Category: Business
PHE Extended
HHS Secretary Xavier Becerra has renewed the public health emergency (PHE) for COVID-19 effective April 21, 2021. This extension will effectively continue all telehealth waivers and other flexibilities pursuant to this determination. As with previous determinations, the renewed PHE will terminate 90 days after its effective date on Tuesday, July 20, 2021, unless it is further extended. The Biden administration has previously indicated that it intends to continue extending the COVID-19 PHE at least for the remainder of 2021.
Prior Auth. Time Frames
Several commercial payers have resumed prior authorization time frames and requirements that had been suspended because of the COVID-19 emergency, while others will continue to approve prior auth requests or suspend them for at least part of the year.
Below is an overview of some payers’ COVID-19 prior authorization policies as of April 2021: Click on the Links for more detail.
Blue Cross and Blue Shield of Texas ended approvals on services with existing prior authorizations on Dec. 31, 2020.
Aetna is approving prior authorization requests for commercial and Medicare Advantage members until the end of the plan year. “Authorization may be extended beyond the plan year, for a period of six months, if continued eligibility can be confirmed.”
Cigna resumed standard prior authorization time frames and requirements beginning April 1, 2021.
Humana resumed standard prior authorization time frames and requirements beginning April 1, 2021
UnitedHealthcare will not require prior authorization for most services through the national public health emergency period, currently scheduled to end April 20, 2021. Exceptions include medical and behavioral health services, post-acute care admissions, site of service reviews, and transfers to new providers. Prior authorizations for medical and behavioral health were not subject to extension on or after April 10, 2020.
Article written by Ellen Terry : https://www.texmed.org/TexasMedicineDetail.aspx?id=53502&utm_source=Informz&utm_medium=Email&utm_campaign=TMT&_zs=cPrdA1&_zl=CvCF6
Check Those Checks!!!
- Don’t get caught in this dirty deal.
- Know what you are endorsing.
- If you receive payment with no patient information this should be a red flag.
- By endorsing you could be agreeing to accept whatever payment they wish to send.
- Your endorsement could also serve as an authorized signature for contract.
Electrical Aggregation News
Many of your offices are part of the POET Electrical Aggregation.
If you will recall, this allows us to aggregate our electrical usage to put out for bid for best rates. If you are currently in the aggregation you have received an important email from POET on Thursday, April 1st.
Please respond to the email as quickly as possible. Any questions? Call POET! ~ Thank you~
Please Help POET Welcome:
POET email addresses: [email protected] and [email protected] have been disabled.
6 Keys to Addressing Denials
6 keys to addressing denials in your medical practice’s revenue cycle
MGMA STAT – MARCH 18, 2021
The Medical Group Management Association’s most recent MGMA Stat poll asked healthcare leaders, “Has your organization seen denials increase in 2021?”
- 69% said “yes.”
- 31% said “no.”
Common responses from respondents included payers not reimbursing for codes related to COVID-19 supplies, critical care claims and imaging CTs.
For those healthcare leaders who reported an increase in denials, the average increase in denials was 17%.
- Half responded that they increased by 1% to 10%.
- 34% said 11% to 20%.
- 12% who stated 21% to 30%.
The poll was conducted March 16, 2021, with 576 applicable responses.
For great tips and strategies to use, follow this link or visit “The Business End” folder located in the InK files.
MGMA Community
This question was posed on the MGMA Community, March 2021.
Question: Posed from Community Member in Clearwater FL.
Would like to know how your offices are notating the total time on the date of patient visit for 99202-99215 OVs? Currently there is no statement from CMS re how the time must be documented other than total time is to be noted. We anticipate denials due to a lack of notation of time–is anyone seeing denials associated with this?
Reply #1: Community Member from Anchorage AK
Our provider’s note has the following statement at the end of each note:
I spent a total of 25 minutes on this appointment, including review of results, histories, x-rays, examination, consultation with the patient, and coordination of care.For office injections (which cannot be included in the total above if the patient came in for an office visit and the decision was made to also do an injection) we have this statement at the end of the procedure note:
I spent a total of 10 minutes prepping and performing the aspiration today, exclusive of and separate from the time spent on today’s appointment.
Reply #2: Community Member from New Jersey
We recommend to our clients that total minutes can be given, but giving the actual start & stop time is better. ” Pt. was seen for… from 9:01 – 9:22 for a total of 21 minutes.” Too many providers have total minutes that exceed 10-12-15 hours which is easy for auditors to see. That will keep providers out of trouble.
Aetna Commercial Drug Changes
Changes to Aetna's Commercial Drug Lists
On July 1, 2021, Aetna will update their pharmacy drug lists.
You’ll be able to view the changes as early as May 1, 2021. They’ll be available on our Formularies & Pharmacy Clinical Policy Bulletins page.
Ways to request a drug prior authorization
- Submit your completed request form through our provider portal on Availity
- For requests for nonspecialty drugs on Aetna Funding Advant age5M , Premier, Premier Plus, Small Group ACA and Value Plus plans, call the Precertification Unit at 1-855-240-0535 (TTY: 711). Or fax your completed prior authorization request form to 1-877-269-9916.
- For requests for nonspecialty drugs on the Advanced Control, Advanced Control – Aetna, Standard Opt Out, Standard Opt Out – Aetna, Standard Opt Out with ACSF, Aetna Health Exchange and High Value formulary plans, call the Precertification Unit at 1-800-294-5979 (TTY: 711). Or fax your completed prior authorization request form to 1-888-836-0730.
- For requests for drugs on the Aetna Specialty Drug List, call the Precertification Unit at 1-866-814- 5506 (TTY: 711). Or fax your completed prior authorization request form to 1-866-249-6155.
These changes will affect all drug lists, precertification, quantity limits and step-therapy programs. For more information, call the Provider Help Line at 1-800-238-6279 (TTY: 711) (1-800-AETNA RX).
Aetna Authorization Changes
Changes to Aetna National Precertification List (NPL)
As published in the March 1, 2021, edition of Aetna Officelink Updates™
As of July 1, 2021, these precertification changes apply:
- We’ll require precertification for:
- Cataract surgery
- Sacroiliac joint fusion surgery
- Knee arthroscopy with meniscectomy
- Vertebral corpectomy procedures
- Additional lower limb prosthetic codes including select foot, ankle and vacuum pump components
- Spinraza® (nusinersen) – precertification required for both the drug and site of care.
Submitting requests
Be sure to submit authorization requests at least two weeks in advance.
To save time, you can make your request online. Doing so is fast, secure and simple. You can submit most requests online through our provider portal on Availity. Or you can use the Electronic Medical Record (EMR) system portal.
Are you asking for drug prior authorization on a specialty drug for a commercial or Medicare member? Then submit your request through Novologix®, also available on Availity®.
Not registered for Availity?
Register online or call 1-800-AVAILITY (1-800-282-4548). For one-on-one support from us, call Aetna at 1-866-752-7021. Then ask to talk with the Availity team.
You can use our “Search by CPT code” search function on our Precertification Lists web page to find out if the code needs precertification.
You can learn more about precertification under the General Information section of the NPL.
UHC Cuts NPP Payments
A recent UnitedHealthcare (UHC) policy will not only cut payments by 15% to physicians who employ nonphysician providers (NPPs), but also cause needless confusion in the billing process.
That’s according to a letter the Texas Medical Association wrote to the insurer expressing concern over the policy, which took effect March 1.
UHC in December announced a policy that requires advanced practice nurses and physician assistants to bill for their services using their own National Provider Identifier (NPI) when they have not met “incident-to” billing requirements.
Payments billed using an NPP’s NPI number are typically 85% of the physician’s rate.
Despite medicine’s concerns, UHC further revised its policy in March to require that services provided by NPPs will be eligible for incident-to consideration – and thus the full 100% payment – only if the NPPs do not have their own NPI number.
That policy is scheduled to take effect May 1.
“It is TMA’s policy on physician assistants and allied health personnel that reimbursement for services performed by a physician assistant should be made directly to the responsible physician,” TMA wrote in a letter in February. “While greater use of nonphysician personnel can improve the system, responsibility for care must be clearly defined if various personnel are to work together effectively to provide high quality services for the patient.”
TMA also urged UHC to provide further education to physicians and NPPs on proper incident-to billing.
“As part of this effort, UHC should make it clear that physicians can continue to utilize advanced practice nurses and physician assistants under proper incident-to billing arrangements, even if the advanced practice nurse or physician assistant has their own NPI,” the letter says.
TMA is setting up a meeting with UHC officials to discuss the policy, and will report on any updates in Texas Medicine Today.
For more information on incident-to billing requirements, TMA has published a questions and answers document and billing guidelines.
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