AMBULATORY SURGERY CENTERS (ASC) WORKSHOP - PowerPoint Presentation

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AMBULATORY SURGERY CENTERS (ASC) WORKSHOP

PRESENTED BY

BLUE CROSS AND BLUE SHIELD OF KANSASSlide2

TODAY'S PRESENTERSJanne DentonContract Consultant & Specialty Provider Rep, Institutional Relations, Blue Cross and Blue Shield of KansasConnie WinkleyEducation Coordinator, Institutional RelationsBlue Cross and Blue Shield of KansasBrent MatileProvider Program SpecialistBlue Cross and Blue Shield of KansasMarie BurdiekElectronic Data Interchange (EDI) Account RepresentativeBlue Cross and Blue Shield of KansasSlide3

AgendaIntroduction Institutional Relations DepartmentBCBSKS Website & Availity Grace Period (Affordable Care Act) Medicare Advantage 2015 Policies & Procedures & MAPs Quality-Based Reimbursement Program (QBRP)  Electronic Data Interchange (EDI)Slide4

Blue Cross and Blue Shield of KSInstitutional Relations (IR) DepartmentWho are we and what do we do?Slide5

Institutional Relations (IR) Org Chart

Sally Stevens,

Provider Rep

Hospitals in Southern KS

Cindy Garrison, Provider Rep

Hospitals in Northern KS

Teresa Van

Becelaere

Manager, IR

Angie

Strecker

, Director

Institutional Relations

Dona

Hewes

Administrative Coordinator, IR

Fred

Palenske

, Senior VP

Provider and Government Affairs

Connie Winkley

Education Coordinator

Janne

Denton

Contract Consultant

& Provider

Rep

Katie Dennison

Claims Research Analyst

Brent

Matile

Provider Program Specialist

Melanie Moriarty

Administrative Assistant (Topeka)

Kristi

Donelan

Administrative Assistant (Wichita)Slide6

Institutional Relations FunctionsIR Functions Include:Provider ContractsMailed annually in JulyIncludes our Quality-Based Reimbursement Program (QBRP)Contracts with and services the following facilities:Hospitals – CAH, PPS, Specialty, Limited Services, VAASCsHome HealthHospiceDialysis FacilitiesSkilled Nursing FacilitiesEducation and TrainingWorkshopsWebinarsOne-on-one provider visitsTraining as requestedNewsletters and ManualseNewsRelevant Topics – i.e. ICD-10Slide7

Institutional Provider RelationsIR Functions include:Provider Claims Resolutions Katie Dennison – Claims Research AnalystProvider RepresentativeAny IR staff memberProvider Liaison CommitteesSolicit input from surgical groups – i.e. Optometrist, Audiologist, etc.Assist in the review and development of BCBSKS medical policiesSlide8

BCBSKS Websitewww.bcbsks.comPublic information includes:Medical PoliciesFormsICD-10 Web pagePrecertification/Prior Authorization Information for Blue PlansNewsletters and Latest News (eNews)SOK & FEP web pagesSlide9

Availity and BlueAccessAvaility (www.availity.com)Single sign-on to Availity and BlueAccessEligibility & BenefitsClaims StatusAvaility TrainingWorkshopsWebinarsProvider VisitAvaility to BlueAccessLink through Payer ResourcesSecure tools on BlueAccess include:Remittance AdviceMember ID Look-upManuals Some forms that can be sent electronicallyQBRP FormSlide10

Affordable Care Act (ACA) Grace PeriodExchange Individual Grace PeriodACA mandates a three-month grace period for those insured through the Exchange who receive a subsidy.Individual has paid at least one month's premiumThe payer is only obligated to pay claims during the first monthDuring the grace period, the payer may pend claims during the second and third monthsPayer must notify HHS of non-payment of premiumsPayer must notify provider of the possibility of denied claims Slide11

Affordable Care Act (ACA) Grace PeriodMarilyn Monroe01/01/2000ABC123456789Female123 Anystreet Apt. 1Anytown, KS 1111108/14/201407/30/201404/01/2014 – 12/31/20149999999999Slide12

Affordable Care Act (ACA) Grace PeriodRhett Butler01/01/2000ABC123456789Male123 Anystreet Anytown, KS 1111108/14/201407/30/201404/01/2014 – 12/31/2014Billy ButlerABC123456789Slide13

Medicare AdvantageMedicare Advantage (MA) facilitates the coordination of Blue Plan Medicare Advantage claims and services for members and providers.MA products must cover the same services as original Medicare Part A/B and may include additional benefits.MA has expanded to allow Plans to offer several types of MA products.CMS Employer Group Waiver GuidanceAllows MA PPO and HMO groups to enroll members in areas where provider networks do not exist.Slide14

Medicare AdvantageMA Private Fee-for-Service (MA PFFS)Member may receive services from any Medicare provider that accepts the Home Plan's terms and conditions.Identifying a MA member:Slide15

Medicare AdvantageMA Claims SubmissionSubmit all Medicare Advantage claims to BCBSKSDo not bill Medicare directly for any services rendered to a Medicare Advantage memberPayment will be made directly by a Blue PlanMA claims cannot and will not be processed pursuant to BCBSKS Policies and ProceduresMember's Plan is solely responsible for determining pricingSlide16

Medicare AdvantageMA Claims SubmissionHome Plans need the following to adjudicate MA claims accurately and timely:National Provider Identifier (NPI)Source of Referral for Admission (one alpha-numeric character indicating transfer or admission)Core Based Statistical AreaTreatment Authorization CodeAdmitting Diagnosis CodeHeight and Weight for End-Stage Renal Disease (ESRD) patientsAmbulance Pick-Up Zip CodeHIPPS Code for Home Health, Skilled Nursing and Inpatient RehabilitationTaxonomy Code (if the provider represents an institutional with more than one subpart to bill)

Certified Registered Nurse Anesthetists (CRNA) Special CodeProvider Service Location ZIP Code, if different than the billing ZIP Code

Present On Admission (POA) IndicatorSlide17

Medicare AdvantageMA Appeals Reason for appeal may include:A delay in providing, arranging for or approving healthcare servicesThe amount a member must pay for a serviceAppeals can be submitted by MemberProviderAssignee or the member's legal representative Appeals submission:Submit to BCBSKS

BCBSKS forwards to member's plan within 3 days of receiptMember's MA Plan will respond to provider within 30 daysMember's plan determines medical policy

Provider agrees to abide by final determination

Obtain appeals policies and procedures from the MA PlansSlide18

2015 Policies & ProceduresUpdates and Changes:Language was added to the provider contracts that encompasses all subsidiaries of BCBSKSA new BCBSKS Subsidiary (a Health Maintenance Organization (HMO)) known as Blue Solutions will be sold to consumers soon with an effective date of January 1, 2015: Blue Choice networkLimited network with in-state contracting providers only Empty SuitcaseSold to individuals on and off the exchange and small group (SHOP) markets

Blue Solutions is not a traditional HMO:Members will not choose a Primary Care Provider (PCP)

No referral is needed for visiting a specialty provider

Members have open access through the BCBSKS Blue Choice network

Providers reimbursed using Blue Choice payment ratesSlide19

2015 Policies & ProceduresBlue SolutionsThe following alpha prefixes will be used for Blue Solutions members

:

XSC - Individual Exchange Solutions

XSG - SHOP Exchange Solutions

XSQ - Individual Solutions Off-Exchange

XSR - Small Group Solutions Off-ExchangeSlide20

2015 Policies & ProceduresUpdates and Changes:Language was added to specify a timeframe for organizing a First Level Appeal PanelBCBSKS has a credentialing program which:consists of an initial full review of the providers credentialing application with re-credential at a minimum of every 36 months. monitors of all network providers for continual compliance with established criteria will occur as needed, but not less than monthly. If a provider does not meet credentialing requirements, they will not be allowed to participate as a network contracting provider.

Providers may appeal this decision by following the appeals process outlined in the Policies and Procedures. Credentialing Program requires BCBSKS to have an appeals panel and BCBSKS will have 60 days from receipt of the appeal to organize the appeals panel. Slide21

2015 Policies & ProceduresUpdates and Changes:A section was added to the P&P to further define the confidentiality provision. BCBSKS requires that all proprietary information be kept confidential. The contracting provider may not disclose any terms of the Agreement to the third party except upon written consent of BCBSKS and as required by state or federal law.Added language to strongly encourage contracting providers to use the Limited Patient Waiver (LPW).A waiver should be used for a variety of reasons included the service is not medically necessary, the benefit is denied per the member contract or the service is considered Experimental or Investigational.Some providers have their own waivers and they may not meet BCBSKS Requirements. If providers want to use your own waiver form to verify that it includes everything that is on the BCBSKS waiver, then please have your BCBSKS rep review your waiver form.Slide22

2015 Policies & ProceduresUpdates and Changes:A section was added outlining the administrative disputes process to comply with health plan accreditation guidelines.This is not new; just clarificationProvider may dispute issues of concern through their BCBSKS RepRep will work with the provider to address the disputeDispute may be escalated to BCBSKS management, if unresolvedBCBSKS will provide written response within 60 days of management receiving the requestSlide23

2015 MAPsCode ChangesBased on additional information submitted by providers, the maximum allowable payments (MAPs) for the following procedures will be increased in 2015 and additional codes will be added in 2015.ASC MAP'd Codes Increased for 2015234102560929863234122980729888

2345529828299142560829862

29915

26619

ASC

Codes Added

in 2015

19020

23140

23145

23146

26500

26742

27455

29193

43280

53450

65091

65093

65103

67112Slide24

2015 MAPsPayment attachment changes:Page 6, Contract Amendments A provision was added to amend the Contracting Provider Agreement whereby BCBSKS could make adjustments to the maximum allowable payment (MAP) for services. "The Contracting Provider Agreement is hereby amended to delete Section IV. B which references certain circumstances under which BCBSKS could make adjustments to the maximum allowable payment (MAP) for services. If the Contracting Provider has signed the Blue Choice Agreement, then Section IV.3 is also amended." Slide25

Quality Based Reimbursement Program (QBRP) OverviewReporting periodsPeriod 1 is due by November 15, 2014Period 2 is due by May 15, 2015Effective datesPeriod 1 incentives will be effective January 1, 2015Period 2 incentives will be effective July 1, 2015Data submissionsPeriod 1 – attestations onlyPeriod 2 – data from all of CY 2014Incentive increasesIncentives earned will be applied to outpatient maximum allowable payments (MAPs) and do not apply to services with a charge below the MAP.Slide26

QBRP PrerequisitesI attest that this facility will file all claims electronicallyI attest that this facility will accept electronic remittance advices Obtain eligibility, benefit and claim status information primarily through electronic transactionsSlide27

Quality Measure 1 (QM1): Prophylactic Intravenous (IV) Antibiotic Timing (CMS ASC-5)Period 1: Attest that this facility has a process in place to ensure that antibiotic infusion is initiated within one hour prior to the time of the initial surgical incision or the beginning of the procedure (e.g., introduction of endoscope, insertion of needle, inflation of tourniquet) or two hours prior if vancomycin or fluoroquinolones are administered.Period 2: Numerator: Number of ASC admissions with an order for a prophylactic IV antibiotic for prevention of surgical site infections (SSI) who received the prophylactic antibiotic on timeDenominator: All ASC admissions with a preoperative order for a prophylactic IV antibiotic for prevention of surgical site infection Incentive: 1.50%Slide28

Quality Measure 2 (QM2): Falls Within the ASC (CMS ASC-2)For Period 1Attest that a process is in place to capture any ASC admissions experiencing a fall within the confines of the ASC.For Period 2Report the number of ASC admissions experiencing a fall within the confines of the ASC.Numerator: falls within the confines of the ASC in CY 2014Denominator: all ASC admissionsIncentive: 1.00%Slide29

Quality Measure 3 (QM3): ASC Transfers to Hospital Upon Discharge (CMS ASC-4)For Period 1Attest that a process is in place to capture any ASC admission (patients) who are transferred or admitted to a hospital upon discharge from the ASC.For Period 2Report ASC admissions who are transferred or admitted to a hospital upon discharge from the ASC.Numerator: ASC admissions requiring a hospital transfer or hospital admission upon discharge from the ASC. Denominator: all ASC admissionsIncentive: 1.50%Slide30

Quality Measure 4 (QM4): Surgical/Procedure Time OutI attest that this ASC has a time-out protocol which requires a hard stop by all after prep and drape and prior to the start of the procedure. The protocol shall include the following: a) identification of the patient by name b) the procedure is stated c) the marked incision site is visible d) allergies are stated and share with the team and selected prophylaxis antibiotics ordered and given e) The team is asked about any concerns before starting. Concerns are shared with the team and discussed to mitigate risk.Incentive: 0.50%Slide31

Form submission Paper forms can be faxed to Brent Matile at 785-290-0734 or emailed to Brent.Matile@bcbsks.comThe QBRP form is available electronicallyAny updates to contact information for Quality Managers should be emailed or indicated on the paper formSlide32

AMBULATORY SURGERY CENTERS (ASC) WORKSHOPQuestions?