Something Else to Worry About
by Marcy Riviezzo
What is CAQH and why does this impact me and my practice?
The best way to describe CAQH comes directly quoted from their website:
"The Council for Affordable Quality Healthcare (CAQH) is a council of 25 of America's largest Health plans and insurers and three of the principal health plan associations working together to help improve the healthcare experience for consumers and physicians. CAQH member health plans have more than 110 million Americans and 600,000 providers in the networks."
It is the standard credentialing source for over two hundred healthcare plans. It maintains the UPD (Universal Provider Data Source). All information you provide to the Universal Data Source is maintained through encrypted technology.
If you are contracted personally or perhaps with a hospital or group, chances are someone in your administrative staff has created a profile for you on CAQH/UPD.
Here's WHY it matters:
ALL major insurance health plans access your profile regularly to keep your contracts and credentialing or recredentialing updated with information such as a copy of your current medical license, DEA License and Malpractice Insurance, just to mention a few requirements for you to practice medicine. The encrypted technology allows CAQH to streamline your data storage and manage it for distribution to all health plans and networks for easier contract applications and renewals. It is important that all physicians and mid level practitioners keep a current profile of their data for easy access.
Every six months CAQH emails a request prompting you to review and submit any new updates or renewals of information. Many of your contracts renew at the beginning of the new year and will want to access CAQH regarding your profile, so now is a great time to be proactive and contact or call CAQH to ensure you are current!
Annual updates to your profile include renewal of your Medical License, DEA license, malpractice insurance, BLS or ACLS, TB skin test, your current practice location and any hospital affiliations.
If you do not have a CAQH ID number and profile, I encourage you find someone to help you to create your CAQH/UPD as it can be frustrating and time consuming to complete it on your own. It is basically a process of gathering your professional profile but is usually an extra task that does not fall into a priority list of our day-to-day activities -- so often times this just doesn't get done. Once you get behind, it takes much longer to catch up.
If you have any questions regarding CAQH please do not hesitate to contact me directly to chat about helpful hints to keep CAQH on your priority list! I can be reached directly at 719.232.5566.
Tuesday, October 25, 2011
Quick Hits
Some Info for You
by AJ Riviezzo
E-Prescribe: The deadline for submitting a request for exemption from the E-prescribe program is November 1st. One way to be exempt is for the practice to be below a 10% threshold of specific codes. Most of these codes are essentially Evaluation and Management codes. Almost all phlebology practices should meet this exemption as the primary payments by Medicare are for surgery and ultrasound services. You need to file a letter with CMS to ensure you are exempt from any possible Medicare penalties.
Ultrasound Report Addition: On your ultrasound reports, we recommend adding a line to the body of the report that states: The permanent ultrasound recording is on file. This will help ensure you meet all legal requirements in your documentation.
Change in Code Use: Code 76942, ultrasound guidance, is receiving another short jab. Medicare and some other payers are now only allowing one 76942 to be billed per day. This means that if you are performing bilateral US guided sclerotherapy injections, you will not only be cut by 50% on the second sclero injection code you can also be cut back by the full amount for the US guidance as well. For Medicare patients we recommend against billing the second guidance code even to receive a denial. Our supposition is that fewer denials may hopefully mean fewer audit reasons.
by AJ Riviezzo
E-Prescribe: The deadline for submitting a request for exemption from the E-prescribe program is November 1st. One way to be exempt is for the practice to be below a 10% threshold of specific codes. Most of these codes are essentially Evaluation and Management codes. Almost all phlebology practices should meet this exemption as the primary payments by Medicare are for surgery and ultrasound services. You need to file a letter with CMS to ensure you are exempt from any possible Medicare penalties.
Ultrasound Report Addition: On your ultrasound reports, we recommend adding a line to the body of the report that states: The permanent ultrasound recording is on file. This will help ensure you meet all legal requirements in your documentation.
Change in Code Use: Code 76942, ultrasound guidance, is receiving another short jab. Medicare and some other payers are now only allowing one 76942 to be billed per day. This means that if you are performing bilateral US guided sclerotherapy injections, you will not only be cut by 50% on the second sclero injection code you can also be cut back by the full amount for the US guidance as well. For Medicare patients we recommend against billing the second guidance code even to receive a denial. Our supposition is that fewer denials may hopefully mean fewer audit reasons.
Administrative Law Judge
Follow Up Information on ZPIC Audit
by AJ Riviezzo
American Physician recently supported a practice that was involved in a ZPIC audit (essentially like a RAC audit except this was prospective and not retrospective). Eight of our ablation claims were denied at the first and second level appeal stages. This left using an Administrative Law Judge (ALJ) as our next recourse.
I have a more detailed article in the next Vein Therapy News but the findings in brief were:
Your documentation has to be viewed not as if another physician can understand and follow it but as if an attorney can understand it. Any, and I do mean any, variation in what is on one form to another was stringently questioned. For example, if your CEAP classification mentions swelling of the legs and your History and Physical does not specifically mention swelling of the legs, that is a problem.
It also became clear that any patient information that was not specifically noted as reviewed by the physician was discounted. Further, patient statements regarding previous attempts at conservative therapy (and thereby meeting the Medicare guidelines) were also discounted. We did argue that this was an unfair burden on both the patient and on the practice. It is normally standard to accept the patient's word when reviewing previous treatment, history, or compliance with something like conservative therapy management. That argument fell completely flat.
With the budget issues facing the Medicare program and recommendations that 'changes' be made to save money without impacting the actual entitlement, I can only assume that audits to find inappropriate or fraudulent treatment will be expanded. The primary weapon at your disposal for combating these audits is your well documented medical record.
by AJ Riviezzo
American Physician recently supported a practice that was involved in a ZPIC audit (essentially like a RAC audit except this was prospective and not retrospective). Eight of our ablation claims were denied at the first and second level appeal stages. This left using an Administrative Law Judge (ALJ) as our next recourse.
I have a more detailed article in the next Vein Therapy News but the findings in brief were:
Your documentation has to be viewed not as if another physician can understand and follow it but as if an attorney can understand it. Any, and I do mean any, variation in what is on one form to another was stringently questioned. For example, if your CEAP classification mentions swelling of the legs and your History and Physical does not specifically mention swelling of the legs, that is a problem.
It also became clear that any patient information that was not specifically noted as reviewed by the physician was discounted. Further, patient statements regarding previous attempts at conservative therapy (and thereby meeting the Medicare guidelines) were also discounted. We did argue that this was an unfair burden on both the patient and on the practice. It is normally standard to accept the patient's word when reviewing previous treatment, history, or compliance with something like conservative therapy management. That argument fell completely flat.
With the budget issues facing the Medicare program and recommendations that 'changes' be made to save money without impacting the actual entitlement, I can only assume that audits to find inappropriate or fraudulent treatment will be expanded. The primary weapon at your disposal for combating these audits is your well documented medical record.
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