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MSMA Objects to Anthem Denial Policy on Emergency Services
MSMA is denouncing a new cost-shifting scheme by Anthem Blue Cross Blue Shield to deny coverage for emergency services when it decides after the fact that the services were not for a true emergency.
In a conjoint letter to the Director of the Missouri Department of Insurance, MSMA, the Missouri College of Emergency Physicians, the Missouri Association of Osteopathic Physicians and Surgeons, and the Missouri Hospital Association called the new policy dangerous for patients and an unacceptable violation of state and federal patient protection laws.
Insurance laws maintain the “prudent layperson” standard that requires coverage for emergency services for any symptom that leads a person possessing average knowledge of health and medicine to believe immediate care is required. That standard is a critically important patient protection that bases coverage on symptoms, not diagnoses. But the new Anthem policy turns that upside down and expects patients to diagnose their own condition and make a clinical decision that could be the difference between life and death. When policyholders learn that they might be held financially responsible for emergency department care, they might delay or not seek vitally important care at a time when they are most critically ill and vulnerable.
MSMA urged the Department of Insurance to enforce the prudent layperson law and take a very hard look at the new Anthem policy, especially its impact on the health and well-being of the Missouri patients.
Medicaid Managed Care Provider Enrollment is Coming
Beginning January 1, 2018, federal regulations require all states to screen and enroll, and periodically revalidate, all network providers of Medicaid managed care organizations. This requirement applies to all ordering, prescribing, and referring providers in the managed care setting, as well. It does not cause managed care network providers to see Fee For Service Medicaid clients.
Missouri Medicaid Audit and Compliance is working with MO HealthNet (Medicaid) and the managed care health plans to provide a streamlined process for enrolling managed care network providers that have not yet enrolled with MO HealthNet. Questions can be directed to MMAC.ProviderEnrollment@dss.mo.gov.
Missouri Medicaid Announces Rate Reduction
MO HealthNet has issued a Physician Program Rate Update Bulletin announcing a 3% rate reduction effective July 1 due to reductions in the state budget. Other Medicaid services receiving the 3% reduction include rehabilitation, dental, DME, audiology, hearing aids, ambulance, behavioral, and optical services. To monitor future announcements, watch MO HealthNet’s website.
Fees for Medical Records Effective 2/1/17
The new maximum fees for copying medical records will be $24.85 plus $0.57 per page for the cost of labor and supplies for copies provided in paper form, and $23.26 for additional costs if records are maintained off-site. The new maximum fees for copies provided electronically will be $24.85 plus $0.57 per page, or $108.88 total, whichever is less. For more information, go to: http://health.mo.gov/atoz/fees.php.
HIPAA and Fees for Medical Records
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), a covered entity may only charge an individual or the individual’s personal representative a reasonable cost-based fee. The Office for Civil Rights has posted guidance regarding what a covered entity provider may charge an individual or the individual’s personal representative here.
Medicare Fraud Alert
If you receive a request for a signature on a Certificate of Medical Necessity for a patient not known to you, the physician area already completed, or if you receive a request for medical record documentation for a patient where you did not order the DME item, or that you do not believe is appropriate for the patient, please treat this as a fraud issue.
You can submit the information to OIG Hotline: 800-HHS-TIPS (1-800-447-8477) or online at https://forms.oig.hhs.gov/hotlineoperations/
CMS issues final MACRA Quality Payment Program rule
The Department of Health and Human Services issued its final rule to implement the Quality Payment Program (QPP) which was created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) to replace the flawed Sustainable Growth Rate formula for updating the Medicare physician fee schedule.
The final rule – a tortuous 2,205-page manifesto and alphabet soup of federal acronyms – sets forth two main options for participating physician practices to consider: The Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs)....read more.