23, 2008. Health care providers do not need to take any action to apply for NPIs at this time. The system that will handle the assignment of NPIs will be ready to accept applications for NPIS after the effective date of the final rule, which is May 23, 2005. Health providers can begin applying for NPIs on that date. CMS will provide the health care industry with information relating to the NPI, including the application process and the availability of the NPI application forms, closer to the effective date. Source: January 23, 2004 Federal Register. For More Information Contact: Kimberly
Fullmer - Health Care Policy Manager |
Content of this page was last modified: Thursday, 22 July 2004 |
