October 2 4 - 2 5 2017 - PowerPoint Presentation

Slide1

October

2

4 - 25 2017

Located at the Greater Richmond Convention CenterSlide2

Medical Fee Schedule, Is change always a challenge?

Presented

By

:Tammy Tomczyk, Lesley Wagner, and Drema ThompsonMedical Fee Services DepartmentSlide3

The making of the VWC Medical Fee Schedule

Key Considerations for Statutory and Regulatory Provisions

Development of Ground Rules

Data used to develop the fee scheduleDesign and Methodology for the fee scheduleMedical Billing and Reimbursement GuidelinesABCs of Coding for the fee scheduleMedical record documentation

Provider medical claim submissionPrompt paymentProvider and Payor Relations

Medical Fee Services Department

Dispute resolution processPost Fee Schedule statute limitations

Required forms and documentation

AgendaSlide4

Tammy Tomczyk

Framework of the Medical Fee Schedule

Key Statutory and Regulatory Provisions

Development of Ground RulesDesign and MethodologyResultsSlide5

Key Statutory and Regulatory ProvisionsSlide6

Key Statutory and Regulatory Provisions

7

provider groups are defined for each of the

6 medical communitiesSlide7

Key Statutory and Regulatory ProvisionsSlide8

Development of Ground RulesSlide9

Design and MethodologySlide10

Design and MethodologySlide11

ResultsSlide12

ResultsSlide13

Lesley Wagner

Billing and Reimbursement

ABCs of Coding for the fee schedule

Medical record documentationProvider medical claim submissionPrompt paymentSlide14

What’s Changing?Contracts (PPO, provider agreement)

Prima Facie (bill is reasonable and necessary)Prevailing Community Rate (PCR) Uncertain Reimbursement

Standardized Coding PrinciplesMedical Fee Schedule (MFS)Defined Reimbursement

No ChangeSlide15

15

ABCs of Coding for the fee schedule

Standardized coding

CPT HCPCsDRGModifiers

NCCISlide16

Documentation Guidelines

Legal record and is requiredAppropriate Support for diagnostic coding

Determines accuracy in procedure coding

Key element for appropriate reimbursement Medical record documentationSlide17

A Clean Claim is a complete and accurate claim

 form that includes all provider and member information, as well as records, additional information, or documents needed from the member or provider to facilitate prompt payment.

Provider Medical Claim SubmissionSlide18

§ 65.2-605.1. Payment and Denials

Payment for health care services that the employer does not contest, deny, or consider incomplete shall be made to the health care provider within 60 days after receipt of each separate itemization of the health care services provided

.

If the itemization or a portion thereof is contested, denied, or considered incomplete, the employer or the employer's workers' compensation insurance carrier shall notify the health care provider within 45 days after receipt of the itemization that the itemization is contested, denied, or considered incomplete. The notification shall include the following information: 1. The reasons for contesting or denying the itemization, or the reasons the itemization is considered incomplete; 2. If the itemization is considered incomplete, all additional information

required to make a decision; and 3. The remedies available to the health care provider if the health care provider disagrees.Payment or denial shall be made within 60

days after receipt from the health care provider of the information requested by the employer or employer's workers' compensation carrier for an incomplete claim under this subsection.Slide19

Drema Thompson

Provider and Payor Relations

Medical Fee Services Department

Medical dispute resolution Required forms and documentationAdministrative Decision ProcessSlide20

Medical Fee Services Department

Team – Rachel McIlyar, Hope Hill, Chris Branham, Drema ThompsonGoals

Ensure medical fee schedules are properly executed, monitored, and audited in accordance with the statute.

Establish billing procedures and support reimbursement levels for health care providers treating injured workers.Provide direction for medical fee schedule disputes as needed.Provide information and training to the public and trading partners on the medical fee schedule requirements.Slide21

Medical Fee Dispute resolution

Providers or payers may not dispute a payment because of dissatisfaction with an MFS scheduled reimbursement amount.

Any dispute between a provider and payer over application of the medical fee schedule can be submitted to the Virginia Workers’ Compensation Commission for determination. Include the appropriate supporting documentationExplanation of ReviewMedical bill with applicable codeDocumentation

A request for determination of such disputes should be forwarded to:  Virginia Workers’ Compensation CommissionAttn: Medical Fee Services Department1000 DMV DriveRichmond, VA 23220Fax (804) 823-6932

medicalfeeservices@workcomp.virginia.gov Slide22

Forms and Notices

 copies of the original and resubmitted bills;

 copies of the explanation of reimbursement/benefit;

 copies of supporting documentation; andMFS Dispute RequestSlide23

Forms and Notices cont.…

MFS Dispute Response Form

 Copies of the bills;

 Copies of the explanation of

reimbursement/benefit; Copies of supporting documentation

Notice issued for Response

Requestor

Date of Dispute Request

Date of Service

Disputed Amount

Response required in

30

daysSlide24

Administrative Decision

The Medical Fee Services Department will make an administrative decision, and provide written notification of its decision to both the provider and the payer within 30

days of receipt of all requested information.

This Dispute Resolution process shall be subject to the prompt payment or limitation of claims provisions of Va. Code Section 65.2-605.1.Slide25

Questions and Discussions