PIPAC Newsletter

In an attempt to alleviate the burdensome administrative task of credentialing and re-credentialing health care providers in the state, the West Virginia State Legislature has implemented standardized credentialing and re-credentialing forms. These forms will be required as of July 1, 2003.

Although this might mean some extra work the first time you are required to submit the standard form, the intent is to make the process run smoother and more consistently in the future.

The good news is that the two-year re-credentialing cycle has been changed to a three-year cycle. Also, once the uniform credentialing form is completed, it may be duplicated and submitted to all health care entities for credentialing purposes, simply by including an original signature (attestation) page for each payer.

The new credentialing forms will be required by all third-party payers in the state,

but will now be submitted every three years

Mary Jane Pickens, the General Counsel for the West Virginia Insurance Commission, sees uniform credentialing as a "positive change." Pickens explained that the rule changing the cycle is Series 53, the Quality Assurance rule, which applies to all health maintenance organizations. This rule can be located on the West Virginia Insurance Commission’s Web site or on the Secretary of State’s Web site.

The standardized forms will be required by all third-party payers in the state to credential and re-credential health care practitioners, and consequently, required by PIPAC as well.

Although sources with the West Virginia Medical Board and the West Virginia Insurance Commission have informed us that most providers in the state have already been told about the new forms, we would also like to clarify the intent of the forms and how they should be used in your practice.

House Bill 3242 was passed by the West Virginia Legislature during its regular 2001 season. The bill amended chapter sixteen of the code of West Virginia, by adding a new article.

Essentially, the article required the Secretary of the Department of Health and Human Resources (DHHR) and the Department of Insurance (DOI) Commissioner to jointly propose rules for legislative approval to set forth uniform application forms for credentialing or re-credentialing, and to update any information provided by the health care practitioner.

Although the ruling was filed jointly, it is designated as a DHHR rule because it was filed pursuant to the provisions of the public health chapter of the West Virginia code.

House Bill 3242 also appointed a new advisory committee to assist the DHHR Secretary and Insurance Commissioner in the development and implementation of uniform credentialing processes in West Virginia. The advisory committee met during 2001 and 2002 to make recommendations concerning these issues.

The ruling, which was authorized by the West Virginia Legislature on March 5, 2003, requires that all health care entities use the uniform forms when credentialing and re-credentialing health care practitioners in the state. This includes clinics or other health care facilities or organizations, hospitals, managed care organizations and third-party administrators, as well as certification verification organizations.

The rule clarifies that the uniform credentialing and re-credentialing forms are to be completed once by the health care provider and then intended to be duplicated, as needed, by the provider so that the same form can be submitted to as many health care entities as he or she wishes.

When the provider attaches a new signature page and release, bearing an original signature and date, each copy of the form then becomes an original document. Each time a practitioner attaches a new original signature page, the document must be accurate as of that date. Therefore, the provider must continue to keep the form updated.

To submit credentialing information to PIPAC, the provider need only submit the new credentialing form with one signature page. When a provider is scheduled to be re-credentialed (in three years), he or she should complete the uniform re-credentialing form with an original signature page. After that, the provider need only submit an original signature page if none of the information included on the re-credentialing form has changed.

The credentialing and re-credentialing forms are available through links on the DHHR and Insurance Commission Web sites at www.state.wv.us/insurance . You can also contact the PIPAC office for copies of the forms if you or your office staff cannot access the new forms online and we will provide you with them.

The credentialing and re-credentialing forms are available through links

 on the DHHR and Insurance Commission Web sites

The forms may be downloaded into Microsoft Word, completed online and printed, or opened as a PDF file and printed as a blank form to be completed by hand or typewriter.

The forms are protected so that they may not be altered. The tab key will move the cursor from box to box. Most text boxes will expand to allow completion of information. If the forms are saved in Word, you will have the convenience of ongoing use of the forms.

If you have any questions on the new credentialing forms or the process by which the forms should be filled out or submitted as of July 1, please forward them to the PIPAC office.

As many PIPAC providers may already be aware, Carelink did not update their systems to reflect accurate reimbursement rates with the appropriate geographical adjustment for West Virginia since 2000, as was specified under their contract.  Therefore, we have been in the process of having Carelink correct those fees and reimburse PIPAC providers accordingly.

At press time, Carelink’s attorney provided PIPAC with the drafted settlement and release letter, which is dated to go out to providers on July 15, 2003. After the provider has reviewed the terms of the letter, signed it, and returned it to Carelink, payment will be made within 15 days.

Claims submitted by PIPAC providers to Carelink have been held as of May 31 until their systems could be updated to reflect the 2003 fees. The payer also wanted to avoid any further incorrect payments to providers.

At a meeting held on June 12, Erika Washington, Contracting Specialist with Carelink, informed us that the provider system administrator (PSA) updated their system with the new fees. The system was tested and scheduled to go live the week of June 16. She stated that she had not heard anything on the claims testing, with the PSA, so that's a good sign that all is going well.

As such, PIPAC providers should now begin seeing corrected reimbursement rates on their explanation of benefits (EOBs) from Carelink.

About the Settlement of Past Claims

Washington clarified that during a meeting with their Finance Department on the issue, it was determined that the settlement agreement letter and manual cut of the checks should take no longer than six weeks. This would put the expected date of completion around the end of July.

However, PIPAC’s attorney, Debbie Robinson at Houston Harbaugh in Pittsburgh, PA,  worked with Carelink’s attorney to expedite the process.

The letter includes the amount owed to the provider and that in signing the agreement constitutes "a full and final settlement of any and all payments due from Carelink to Provider for the Disputed Amount. Payment shall be made within fifteen (15) days of the counter-execution of this Settlement and Release."

In signing the agreement, the Provider provider has agreed not to submit any claims and/or appeal of claims prior to May 31, 2003 for Carelink managed care members to Carelink.

When you receive settlement agreement from Carelink, we encourage PIPAC providers to review their Carelink claims during this time period against an individual provider report that they will be sent.

Note that the Carelink settlement amount will be based only on claims that were approved by Carelink. If a claim was denied due to medical necessity requirements or submitted too late to be reimbursed, these figures would not be reflected in the Carelink report or the settlement amount.

After you have reviewed Carelink’s report and compared the charges billed with what you have in your system, if there are any discrepancies and you have documentation to back them up, contact the PIPAC office. That is, you should not direct them through Carelink’s usual appeals process. Inquiries should be directed to PIPAC.

Top It Off with a Provider Training Session

Carelink also held a provider training session for PIPAC providers on June 25, 2003 at the EuroSuites Hotel in Morgantown.

The session included updates on administrative and operational procedures, including the recent changes to the appeals and pre-certification processes, various issues that have been implemented over the past six months, and general Carelink information.

If you were unable to attend this provider training session, you can contact Carelink’s Provider Relations Department at (304) 561-6919 with any questions.

In a regulation proposed by the Bush Administration in late April, Medicare will require physicians to revalidate enrollment data every three years, institute onsite visits by investigators to verify applications, and force most physicians already providing care to Medicare beneficiaries to reapply to the program.

The Centers for Medicare and Medicaid Services (CMS) stated that the proposed rule helps to standardize enrollment procedures among carriers across the country. Some carriers have required physician practices to revalidate their data every year.

If CMS determines that the information submitted by the provider

is incomplete, invalid, or insufficient, the agency has the discretion to

 reject, deny, deactivate, or revoke billing privileges.

Tim Allman, Community Education Administrator for Palmetto GBA, the Medicare Part B carrier for West Virginia, has clarified that the Medicare enrollment form is federal and thereby supercedes state requirements, as specified in the new credentialing form. (Refer to the article beginning on page 1.) He states that the CMS 855 applications "are the only option for Medicare."

Under the proposed process, which was published in the April 23, 2003 Federal Register, physicians who were already billing the program before the initial enrollment form was introduced in 1996 will now have to complete a form so that the program has their data on file.

Statutory provisions require the Secretary of Health and Human Services (HHS) to ensure that all Medicare providers and suppliers are qualified to provide the appropriate health care services.

The information must clearly identify the provider or supplier and its place of business, provide documentation that it is qualified to perform the services for which it is billing, ensure that it is not currently excluded from the Medicare program, and meets any other applicable Medicare requirements.

CMS states in the proposed rule that if "we determine that the information submitted is incomplete, invalid, or insufficient to meet Medicare requirements, we would have the discretion to reject, deny, deactivate, or revoke billing privileges."

The statutory provisions include requirements meant to protect beneficiaries and the Medicare trust fund by preventing unqualified, fraudulent, or excluded providers and suppliers from providing services to Medicare beneficiaries or billing the Medicare program or its beneficiaries.

CMS clarifies that the provisions of the rule supplement, but do not replace or nullify existing regulations concerning the establishment of provider or supplier billing numbers and payment for Medicare covered services or supplies to eligible providers or suppliers.

The new CMS 855 application will be used to gather information on providers and suppliers for the purpose of authorizing billing numbers and establishing eligibility to furnish services to Medicare beneficiaries.

Every three years, physicians will receive a copy of the completed form. If none of the information on the form has changed, physicians can simply sign the document and return it. Changes would require physicians to submit evidence to document the validity of the new information.

Physicians also would be required to notify CMS within 90 days of any personnel changes that affect the day-to-day management of their practices, and within 30 days of any change in practice ownership.

Upon receipt of any changes, CMS will determine if continued enrollment in the Medicare program is "proper." Failure to notify CMS within the specified timelines could launch immediate revocation proceedings, during which the practice would be unable to bill Medicare.

Integrating Site Visits Into the Process

CMS states that the agency also reserves the right to integrate site visits into the enrollment validation process. These would be done to verify that the information submitted to CMS or its agents is accurate and to determine compliance with the Medicare enrollment requirements.

Site visits for enrollment purposes would not affect those site visits performed for establishing conditions of participation, according to CMS.

Site visits currently are limited to larger entities, such as hospitals, nursing homes and home health agencies.

References: April 23, 2003 Federal Register, and CMS transmittal #41, dated May 23, 2003.

Without any action by Congress, Medicare payment rates for physicians and other health care practitioners are predicted to fall again by 4.2 percent in 2004, with additional cuts in 2005, 2006, and 2007. In fact, a cut in 2004 would be the fifth since 1991.

PIPAC physicians need to keep on top of this issue not only in relation to how the update to the conversion factor affects their Medicare fees, but also affects reimbursement from other third-party payers. This is especially the case when the payer reimburses physicians on a certain percentage of Medicare fees.

If Congress doesn’t act,

it could spell a predicted 4.2 percent cut in Medicare fees in 2004.

Payments to physicians and other practitioners were cut by 5.4 percent in 2002. Another 4.4 percent cut in 2003 was averted only after Congress intervened. The legislation passed by Congress earlier this year allowed the Centers for Medicare and Medicaid Services (CMS)—formerly the Health Care Financing Administration (HCFA)—to correct the 1998 and 1999 projection errors in the Medicare physician fee schedule.

The end result was an increase of 1.6 percent in physician Medicare payments on March 1, 2003, instead of the 4.4 percent reduction. Despite the correction of these projection errors, CMS estimates indicate that physicians again face negative updates in Medicare fees over the next several years, beginning with a 4.2 percent reduction in 2004.

As was the case with the reduction that actually occurred in 2002 and almost occurred in 2003, the cause of these projected cuts was the flawed formula used to make the annual updates to physicians’ Medicare fees.

Under the legislatively mandated formula, if physician services grow more rapidly than a pre-established expenditure target, called the Sustainable Growth Rate (SGR), then physicians may be subject to cuts in Medicare reimbursement.

This is precisely what has happened over and over again. In the last quarter of 2002, the Gross Domestic Product—on which part the SGR is partly based—fell and the volume and intensity of physician services grew. The result is the projected 4.2 percent cut in 2004.

Between 1991 and 2003, payment rates for physicians and health care professionals fell 14 percent behind practice cost inflation as measured by Medicare’s own conservative estimates. Another 4.2 percent cut in 2004 would result in payments 8 percent lower than in 2001 and widen the gap between inflation and cost increases to 19 percent.

A coalition of medical specialty organizations, called the Alliance of Specialty Medicine, has been assessing the political climate and working with key lawmakers and Congressional staff on the issue. The Alliance has also hired a top notch Washington economist to study the update formula to develop possible changes that could be recommended to Congress.

After several years of discussions with physician specialty societies, the Centers for Medicare and Medicaid Services (CMS)—formally the Health Care Financing Administration (HCFA)--has agreed to make its National Correct Coding Initiative (NCCI) edits available on its Web site later this summer.

NCCI edits are pairs of codes that are not separately payable, except under special circumstances. Medicare and other third-party payers use these edits to decide whether to pay claims in full, pay a partial claim, completely deny claims or recode the submitted procedures. The NCCI currently contains more than 100,000 coding edits.

Physicians have been frustrated because they haven’t had free access to NCCI information on how to code "properly." Currently, physicians must purchase the edits and quarterly updates for an annual subscription of $300 for print version or $260 for an electronic version. When the information is available online, it will be free of charge its Web site later this summer.

For more information on the NCCI, go online to http://www.cms.gov/medlearn/ncci.asp .

Updated Fee Schedules Available for Health Plans  (Back to Top)

Fee Schedules on CD

PIPAC has recently been successful at getting updated fee schedules for health plans with which we contract, some of which have resulted in increased reimbursement to providers.

The PIPAC office has acquired updated fee schedules, including those utilizing 2003 relative value units (RVUs) that reflect these rate increases for the following health plans:

• Select Net
• Health Coalition Partners (HCP)
• Mountain State Blue Cross Blue Shield (MSBCBS)
  
• Private Health Care Systems (PHCS)
• Carelink
• CCN
  

You may contact PIPAC  to request a CD with the new fee schedules.

Providers should also be aware that we are in negotiations with MSBCBS and CIGNA. We will update you in a future issue of the newsletter.

Take Advantage of New Group Purchasing Offers  (Back to Top)

PIPAC members can take advantage of several new options that have been made available through group purchasing agreements with GlaxoSmithKline (GSK), CellularONE, U.S.Cellular, One Star, and Citynet.

• Exclusively extended pricing agreement with GlaxoSmithKline (GSK) for the following types of vaccines:
  • Energix-B (brand of hepatitis B vaccine)
  • Havrix (brand of hepatitis A vaccine)
  • Infanrix (brand of diptheria and tetanus toxoids and acellular pertussis vaccine absorbed [DtaP])
  • Pediatrix (brand of diptheria and tetanus toxoids, acellular pertussis absorbed, hepatitis B recombiant and inactivated poliovirus vaccine combined)
  • Twinrix (brand of hepatitis A and B combination vaccine)

If you are interested in finding out about the contracted rates for these vaccines, you may contact the GSK sales representative, Angela Snyder, directly. She may be reached at (800) 668-6240 or by e-mail at andela.d.snyder@gsk.com.

Other Offers
PIPAC members are also privy to a new plans (with various terms and rates) being offered by:

•  CellularONE
•  U.S. Cellular
• OneStar
• CityNet

Although we can’t print the specifics of these plans in the newsletter, you can contact us for details.

For More Information Contact:

Carol Polosky - Group Purchasing Manager
 
 Preferred Integrated Provider Access Corporation
 1212-B Van Voorhis Road, Morgantown, WV 26505
 Tel: 304-598-0363
 FAX: 304-598-0473
 Internet: carolpolosky@mountain.net

A petition filed in early June with the West Virginia Supreme Court will be the first challenge to the state’s recently passed medical liability reform regulations, which are slated to take effect July 1, 2003.

Essentially the issue at hand is that the plaintiff’s attorney’s are challenging the effective date of the malpractice bill (HB 2122). They are questioning the applicability of the new statute to cases that involve malpractice that has allegedly occurred before July 1, 2003, but the case is not filed until after July 1, 2003.

The West Virginia State Legislature has made significant strides in the Medical Professional Liability Act, which was passed on March 8, 2003. The reforms include a reduction of the non-economic damage caps from $1 million to $250,000, several liability rather than modified joint and several liability, elimination of the collateral source rule, elimination of third-party negligence actions, and a flat cap of $500,000 on cases involving injuries received during treatment of trauma cases.

The petition states that the new Medical Professional Liability Act affects the substantive rights of all patients upon whom medical malpractice has been committed. It states that the regulation cannot be constitutionally applied retroactively to causes of action that have accrued, but have not yet been filed.

Specifically, the statute is written to apply to any actions "filed" after July 1, 2003. If the Plaintiff’s are successful, it will delay the effectiveness of the statute for essentially two years (statute of limitations).

At press time, attorneys with the West Virginia State Medical Association (WVSMA) were in the process of filing an amicus brief to the case. Many healthcare advocacy organizations have joined WVSMA in the amicus effort.

We will update you on any further developments on this issue.