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March 2010 - Volume 10, Issue 1
The March 2010 issue of MedNet News includes information about the HIT federal stimulus money guaranteed by athenahealth, MedNet's new fee schedule, major payor updates, and important info regarding HPHC's radiology protocol changes.
Quality Advance Program from HPHC
Payment systems continue to evolve in recognition that the value equation for medical services must not only include cost, but also medical necessity, effectiveness, and outcomes.
Pay-for-performance and value-based purchasing are becoming increasingly prevalent and quality performance guidelines are following suit. Many healthcare organizations, professional associations, payers, accrediting bodies, and consumer groups are now aligning reimbursement systems with the national Bridges to Excellence (BTE) and National Committee for Quality Assurance (NCQA) reporting standards.
The Quality Advance Program from Harvard Pilgrim Health Care, as well as those from other private insurers, seeks to align the intrinsic benefits of providing better quality healthcare for your patients with the potential for financial incentives for aggregate quality improvement.
Physicians can position their office for increased reimbursements by systematically collecting, managing, retrieving, and reporting quality data.
Identifying patients who are experiencing gaps in care and improving outcomes through reliable utilization of best-practices and standardized care programs can be achieved through better health information technology (HIT). However, the financial investment in HIT, such as EMR/EHR's and chronic disease registries, can be burdensome for practices. To assist practices in this effort MedNet has strategically aligned with athenahealth, and their guaranteed compliant HIT products and services.
Action Item: Plan to report your quality data this year and take advantage of the Harvard Pilgrim Healthcare - Maine Quality Advance Program. The Harvard Pilgrim Health Care rewards are based in part on BTE and NCQA quality data, reported through the Maine Health Management Coalition. MedNet can assist you in understanding the data submission processes.
MedNet Provider Applications and Edits
New Applicants
Go to www.mainemednet.com, select Services and choose your provider type for all required forms and mailing instructions. On receipt of communication from the Council for Affordable Quality Healthcare (CAQH), go to www.caqh.org/cred and either create or update your file.
MedNet Provider Edits
Report all provider practice name, address, TIN, and other changes with the effective date in writing to MedNet Credentialing Dept. by:
FAX: (207) 773-1739 or
Email: cbelliveau@mainemednet.com
and to
HPHC - FAX: (866) 884-3843 or
Email: ppc@harvardpilgrim.org.
Timely reporting of changes ensures proper claims payment for services rendered and accurate practice information on MedNet's website.
New 2010 Fee Schedule
MedNet's Fee Schedule update will go into effect July 1, 2010. Sample files can be made available by contacting MedNet's Provider Relations Dept. at:
(207) 773-5116 Opt #4 or
(800) 556-1144 Opt #4
Harvard Pilgrim Health Care's (HPHC) updated Fee Schedule is in effect April 1, 2010. MedNet has sample files available for providers who are covered under the HPHC/MedNet Local Care Unit (LCU) 87 agreement. Those physicians and allied health professionals who participate in separate HPHC LCUs should receive their update directly from HPHC.
HIT Federal Stimulus Money Guaranteed by athenahealth
MedNet providers now have preferred access to the nationally recognized HIT system created by athenahealth Inc., that enables even the smallest practice to meet the definition of meaningful use.
To benefit from President Barack Obama's 2009 American Recovery and Reinvestment Act (ARRA) and the recent enactment of the Health Information Technology for Economic and Clinical Health (HITECH) Act, providers must be able to easily report accurate data on quality measures, and potentially improve their ability to deliver higher quality care. According to the HITECH Act, physicians are eligible to receive up to $44,000 over five years in total incentives per physician from Medicare if they have adopted and are providing "meaningful use" of a certified Electronic Health Record (EHR) starting in 2011. Note: Physicians reimbursed by Medicaid can receive up to approximately $65,000 starting in 2011 based on state-defined guidelines.
MedNet providers now have preferred access to the nationally recognized services offered by athenahealth, Inc. that enables even the smallest practice to meet the definition of "meaningful use". athenahealth is so confident in their low-investment, web-based software solutions they are offering a guarantee that clients will qualify for HITECH Act incentive payments in the first year. Their approach enables all of their client practices to access new mandates from Washington, D.C. in real time and makes updates immediately available to you and everyone in your practice. To make the process of qualifying for meaningful use even easier, the virtual back-office service team will help you enroll in the program, report on necessary clinical measures, and collect payment.
The unique collaboration between MedNet and athenahealth has a common goal of introducing technology and services that will allow Maine's medical providers to elevate the quality of care delivered while minimizing the administrative complexity of practice operations. athenahealth's products deliver consistent financial and clinical results with very low initial investment costs and rapid implementation. Additionally, small independent physician practices can utilize athenahealth to overcome the inherent challenges presented by emerging pay for performance and quality recognition programs. athenahealth products and services include, but are not limited to the following:
athenaCollector - a web-based physician revenue cycle management product designed to deliver faster reimbursement, increased revenue, improved practice workflow, continually updated payer knowledge, and back-office processing support.
athenaClinicals - A low-investment, high-return web-based EHR solution that combines industry-leading support, intelligence and technology to actually boost your bottom line, and integrally linked to athenaCollector.
athenaCommunicator - An on-demand, live, and automated patient communications system which streamlines workflow, supports compliance, drives more revenue and improves patient care.
Contact list for more information on athenahealth's products and services:
• Deidre DeRoche, MedNet
Provider Relations Manager
(207)-773-5116, ext. 128 or
dderoche@mainemednet.com
• Tom Drottar, MedNet
Director of Networks & Business Development
(207) 773-5116, ext. 106 or
tdrottar@mainemednet.com
• athenahealth website at: www.athenahealth.com
Harvard Pilgrim Healthcare Update
Important updates regarding Radiology Management, Provider Analytics, and Provider Training Sessions.
Radiology Management Program
Effective April 1, 2010, Harvard Pilgrim's radiology management program includes medical necessity review for certain non-emergency, outpatient advanced imaging services. Providers should continue to contact National Imaging Associates (NIA) to request authorization prior to scheduling CT/CTAs, MRI/MRAs, PETs and Nuclear Cardiology. However, NIA will review authorization requests based on clinical criteria, and issue either an authorized approval number or a medical necessity denial. Denials will result in a written denial notification letter, mailed to the patient, with copies sent to the servicing and requesting providers.
In addition, payment policies for Positron Emission Tomography (PET), Nuclear Cardiac Imaging and Myocardial Perfusion Studies have been updated for April 1, 2010, to support reimbursement for these services only when performed for covered clinical indications.
Go to: www.hphc.org/Providers and click on the Radiology Management Program link for more information.
Provider Analytics
The HPHConnect reporting tool from Harvard Pilgrim lets providers manage accounts receivable, identify trends, drill down to claim details and reduce administrative denials. It enables staff to access 13 months of claims history, EDI submission data and demographic details on associated providers. HPHConnect users can also view reports, submit requests, see remittance reports and retrieve available download requests. Go to www.hphc.org/Providers and click on "HPHConnect" for details.
UnitedHealthcare Update
Final Changes to Admission Notification Rules Now in Effect.
Effective January 19th, 2010, UnitedHealthcare has finalized standards for its Hospital Admission Notification programs for commercial product admissions.
Weekday Admissions
Weekday admissions are defined as occurring between 12:00 a.m. Monday through 4:59 p.m. Friday, local time.
Admissions notification is required. Reimbursement reductions may be applied if notification does not occur at the time of admission, or occurs more than 24 hours after admission.
Weekend and Federal Holiday Admissions
Weekend admissions are defined as occurring between 5:00 p.m. Friday and 11:59 p.m. Sunday, local time. Federal holiday admissions are defined as occurring between 5:00 p.m. local time on the business day before the federal holiday and 11:59 p.m. local time on the day of the federal holiday.
Reimbursement reductions may be applied if notification does not occur at the time of admission, or notification occurs after 5:00 p.m. local time the following business day.
Further questions or more specific details regarding UnitedHealthcare's Advance and Admission Notification policies and procedures, go to: www.unitedhealthcareonline.com
> Clinician Resources > Care Management > Admission Notification
An Important Update Regarding UnitedHealthcare's Radiology Notification & Authorization Programs
As a reminder for UnitedHealthcare's commercial membership, notification is required for each of the following Advanced Outpatient Imaging Procedures:
- CT/CTA scans
- MRI/MRA
- PET scans
- Nuclear medicine/cardiology
Place of Service Exclusions:
- Inpatient
- Emergency Room
- Observation unit
- Urgent care centers
In addition and effective June 7, 2010, UnitedHealthcare's Medicare Advantage membership (Secure Horizons) will be subject to UnitedHealthcare's Radiology Authorization program. Although similar in scope, the Radiology Authorization program dictates receiving approval of services prior to scheduling and delivery.
It is the responsibility of the ordering provider to perform notification or prior authorization. Failure to perform notification or prior authorization can or will result n a denial at point of service or reduction in payment to the rendering provider.
For more details regarding UnitedHealthcare's Radiology Notification & Prior Authorization Program, including specific CPT codes go to: www.unitedhealthcareonline.com
> Clinician Resources > Radiology Notification & Authorization
For ordering physicians or rendering providers, prior authorization may be obtained by contacting UnitedHealthcare in the following ways:
Online: www.unitedhealthcareonline.com
> Notifications > Radiology Notification
> Authorization Submission & Status
Phone: (866) 889-8061, 7:00 a.m. to 7:00 p.m., M-F
Fax: (866) 889-8061
Fax forms are available at: www.unitedhealthcareonline.com
> Clinical Resources > Radiology
> Radiology Notification & Authorization > Authorization Resources: Modality Specific Forms
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