August 4th – UPDATE ON PHYSICIANS BEING LOADED FROM BCBSTX BELOW:

“I’m working on getting the providers loaded asap.  I don’t know exactly when they will be loaded but I have requested them to be loaded as urgent and will notify you as soon as that’s done so that members can select their Primary Care Physicians.”

The following memo is for POET physicians participating in POET Blue Essentials contract with BCBSTX. Bottom line is if you do not wish to see ANY Blue Essentials member please contact POET. Otherwise you are now completely in the Blue Essentials product (unless there are carved out benefit plans. )

As you may be aware TRS will have an option of Blue Choice or Blue Essentials as of September 1, 2020.

Currently our Blue Essentials agreement only allows for ERS through the definition of Member.

To add TRS and other members, the definition of Member has been changed to:

“Blue Essentials Member (“Member”) means an individual who is eligible to receive Covered Services under a Health Plan that utilizes the Blue Essentials HMO Network. “

This means you will be in network possibly (always check benefits) for ANY patient with Blue Essentials.

If you do not wish to participate in the agreement with this change, please contact POET to request a “opt out” form to sign.

HOW TO LEARN MORE:

BCBSTX is offering webinars to help educate you and your staff about Blue Essentials.  See the below link for more information.

Link to BCBSTX article: https://www.bcbstx.com/provider/providersearch.html?keyword=TRS&state=tx&portal=&collectionType=tx_prod_provider&x=10&y=4

As always if you have questions please feel free to contact POET.

UPDATE: BCBSTX has sent the following reply to POET asking when physicians would show up in website as in network:

“To answer your questions providers can be loaded into the system prior to the effective date; however, they will not be visible for members select on the website until the date the contract takes effect.”

The Texas Chapter of MGMA has announced it’s annual meeting will be virtual. The price for Members and Non- Members ($99) are the same.

The 2020 Annual Meeting is going Digital! 

September 8-11, 2020 

As a precaution and in consideration for the safety of our members and vendors the TMGMA Board has decided to hold a virtual meeting this year.

Topics Include:

• Best Practices for Medical Group Managers & the Pandemic
• Active Shooter Training: Stop the Bleed
• Cybersecurity Panel
• How to Avoid Burnout
• Commercial Payor re: Denials/Appeals Process for Prior Authorization and/or Contract Negotiations for In Network
• Medicare/Medicaid: Coding Updates for 2020
• Prior Authorizations in Texas: Burdens and Policy
• Status of Rural Health
• TMGMA Annual Business Meeting
• Principal Care Management
• MGMA Legislative UpdateTexas Bills: Prior Authorization, Claim Denials, Sales Tax Bills, Surprise Billing

Registration Information

Before August 15, 2020
*ALL PRICING BELOW WILL INCREASE $100 AFTER 08/15/20

Members
Active – $99
Affiliate – $99
Faculty – $99
Student – $99

Non-Members
Non-Member – $99
Affiliate Non-Member – $99

HHS has extended the PHE for another 90 days as indicated in the announcement on this link and below. https://www.phe.gov/emergency/news/healthactions/phe/Pages/covid19-23June2020.aspx

Renewal of Determination That A Public Health Emergency Exists

As a result of the continued consequences of Coronavirus Disease 2019 (COVID-19) pandemic, on this date and after consultation with public health officials as necessary, I, Alex M. Azar II, Secretary of Health and Human Services, pursuant to the authority vested in me under section 319 of the Public Health Service Act, do hereby renew, effective July 25, 2020, my January 31, 2020, determination that I previously renewed on April 21, 2020, that a public health emergency exists and has existed since January 27, 2020, nationwide.

From MGMA 7/22/2020

FROM MGMA

HHS released an overview of future reporting requirements for providers that received payments under the Provider Relief Fund. HHS outlined the timing of future reporting requirements for providers that receive payments that exceed $10,000 in the aggregate from any Provider Relief Fund distribution (i.e., any payment under the $50 billion general distribution; Medicaid distribution; or a targeted distribution). The overview released on July 20 does not indicate whether providers that received $10,000 or less will be subject to any reporting obligations, and does not provide detail as to the form or content of reports. However, the following timeline is provided:

• August 17, 2020: Detailed instructions will be available by this date
• October 1, 2020: Reporting system comes available
• February 15, 2021: Report due
• July 31, 2021: Second report due for those who expended funds in 2021

MGMA will continue to monitor this issue and update the community as soon as detailed instructions for reporting become available.

Drew Voytal
Associate Director
MGMA Government Affairs
Washington, DC

by Joey Berlin, July 17, 2020

The Texas Medical Association has updated its white paper on Texas’ law for settling out-of-network billing disputes involving state-regulated health plans.

The eight-page white paper, first released last December, covers the ins and outs of Senate Bill 1264, the 2019 legislation now in effect. SB 1264 took patients out of the middle of surprise-billing disputes between certain out-of-network physicians and state-regulated health plans, allowing them to settle those disputes through an arbitration process similar to the one used to settle salary disputes in Major League Baseball.

The white paper update comes after the Texas Department of Insurance  adopted a final rule touching on exceptions to SB 1264’s general ban on balance billing for out-of-network services the law covers. SB 1264 prohibits balance billing except in certain circumstances, which include required notice and disclosure.

The newly amended rules include these changes that TMA requested:

• Legal representatives or guardians of a patient may be the people to agree to an out-of-network physician’s required notice and disclosure of a potential balance bill;
• A physician may delegate the record-keeping of that notice and disclosure statement by allowing a practitioner’s “agent or assignee” to maintain a copy of the statement. Also, the statement only has to be maintained if the practitioner provides the medical service or supply at issue and sends a balance bill.

You can read the complete adopted rule on page 4,204 of the June 19 Texas Register.

To view the TMA updated white paper on Ink, follow this link.

…Now they tell us….

POET has recently been notified by a physician office they were not paid according to the Aetna fee schedule. When the issue was brought to the attention of Aetna, they indicated the fee schedule had been updated back in April.

In the past POET has always been notified of such updates and provided a fee schedule. Yes, the fee schedule always arrived after the effective date but at least we knew it was coming. This year they have apparently chosen not to notify us. We requested the fee schedule and have received it.

We will be sending out packets for participating physicians under the POET Aetna contract. From our first glance at the fee schedule it does appear to follow CMS changes and no other surprises.

Please be on the look out for your packets late next week. If you need information sooner please call or email us.

This Month’s edition includes the following:

• SDOH – Food Insecurity
• Hepatitis Awareness
• COVID-19 Resources
• CAHPS Corner – HOS (Fall Risk)

Family First Coronavirus Response Act (FFCRA) leave based on the closure of summer camps, summer enrichment programs, or other summer programs.

Please see the Field Assistance Bulletin (FAB) that provides guidance for Wage and Hour Division (WHD) investigators regarding when an employee may take leave under the FFCRA.

POET has received the following information from Anita Kindred, the UHC representative. And we quote:

“We have a new service model for provider to follow to get claim issues resolved:

1. Use LINK to request a claim reconsideration or contact Provider Service at the number listed on flyer if you have questions (must get a reference number for).

2. If issue still have not been resolved through the reconsideration above, please send the all information (including claim info, questions and/or issues), with the reference number from above  (1) to email box:  [email protected].” 

Attached to Anita’s email was the UHC Service Model Flyer for TX and OK. You can find it by clicking on the blue text.

From POET’s perspective, this looks like POET will no longer be able to help with UHC claims resolution or escalation.

However, POET took an extra step and found additional information to help you with the process.

1. UHC-Corrected Claim and Claim Reconsideration Request Guide. This is an overall General Guide.
2. UHC-Claim Research Project Quick Guide. This is a step by step guide on how to research and submit a reconsideration request for multiple claims with the same reason for denial.
3. UHC-Claim Reconsideration & Corrected Claims Quick Reference Guide. Is a step by step guide on how to look up the claim status and payment information. It also tells you how to submit claims for reconsideration or appeal a decision. This guide also reviews how to submit and check the status of a reconsideration request.

POET is very sorry to hear that UHC has decided to implement this new process.

Physician Practice, June 25, 2020, Rahul Varshneya

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