In this month’s newsletter you will find the following topics:

• Star Rating Highlights
• Closing Out Gaps
• Express Scripts Pharmacy Home Delivery
• AIDS Awareness Month
• CAHPS Corner – encouraging patients to make healthy choices during the holidays
• Valuable Insights – Care Coordination

Important Information for your Office. This Aetna OfficeLink Update covers a variety of topics including: Precertification, Claims Editing, Drug Coverage and much more. Click here to view this Update.

The following physicians have been added to the Physician Directory:

Bao Bui, MD – Hospitalist/Internal Medicine

Robert Busuego, MD – Hospitalist/Internal Medicine

Srinivasa Gurram, MD – Hospitalist/Internal Medicine

BCBSTX Fee Schedule Update Coming March 1, 2020

POET has received notice from BCBSTX of an upcoming fee schedule update.

We will be sending out the notice to POET physicians participating in the POET/ BCBSTX agreement.

We have not received the actual fee schedule. Once POET receives the fee schedules we will prepare opt in/out packets for physicians under the POET agreement.

FROM TEXAS MEDICAL ASSOCIATION

Arbitrary. Confusing. Frustrating. Never-ending. Maddening. Those are some of the terms we can actually print that describe physicians’ perceptions of insurance companies’ prior authorization requirements and approval processes. 

According to a recent American Medical Association survey, 86% of American physicians rated the prior authorization burden in their practices as “high” or “extremely high,” and 50% said that burden has “increased significantly” in the past five years. 

But this is more than a doctor’s office hassle. Patients are paying the price with their health. 

In that same survey, 91% of physicians said the prior authorization process has a somewhat or significantly negative impact on their patients’ clinical outcomes; 75% said wading through the delays, denials, and appeals leads to patients abandoning their recommended course of treatment; and 28% reported that the prior authorization intrusion led to a serious adverse event for a patient under their care. 

Your personal stories of patient harm due to prior authorization request delays or denials can give the Texas Medical Association the ammunition it needs to fight this problem. 

TMA made some progress with the passage of Senate Bill 1742 this year. That new law requires state-regulated health plans to post any prior authorization requirements on the internet and opens the door for utilization reviews to be conducted earlier in the appeal process by a physician in the same or similar specialty as the physician requesting treatment approval. 

“Senate Bill 1742 will shine a bright light into the shadowy world where insurance companies grant or deny prior approvals,” said TMA President David C. Fleeger, MD. “But we need to do more to help physicians make sure that our patients get the medicines, tests, and treatments that they need, when they need it.” 

That’s where you come in. Nothing moves elected officials to action like a slew of real, serious complaints from constituents. In the run-up to the 2020 elections and the 2021 Texas Legislature, TMA plans to collect and publicize patients’ prior authorization nightmare stories. We’ll “prime the pump” with stories physicians like you provide and use them to solicit more from the public directly. 

“We want to build enough momentum that lawmakers have no choice but to pass comprehensive prior authorization reforms,” Dr. Fleeger said. 

Please submit your stories via TMA’s secure email portal. It is important to ensure that your story submission complies with state and federal laws, including, to the extent applicable, the HIPAA privacy rule. HIPAA’s safe harbor list of 18 de-identification requirements, in accordance with Code of Federal Regulations, is available here. We won’t use or publicize your stories without reaching out to you first.

New Medicare Card: If an MBI Changes

From CMS MLN Connects November 2019

Medicare beneficiaries or their authorized representatives can ask to change their Medicare Beneficiary Identifiers (MBIs); for example, if the MBI is compromised. CMS can also change an MBI. It is possible for your patient to seek care before getting a new card with the new MBI. 

If you get an eligibility transaction error code (AAA 72) of “invalid member ID,” your patient’s MBI may have changed.  

• Do a historic eligibility search to get the termination date of the old MBI.
• Get the new MBI from your Medicare Administrative Contractor’s secure MBI look-up tool. Sign up for the Portal to use the tool.

Reminders about using the old or new MBIs:

Fee-For-Service (FFS) claims submissions with:

• Dates of service before the MBI change date – use old or new MBIs
• Span-date claims with a “From Date” before the MBI change date – use old or new  MBIs
• Dates of service that are entirely on or after the effective date of the MBI change – use new  MBIs

FFS eligibility transactions when the:

• Inquiry uses new MBI – we will return all eligibility data.
• Inquiry uses the old MBI and request date or date range overlap the active period for the old MBI – we will return all eligibility data. We will also return the old MBI termination date.
• Inquiry uses the old MBI and request date or date range are entirely on or after the effective date of the new MBI – we will return an error code (AAA 72) of “invalid member ID.”

See the MLN Matters Article for more information on how to get and use MBIs.

Bentegrity/TACT termination from HealthSmart

POET has been informed as of October 31, 2019 Bentegrity/TACT has termed from their HealthSmart agreement.

If you have any questions, please call us..

from CMS MLN Connects

Starting January 1, you must use Medicare Beneficiary Identifiers (MBIs) when billing Medicare regardless of the date of service:

• We will reject claims submitted with HICNs with a few exceptions
• We will reject all eligibility transactions submitted with Health Insurance Claim Numbers (HICNs)

See the MLN Matters Article to learn how to get and use MBIs.