RCM eNews – August 2024

The U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), proposed new policies in the calendar year (CY) 2025 Medicare Physician Fee Schedule (PFS) proposed rule to advance health equity and support whole-person care. The proposed rule would also strengthen primary care, expand access to behavioral health, oral health, and caregiver training services, maintain telehealth flexibilities, and expand access to screening for colorectal cancer and vaccinations for hepatitis B.

Because of factors specified in law, average payment rates under the PFS are proposed to be reduced by 2.93% in CY 2025 compared to the average amount these services will be paid for most of CY 2024. The change to the PFS conversion factor incorporates the zero percent overall update required by statute, the expiration of the 2.93% increase in payment for CY 2024 required by statute, and a small adjustment necessary to account for changes in valuation for the work RVU portion of particular services. This amounts to a proposed estimated CY 2025 PFS conversion factor of $32.36, a decrease of $0.93 (or 2.80%) from the current CY 2024 conversion factor of $33.29.

Expanding Access to Behavioral Health, Oral Health, and Caregiver Training Services
CMS is proposing new payments for practitioners who are assisting people at high risk of suicide or overdose, including separate payment for safety planning interventions and post-discharge follow-up contacts. CMS is also proposing new payment and coding for use of digital tools that further support the delivery of specific behavioral health treatments, and also new coding and payment to make it easier for practitioners to consult behavioral health specialists.

In response to public feedback about Medicare coverage of dental services, CMS continues to explore payment policies for dental services critical to the success of certain medical care. CMS previously finalized that payment can be made for dental exams and certain necessary diagnostic and treatment services in connection with organ transplants (including stem cell and bone marrow transplants), cardiac valve replacements, valvuloplasty procedures, head and neck cancers, chemotherapy, chimeric antigen receptor T- (CAR-T) cell therapy and high-dose bone modifying agents (antiresorptive therapy). In this year’s rule, CMS proposes that payment can be made for certain dental services associated with dialysis treatments for end-stage renal disease and includes a request for comment about dental services related to diabetes care and covered services for individuals with autoimmune diseases receiving immunosuppressive therapies.

Finally, caregivers provide crucial, daily care to many people with Medicare, and CMS continues to prioritize caregiver training services. In this year’s rule, CMS proposes new payment for caregiver training services related to direct care services and supports and would allow caregiver training services to be provided virtually, as clinically indicated.

Maintaining Telehealth Flexibilities
During the COVID-19 public health emergency, CMS took action to expand access to telehealth services to ensure people could continue to access health care. Congress’ temporary extension of flexibilities related to payment for many telehealth services is scheduled, by statute, to expire at the end of 2024. In that context, CMS continues to examine telehealth and its impact on access and quality. Proposals in this year’s rule would allow CMS to maintain some important, but limited, flexibilities where possible and reflect CMS’ goal to maintain and expand the scope of and access to telehealth services where appropriate.

To view the CY 2025 Physician Fee Schedule and Quality Payment Program proposed rule, click here.

Starting August 1, 2024, providers in Highmark’s New York service areas must use Availity to check claim status or submit a claim inquiry.

Medical Record Collection Requests
Starting in August, your office may receive a medical records request from Datavant, a risk-adjustment vendor, to obtain medical records on our behalf.

This record review is conducted annually and is required to comply with CMS. The request will include dates of service between January 1, 2023 and December 31, 2023 and only applies to Medicare Advantage members.

Univera Healthcare Members
Reminder that under your participating agreement with Excellus BCBS, you can accept patients who have insurance coverage through Univera Healthcare. Eligibility and benefits can be checked at HealtheNet.com or Provider.UniveraHealthcare.com.

For further details and to read the entire Excellus BCBS Connection Newsletter, click here.

Effective August 1, 2024, there will be updated requirements for inpatient and observations admissions. These requirements are included in the Inpatient and Observation Care Notification Requirements Policy).

From CareFirst:

Which members will these changes impact?

The requirements outlined below apply to all CareFirst members. This includes members covered under Commercial, Federal Employee Program (FEP), Medicare Advantage, CareFirst CHPMD (Medicaid), and CareFirst BlueCross BlueShield Advantage DualPrime lines of business.

What are the updated requirements?

1. 24 Hour Notification Required for Inpatient Admissions
   Beginning August 1, 2024, CareFirst requires all Facilities to provide notification of an inpatient admission (see policy and FAQs for specifics) within 24 hours of admission. CareFirst’s preference is that an inpatient notification be submitted through the inpatient section of the Prior Authorization/Notification Portal.
2. 24 Hour Notification Required for Observation Stays
   In addition, all observation stays will require 24-hour notification to CareFirst (see policy and FAQs for specifics). CareFirst’s preference is that observation notification be submitted through the inpatient section of the Prior Authorization/Notification Portal. Despite this entry point observation stays are still considered outpatient.
3. Level of Care Required on Inpatient Requests
   Level of care will need to be indicated on all inpatient requests as well beginning August 1, 2024. To indicate the level of care information, providers will be asked to include the appropriate revenue code as part of the request.

Registered users with the Precertification – View and Submit entitlement now have access to digital precertification correspondence via the Messaging Center on CignaforHCP.com.

Digital correspondence notifies users when precertification letters are available, or when action is required to continue processing.

Designate the following communication preferences by logging into CignaforHCP.com > Settings and Preferences > Communication Settings:

• The type of correspondence you want to receive (e.g., emails and/or alerts) when digital correspondence is available.
• Email notifications and frequency to alert you when new digital correspondence is available.

Learn about digital precertification correspondence by reviewing the frequently asked questions.

From United Healthcare:

Starting Aug. 1, 2024, UnitedHealthcare Community Plan of New York health care professionals must include a National Provider Identifier (NPI) number and taxonomy code when submitting claims.

How to obtain an NPI number and register your taxonomy code

• Apply for an NPI number with the (NPPES)  National Plan and Provider Enumeration System
• During the application process, you will register your taxonomy code with NPPES
• Once approved, NPPES will send you a confirmation notice with your assigned NPI number
• You can have multiple taxonomy codes, but each one must be registered with NPPES
• Make sure to use the correct registered taxonomy code that matches your specialty when submitting claims

Submitting a claim
We suggest submitting claims electronically. If the taxonomy code is missing on an electronic submission, we will reject the claim as incomplete. However, if you submit a paper claim missing the taxonomy code, we will deny the claim. You can resubmit both electronic and paper claims to include a missing taxonomy code.

From AmeriHealth:

Starting August 1, 2024, AmeriHealth commercial members with the NY Access or National Access network will receive a new ID card when their plan renews, as part of the transition to our new operating platform.

In addition to the network indicator (e.g., Local Value and Regional Preferred) located on the top right of the card, the new ID cards may show one of these options, depending on the benefits purchased:

• A Private Healthcare Systems Inc (PHCS) logo- for members with National Access
• Both the PHCS logo and a New York ONLY indicator for members with NY Access

…

New ID cards will be distributed throughout the platform transition as a member’s plan renews. Therefore, it’s imperative that provider offices do the following:

• Obtain a copy of the member’s ID card at every visit to ensure that you submit the most up-to-date information to AmeriHealth.
• Verify the member’s plan using the Eligibility & Benefits transaction via the Practice Management application on the Provider Engagement, Analytics & Reporting (PEAR) portal.

Although ID cards will be changing, the processes for contracted providers will remain the same. You should continue to submit claims to AmeriHealth, send precertification requests to us, and contact us with any questions related to the National Access network.

From Excellus BCBS:

Be advised that effective October 1, 2024, our site of care program will be updated to include required redirection as an option for our self-funded Commercial groups. Additionally, effective January 1, 2025, our site of care program will be updated to require site of care redirection for all fully insured Commercial lines of business.

Patients who have fully insured Commercial coverage and currently receive select infusion or injectable drugs at certain hospital-based outpatient facilities will be required to obtain services from the most cost-effective site of service, when medically necessary. Program enrollment will continue to be optional for self-funded Commercial groups. Required site of service redirection will NOT apply to Medicare or Medicaid patients.
For all patients enrolled in required site of care redirection:

• Select infusion and injectable medications will be reviewed for medical necessity of the intended site of care.
• Reviews for existing users of applicable drugs will take place at the time of reauthorization of the requested drug(s). If redirection is required, the existing user and their provider(s) will be notified 90 days prior to this review to allow adequate time for site of care transition.
• Reviews for new users will be granted a short-term authorization (at least 90 days) to allow adequate time for site of care transition.
• The Health Plan will reach out to impacted patients during the transition period to assist with redirection and to help coordinate a prior authorization exception request, if necessary.

Empire Blue Cross & Blue Shield and Empire Blue Cross are changing names to Anthem Blue Cross & Blue Shiled and Anthem Blue Cross. “Empire has been an Anthem company since 2006. Becoming Anthem in New York represents our continued journey to bring together everything that Anthem offers our members and our communities across our 14 states.”

Contracts, credentialing and access to portals will remain unchanged. Members will receive new ID cards, but Empire ID cards should still be accepted through 2024.

For further details and to view the FAQs, click here.

Immunosuppressive Drug codes J2920 and J2930 for methylprednisolone sodium succinate, up to 40 MG and 125MG have been discontinued for use and replaced with code J2919 methylprednisolone sodium succinate, 5 mg. Code 1 unit for every 5MG of J2919.

For further details, click here.