Section 1011 Provider Symposium December 5, 2007 Dallas, Texas Company LOGO 1 Symposium Topics 1. Program Information 2. Enrollment 3. Eligibility 4. Payment Processing 5. Compliance Reviews 6. Web Updates Section 1011 2 Section 1011 Provision Allows $250 million annually for Fiscal Years (FYs) 2005-2008. Allows annual state allotments based on the state’s relative percentage of undocumented aliens. Percentage determined by number of undocumented aliens who reside in each state divided by the total number of undocumented aliens in all states. (Data obtained from Census bureau). Section 1011 3 Section 1011 Provision Two-thirds of funds are divided among 50 states and the District of Columbia. One-third of funds is divided among six states with the largest number of undocumented alien apprehensions. (Dept. of Homeland Security data) Section 1011 4 Pro Rata Reduction Section 1011 Pro Rata Reductions Q1 FY 2007 - 10/1/06 to 12/31/06 Value of Total Amount of Total Available Value of Final % of Pro Rata State Funds Payments Pro-Rata Payments Balance Reduction Reduction AL $ 144,163.01 $ 546,553.27 $ 402,392.79 $ 144,160.48 $ 2.53 73.62% CT $ 232,509.72 $ 880,276.05 $ 647,771.08 $ 232,504.97 $ 4.75 73.59% DE $ 133,623.55 $ 224,127.84 $ 90,504.52 $ 133,623.32 $ 0.23 40.38% FL $ 2,968,403.03 $ 5,435,887.08 $ 2,467,502.67 $ 2,968,384.41 $ 18.62 45.39% KS $ 286,660.04 $ 590,261.65 $ 303,602.96 $ 286,658.69 $ 1.35 51.44% LA $ 34,698.70 $ 131,174.62 $ 96,477.59 $ 34,697.03 $ 1.67 73.55% NE $ 161,041.89 $ 180,148.27 $ 19,106.88 $ 161,041.39 $ 0.50 10.61% NV $ 1,032,735.94 $ 1,426,766.31 $ 394,045.65 $ 1,032,720.66 $ 15.28 27.62% 5 Medicare Similarities Section 1011 is contracted by the Centers for Medicare & Medicaid Services (CMS). TEXT TEXT Section 1011 is administered through TrailBlazer Health Enterprises, LLC. Section 1011 uses the Medicare payment methodology (formula) and a replicate of the Medicare Part A processing system. Section 1011 6 Medicare Differences Section 1011 is a quarterly reimbursement program, not an “insurance” plan. You submit payment requests instead of claims. Section 1011 is not a Medicare Carrier, Fiscal Intermediary (FI) or Medicare Administrative Contractor (MAC). Reimbursement based on the Section 1011 Final Implementation Notice. Program does not change. Section 1011 7 The TrailBlazer Connection TrailBlazer Medicare Carrier Centers for Medicare & MAC Medicaid Services Fiscal Intermediary Section 1011 Section 1011 8 Terminology Alien – A non U.S. citizen. Undocumented alien is a person who enters the U.S. without legal permission or who fails to leave when permission has expired or Aliens who have been paroled into the U.S. at a U.S. port of entry. GPNet – Gateway Production Network allows electronic connectivity to TrailBlazer’s processing system. Section 1011 9 Terminology Laser Visa – Biometric, machine readable, border crossing identification card. Pro Rata Reduction – Calculated reduction of total payments for a state if available funds are exceeded. Section 1011 10 Acronyms ACT – Ask the Contractor Teleconference. CMS – Centers for Medicare & Medicaid Services. DRG – Diagnosis Related Group. Payment methodology used in calculating 1011 payments. DDE – Direct Data Entry. Section 1011 11 Acronyms continued EDI – Electronic Data Interchange. EFT – Electronic Funds Transfer. EMC – Electronic Media Claims. EMTALA – Emergency Medical Treatment and Labor Act. (Section 1867 of the Social Security Act) ERA – Electronic Remittance Advice. Section 1011 12 Acronyms continued HIPAA – Health Insurance Portability and Accountability Act of 1996. NPI – National Provider Identifier. PR – Payment Request. PPD – Provider Payment Determination Form. UARS – Undocumented Alien Reimbursement System. UPIN – Unique Physician Identification Number. Section 1011 13 Provider Enrollment Section 1011 14 Enrollment Requirements Medicare Participating Providers Provider Enrollment Application (CMS Form 10115). Authorization Agreement for Electronic Funds Transfer – EFT (CMS Form 588). Must include voided check, pre-printed deposit slip or banking verification letter must be included with EFT. Electronic Remittance Advice (ERA) request form. Section 1011 15 Enrollment Requirements continued Non Medicare Participating Providers: Section 1011 Provider Enrollment Application (CMS Form 10115 in hard copy): Form 855I - Physicians. Form 855B - Ambulance companies. Authorization Agreement for Electronic Funds Transfer – EFT (CMS form 588). Voided check, pre-printed deposit slip or banking verification letter must be included with EFT. Electronic Remittance Advice (ERA) request form. Section 1011 16 Provider Enrollment Cycle Fiscal Year 3, 4th Quarter Section 1011 17 Enrollment Application Change 2. Applicants Legal Business Name 3. Doing business as (DBA) 4. Address (Include county) 6. State of Service 7. Current Fiscal Intermediary / Carrier 9. Applicant’s Medicare ID Number 10. Hospital election (Hospital only) 11. Physician Privileges (Physician only) Section 1011 18 Enrollment Application page 2 14. Type Name and title of authorized representative. Section 1011 19 Hospital Roster Attachment 1 Section 1011 20 Physician Privileges Roster Attachment 2 Section 1011 21 EFT Authorization National Provider ID (NPI) Section 1011 22 ERA Request Form Existing ERA Receiver ID #, if applicable Provider Number(s): Section 1011 23 Enrollment Changes Changes may include: Enrollment Form Data Changes. Roster Changes. Hospital Election Changes. Section 1011 24 Application Change Process When changing physical address, hospital election, physician privilege, etc., follow these steps: Write change at the top. Make necessary changes in applicable sections. Include Attachment 1 if adding or removing physicians from your roster. Include Attachment 2 if adding or removing hospital facilities from your roster. Section 1011 25 Application Change Process Enrollment application form must be signed by the Authorized Representative. Enrollment application form must be mailed and not faxed. Indicate if the Authorized Representative’s information has changed. Section 1011 26 Election Changes Hospitals choosing to change their election should: Notify all practicing physicians of their intent to change. Submit a new Enrollment application with explanation of the change. (Application must have Authorized Official’s Signature). When a hospital is no longer billing for a physician, the physician is withdrawn from the program. Section 1011 27 Election Changes When a hospital changes its election to bill for a physician and the physician is already enrolled in the program, the physician’s PIN for that hospital will be terminated. Election changes must be made by July 1st of the same year. Election changes occur annually and are effective October 1st of each year. Section 1011 28 Enrollment Summary EFT Agreement and ERA requests are required in the enrollment process. Changes to the enrollment form must have change written at the top of the form and the form must be signed by the authorized representative. Section 1011 accepts the original signature of authorized official on enrollment and EFT forms. Photocopies will be returned. All incomplete documents are returned to you. Section 1011 29 Section 1011 Eligibility Section 1011 30 Section 1011 Eligibility Eligible services are EMTALA-related services (including medical screening) to the point of patient stabilization. (FPN notes usually two days). Eligible providers are hospitals, physicians and ambulance providers that meet the program requirements. Eligible aliens are undocumented aliens, paroled aliens and Mexican citizens permitted to enter the United States for not more than 30 days under “laser visa” authority. Section 1011 31 Eligible Services “…Health care services required by the application of section 1867 [EMTALA] of the Social Security Act…” and these services include related inpatient, outpatient and ambulance services as defined by the Secretary of Health and Human Services. Section 1011 32 Eligible Services continued Covered services for hospitals begin when EMTALA begins and continue until the point of stabilization. There is no EMTALA obligation after patient stabilization. Triage (screening) services are covered and billable to Section 1011. Section 1011 33 Eligible Providers Hospitals: Medicare participating hospitals that meet the program requirements Indian Health Service (IHS) facilities. Providers of ambulance services: State licensed providers of ambulance services for covered transports to a hospital ER or from one hospital to another. Section 1011 34 Eligible Providers continued Eligible physicians: Doctors of medicine. Doctors of osteopathy. Under statutory restrictions, legislation allows if EMTALA related: Doctors of podiatric medicine. Doctors of optometry. Doctors of dental surgery. Chiropractors. Section 1011 35 Ineligible for Section 1011 Mid-level practitioners. Nurse practitioners. Physician assistants. Clinical nurse specialists. Certified Registered Nurse Anesthetists (CRNAs). Section 1011 36 Determining Eligibility Complete and sign the PPD (or other acceptable collection instrument). Section 1011 asks that you not ask if a patient is an undocumented alien. Follow normal screening procedures. Can your form be used to answer the PPD? If patient refuses (or is unable) to provide proof of eligibility, do not submit a payment request. Additional 10 percent reimbursement for outpatient payment requests. Section 1011 37 Determining Eligibility continued Some acceptable forms of ID: Foreign voting card, driver’s license or passport. Matricula Consular card (Mexican Gov’t). Border-crossing card (“laser visa”). Form I-94 stamped Parole or Parolee. Some unacceptable forms of ID: Foreign student ID. Resident Alien card (green card) issued by U. S. Citizenship & Naturalization Services. Patient is documented, unless green card has expired. Section 1011 38 Ineligible Patients US Citizens. Permanent Residents. Aliens with employment authorization. Individuals with valid non-immigrant visas: Tourists. Students. Business travelers. Section 1011 39 Provider Payment Determination PPD Page 1 40 Eligibility Summary Eligible Section 1011 services must be EMTALA–related services to the point of stabilization. When completing the PPD form (CMS 10130A) to determine patient eligibility: If you checked yes – stop. Sign and date. If you checked no – continue to the next question. If you choose an alternative collection document, it must capture the same data as the PPD to be acceptable. Section 1011 asks that you not inquire if a patient is an undocumented alien. Section 1011 41 UARS: Undocumented Alien Reimbursement System Section 1011 42 UARS Undocumented Alien Reimbursement System, designed for processing and paying Section 1011 payment requests exclusively. Ensures all payment requests are submitted electronically in a HIPAA-compliant format. Replicate of the Fiscal Intermediary Shared System (FISS). Section 1011 43 UARS continued All provider types can access UARS and submit payment requests through Direct Data Entry (DDE). Hospitals also have the option to submit payment requests via Electronic Media Claims (EMC). Electronic PR submissions only: Final Policy details that payment requests cannot be submitted hard copy. Section 1011 44 UARS Entry continued Section 1011 45 UARS Entry continued Section 1011 46 UARS Entry continued Section 1011 47 UARS Entry continued Section 1011 48 UARS Entry continued 51881 Section 1011 49 UARS Entry continued Section 1011 50 UARS Entry continued Section 1011 51 UARS Availability UARS hours of availability: Monday through Friday 7 a.m. – 8 p.m. (CT) Weekends and holidays 7 a.m. – 2 p.m. (CT) Section 1011 52 Billing Example If patient or third party payment is received prior to billing Section 1011, the payment is reported on the payment request in the value codes field and is subtracted from the Section 1011 reimbursement. Example: Hospital submits payment request for $1000. The Section 1011 reimbursement amount is $600. Patient pays $100. Section 1011 subtracts the $100 payment and reimburses the hospital $500. Section 1011 53 UARS Common Mistakes Billing mistakes: Professional fees should not be submitted with type of bill (TOB) 111. Only hospitals can submit TOB 111. Duplicate charges which occur because the patient HIC is used on more than one payment request (system retains information from initial submission). Coding mistakes: Many providers fail to include the ICD-9 procedure code and procedure dates while billing operating room charges (revenue codes with 036X prefix) . Section 1011 54 UARS Common Mistakes continued Anesthesia billing mistakes: Submit payment requests with the inappropriate modifier(s). Submit the anesthesia duration in minutes only. Time can be two or three digits and must be entered in the total covered (TOT COV) field. Example: If the anesthesia duration is 2 hours, enter the duration as 120 instead of 002. Section 1011 55 UARS Corrections UARS does not allow online corrections or adjustments. If an error is discovered: Identify the error via fax or e-mail and include the correction. E-mail correction to: email@example.com. Subject: Payment Request Correction Needed. Or, fax correction to (469) 372- 6143. Subject: Payment Request Correction Needed. Section 1011 56 UARS Corrections continued Body of e-mail or fax must contain: Section 1011 PIN. Patient Identification number. Patient control number. Medical record number. Payment request dollar amount. Date(s) of service. How the error should be corrected. Name, title and telephone number of billing contact person. Section 1011 57 Payer of Last Resort Section 1011 is payer of last resort You should seek payment from all available funding sources prior to billing Section 1011. This includes federal, state and third party payers: Department of Homeland Security. Medicaid or State Children’s Health Insurance Program. Private insurers or Health Maintenance Organizations (HMOs). Patients. This process is consistent with the statute and it limits reimbursement to instances where no other reimbursement will likely be received. Section 1011 58 Overpayments Receipt of a payment from the patient or third party subsequent to Section 1011 payment. Assessed due to Medical Review and Compliance Review findings. Providers should notify Section 1011 that an overpayment has occurred. Withhold overpayments from the next quarterly Section 1011 payment. Section 1011 59 Overpayments If the balance is not a sufficient balance in the next quarterly payment (to repay the overpayment in full), TrailBlazer will notify you and allow 30 days to repay the overpayment without accrual of interest. Section 1011 60 Excluded Services Based on EMTALA regulations, certain revenue centers are not considered emergency services and are excluded from 1011 payment. Additionally, certain diagnosis codes, when used as the primary diagnosis, are excluded from the 1011 program. Section 1011 61 Excluded Codes View the Revenue Center Exclusion List for excluded codes. The following revenue codes are always excluded from Section 1011 reimbursement: 0960 0961 0962 0964 0969 Section 1011 62 Professional Fees Professional fees are outpatient charges and are billed under the physician’s Provider Identification Number (PIN) with bill type 131. Specific revenue codes apply only to physicians’ services for billing purposes. For the billing codes, see Revenue Codes for Physicians on the Section 1011 website under payment request processing. Section 1011 63 UARS Summary UARS is an electronic system: Submit through DDE (all provider types) or EMC (facility charges only). Section 1011 does not accept hardcopy payment requests. Corrections may not be made online (you should fax or e-mail the corrections). Revenue code 036X must have procedure code(s) and procedure date(s). Bill type 111 is for Inpatient and 131 is for Outpatient. Section 1011 64 Compliance Reviews Section 1011 65 Compliance Reviews Why conduct Compliance Reviews? 1. To ensure payments are made to providers for eligible services. 2. To ensure hospital on-call payments to physicians are properly calculated. 3. To ensure inappropriate, excessive or fraudulent payments are not made from state allotments. 4. To ensure PR submissions are supported by clinical and non-clinical documentation. Section 1011 66 Basis for Reviews Included but not limited to: Identified billing inconsistencies. High utilization rates or high denial rates. Section 1011 67 Compliance Review Process Two types of Compliance reviews: performed in conjunction with In-house, Medical Review. On-site,more detailed reviews performed at the provider facility. Section 1011 68 In-House Compliance Review Payment requests selected for Medical Review and Compliance Review. You are required to furnish PPD form (or other acceptable collection instrument) and applicable supporting documents in a hardcopy format. PPD form (or other acceptable collection instrument) must be consistent with medical records and other supporting documents associated with the services rendered. Section 1011 69 On-Site Review You will be notified six to eight weeks prior to the scheduled review. Compliance auditors come to your site to review: Patient eligibility documentation. Medical records. Social workers notes. Patient accounts receivable. Section 1011 70 On-Site Review Conduct an entrance conference to communicate review purpose. Review your policies and procedures to determine patient eligibility. Interview staff members associated with admitting patients and completing the Provider Payment Determination (PPD) form. Section 1011 71 On-Site Review Review business records to ensure collection efforts from all payment sources have been made. Review medical records to ensure patient information is complete and consistent. Communicate daily audit findings to provider. Conduct an exit conference to communicate audit findings and recommendations. Section 1011 72 On-Site Review Preparation If eligibility data is stored electronically, be prepared to provide a copy of the form(s) used to determine eligibility. Ensure availability of all records associated with the payment requests being reviewed. Section 1011 73 Compliance Review Summary Ensures integrity of the Section 1011 program. Ensures eligibility, accuracy and consistency of patient’s medical records. Ensures payments are not fraudulent or excessive. Section 1011 74 Medical Review Section 1011 75 Medical Review July 2, 2007 – the Medical & Compliance Review processes were streamlined. Providers now receive one letter. Payment requests selected for Medical Review are also reviewed for eligibility. Every payment request sent to TrailBlazer is subject to review by two Section 1011 departments. The Medical Review department examines all billed services, while the Compliance Review department verifies patient eligibility. Section 1011 76 Medical Review New Process for Reducing Payment Requests: When the number of days submitted in a payment request is reduced by Medical Review, this is referred to as a reduction to the point of stabilization. Effective Monday, November 12, 2007, Medical Review implemented a new process for handling these reductions. Section 1011 77 Medical Review Providers will now receive a letter notifying them of the number of days approved and requesting the following documentation relating to those days: A corrected hard copy bill in the form of a UB-04 (CMS-1450) for the payment requests that were reviewed and reduced to the point of stabilization. An itemized bill showing charges for room and board only and ancillary expenses associated with the days approved. A hard copy of the notification letter received to help expedite the match-up and processing of the corrected bill to the provider file. Providers will have 30 days to submit the corrected bill before the payment request is denied or funds are set up to be withheld. Medical Review decisions may be disputed within the allowable time frames. Section 1011 78 Dispute Resolution Section 1011 79 Dispute Resolution Process Most disputes received are the result of Compliance Review denials. Submit disputes no later than 45 days after payment date or any post-pay activity. Must submit PPD (and supporting documents) along with the completed dispute request form. If disputing a medical decision, all applicable documentation that supports the dispute should be submitted. Once dispute is received, a second review is conducted. Dispute decisions are final and may not be appealed. Section 1011 80 Web Navigation Section 1011 81 Web Navigation Let’s navigate the following web links: ListServ. Section 1011 hospitals. Participating Questions and Answer document. Program payments. Section 1011 82 Thank you for attending! Section 1011 83
"Request for Billing and Payment Records Letter"