New law eliminates access to FL Medicaid claims portal

New changes to the Agency for Health Care Administration (AHCA) in Florida could impact your practice’s claims submission and remit processes. CS/HB 1057, signed into law in June, eliminates parts of the AHCA’s requirements for Medicaid reporting. As part of those changes, Florida providers will no longer have access to CMS’ free Medicaid reporting portal.1

The changes included in the bill come with some good news and some challenges, as some providers will need to adjust in order to make reports and submit claims through clearinghouses, rather than directly through the Medicaid portal. Let’s take a look at what’s changing and how you can prepare for the measure, which took effect July 1.1

What’s in the new law?

The good news is that it eliminates some reporting requirements that have been in effect for several years. Providers will no longer need to report on:

  • Medicaid Managed Care Transition
  • Pharmaceutical Expense Assistance Program
  • Medicaid Drug Spending Control Program

The first of these requirements, Medicaid Managed Care Transition Report, was implemented in the transition from traditional Medicaid programs to the new Medicaid Managed Care program. Since this transition has been complete for the last seven years, this report is now redundant and can be ended.1

The Pharmaceutical Expense Assistance Program Report only applies to Medicaid recipients who have been eligible since 2006 or earlier. There are now only 14 patients still eligible for this assistance in Florida, and while they will continue to enjoy eligibility, reporting on this program is no longer necessary.

Finally, the Medicaid Drug Spending Control Program is another legacy reporting requirement that was implemented in the transition from Medicaid Fee-for-Service (FFS) to the new model. Because much of the eligible population for this program has dual eligibility with Medicare and may also be receiving medications through skilled nursing facilities, the data collected from this report may not be an accurate reflection of medication spending trends for the Medicaid population.

What does the law mean for your healthcare organization?

While Florida providers are now no longer responsible for these reporting requirements, the bill also eliminates access to the free portal for Medicaid claims submissions. Instead, providers must send those claims through a clearinghouse connecting them indirectly to federal payers.

Fortunately, ABILITY works with organizations in Florida and across the country to simplify claims submission and remit processes – bringing all submissions together through a single, centralized portal for all payers.

To learn more about how ABILITY can help you automate claims submissions, decrease denials and streamline remits, request a demo today.

 

1.“New bill revises AHCA Medicaid practices,” Nicole Pasia, State of Reform, June 22, 2021. https://stateofreform.com/news/florida/2021/06/new-bill-revises-ahca-medicaid-practices/

ABILITY and design® and ABILITY® are trademarks of ABILITY Network, Inc.

How a family medicine practice protected revenue and served more patients with telehealth

How can practices protect revenue while serving more patients and improving outcomes? During the COVID-19 pandemic, Southwest Family Medicine was faced with a serious challenge: how to reach patients and provide outstanding care when in-person appointments weren’t an option. Thanks to the right telehealth technology, the practice was able to see more patients and maintain cash flow. “Instead of losing revenue during a time when everyone was experiencing a downturn, we’ve stayed busy,” said office manager Shanna Hammond.

In her time at Southwest Family Medicine, Shanna has seen it all: patients arriving with common colds, broken bones and chronic conditions. What she hadn’t seen before 2020 was a once-in-a-lifetime, pandemic-driven shutdown that left her office deserted. With patients unable to attend in-person appointments, Southwest Family Medicine turned to other options to treat patients virtually.

Like many practices, Southwest Family Medicine did not previously offer telehealth services. So, when faced with a pandemic and the need to see patients from afar, they turned to existing virtual appointment apps.

These off-the-shelf appointment applications were not only clunky and difficult for patients and providers to use – they also presented HIPAA compliance issues. Worse yet, patients ran into compatibility issues with their mobile devices and desktops, creating a nightmare for scheduling and keeping appointments.

“We started out using systems that were the quickest and most familiar to our patients,” Shanna said, “but we realized that we were fighting an uphill battle with apps that weren’t designed for healthcare settings.”

To address compliance and accessibility issues, the team at Southwest Family Medicine turned to ABILITY Virtual Care, a secure and user-friendly platform that was much easier for patients and staff to use. For details on their success, check out our case study now.

 

ABILITY and design® and ABILITY® are trademarks of ABILITY Network, Inc.

Hospice providers now may submit claims to Medicare Advantage Organizations

More Medicare beneficiaries may enter hospice care with complementary Medicare Advantage (MA) plans as the Centers for Medicare & Medicaid Services (CMS) rolls out health plan innovations under the Medicare Advantage Value-Based Insurance Design (VBID) Model. The innovative plans are meant to reduce costs and improve care for Medicare beneficiaries.

Once hospice providers have registered with CMS to participate in the program, they can begin identifying eligible patients and can bill the appropriate Medicare Advantage Organization (MAO) by first submitting a notice of election (NOE).

Identifying hospice patients with MA coverage

To take advantage of VBID coverage, hospice providers first must determine if patients with Medicare coverage also are beneficiaries of an eligible MA program. Patients who present a Medicare card with a Medicare Beneficiary Identifier can check eligibility using their normal processes or by utilizing the MAC Portal, the MAC Interactive Voice Response System, the Health Insurance Portability and Accountability Act Eligibility Transaction System (HETS), billing agencies, clearinghouses or software vendors.

The same resources can be used for beneficiaries whose cards do not list a Medicare Beneficiary Identifier by using the MA contract number and plan benefit package identification information on the MA enrollment card.1

Submitting claims to participating MAOs

To be paid at original Medicare rates for eligible patients, hospice providers that are not contracted with participating MAOs first must submit original Medicare claims for the covered hospice care.

To begin a bill for an eligible patient, provider must confirm that the hospice start date was on or after Jan. 1, 2021, and file a NOE with the provider’s MAC and the participating MAO. Next, claims should be submitted to MAC following normal procedures. Those claims will be returned with the following message:

  • Claim Adjustment Reason Code (CARC) 96: Non-covered charge(s)
  • Remittance Advice Remark Code (RARC) MA73: Information remittance associated with a Medicare demonstration. No payment issued under Fee-for-Service Medicare as patient has elected managed care
  • Group Code Contractual Obligation (CO): MAOs participating in the VBID Model’s hospice benefit component will be responsible for coverage of the above services

The claim also must be submitted to the MAO. Hospice providers that already are contracted with the participating MAO should follow the contractual billing and claims-processing guidelines. Providers that are not in the MAO’s network can use the same forms they use to submit claims to their MAC. Once the patient is discharged from hospice, or the benefit is revoked, the provider needs to file a Notice of Termination or Revocation with the provider’s MAC and the patient’s MAO.

Hospice providers who use ABILITY EASE All-Payer will not see a change in claims submissions, as a MAO is treated similarly to a secondary payer. ABILITY EASE All-Payer users already are able to submit NOEs to MAOs.

To register or to get more information on the VBID program, visit the CMS website. If you have any questions about how to submit VBID claims within your claims system, reach out to an ABILITY expert for guidance.

1. “VBID Model Hospice Benefit Component Billing & Payment: CMS Innovation Center.” Innovation Center. Centers for Medicare & Medicaid Services, October 28, 2020. https://innovation.cms.gov/innovation-models/vbid-hospice-benefit-billing-payment.

ABILITY and design®, ABILITY® and ABILITY EASE® are trademarks of ABILITY Network, Inc.

Overcoming the biggest challenges facing skilled nursing facilities today

Over the last few years, skilled nursing facilities have been put through the wringer as they’ve grappled with a new Medicare payment model, higher acuity patients, declining reimbursements, increased regulatory scrutiny and most recently, the COVID-19 pandemic and staff turnover.

Staying afloat in this ever-changing post-acute care industry can be an uphill battle; however, it is not insurmountable. Adopting technology to simplify quality management is key to remaining financially viable while delivering high quality care.

Here are the four most significant clinical burdens SNFs are facing today, with tips on how your organization can overcome them.

Challenge #1: Maintaining clinical quality performance

SNFs are caring for patients with greater medical complexity as the overall population ages and hospitals discharge ill patients sooner. Higher acuity rates strain SNF resources and require higher staffing levels to maintain quality care.

At the same time, facilities must report key performance indicators required by CMS and reflected in the regulatory agency’s Five-Star Quality Rating System to assess quality, such as:

  • Daily staffing levels via the Payroll-Based Journal (PBJ) system
  • Several different Quality Measures (QMs) related to the physical and clinical needs of residents
  • Results from recent health inspections based on CMS minimum quality requirements

Tip: Implement technology that streamlines quality reporting and monitoring and offers data insights for continuous performance improvement.

Challenge #2: Keeping up with changing reimbursement policies

Reimbursements are the financial lifeblood of SNFs – so there’s no question the stress of staying afloat in the face of changing and diminishing reimbursements is real.

The Patient Driven Payment Model (PDPM), for example, upended how SNFs were accustomed to being reimbursed, by shifting from payments based on volume to quality.

Though the industry is acclimated to the Skilled Nursing Facility Value-Based Purchasing (SNF VBP) program, which rewards facilities with incentive payments linked to the quality of care they provide to their fee-for-service Medicare patients, changes may be coming.

The Medicare Payment Advisory Commission (MEDPAC) recently recommended to Congress the elimination of the current SNF VBP program in favor of a new value incentive program (VIP). The new initiative would include several quality measures, a change in distribution of rewards, and would account for differences in patients’ social risk factors.

Tip: Use an application that helps you manage PDPM and SNF VBP revenue, keeps you up to date with changing policies and provides real-time and predictive reporting.

Challenge #3: Staying accountable and compliant

When it comes to regulatory compliance, documentation integrity and accountability are key. With SNFs under increased scrutiny in light of the COVID-19 pandemic, these factors have taken on greater weight.

The Triple Check Process is fundamental to ensuring billing accuracy and compliance with regulatory guidelines. Because of all the steps involved, there is a lot of room for error.

A properly conducted Triple Check ensures medical necessity and diagnoses are supported by clinical documentation, and MDS assessments are submitted on time and match the UB-04. Getting this process right means the difference between a paid and unpaid claim.

Tip: Automate this time-consuming process to ensure MDS accuracy before assessment and submission.

Challenge #4: Managing operational burdens

The pandemic has magnified the operational issues of the post-acute industry. SNFs face daily operational challenges and risks, such as retaining adequate staffing, ensuring the safety of workers and residents, managing infection control, and operating on thin margins.

A recent survey conducted by the American Healthcare Association and National Center for Assisted Living found that 65% of post-acute facilities are currently operating at a loss and 90% have profit margins of 3% or less. In fact, as many as 66% say they could close in 2021 because of COVID-19 costs.

Tip: Find a platform that helps you oversee operations, minimizing risk and infection incidence while boosting efficiencies for a better bottom line.

Thriving through the changes

Fortunately, your facility doesn’t have to face these challenges alone. With ABILITY, you have access to one suite of applications that keeps patient care at the forefront and helps your skilled nursing business thrive.

Prefer a visual depiction of the challenges and solutions? Check out our handy infographic now.

ABILITY and design® and ABILITY® are trademarks of ABILITY Network, Inc.

How telehealth helped a marriage and family therapy practice expand access to care

How do you provide patients access to care when you can’t meet them in person? Like all healthcare providers across the country, Dawn Theodore faced a once-in-a-lifetime challenge in the worldwide COVID-19 pandemic. But COVID wasn’t the only thing keeping patients from accessing care from the marriage and family therapist.

Even before the pandemic,” Theodore remarked, “some of my patients had trouble driving long distances and finding parking near my office. With social distancing and shelter-in-place orders, it felt like an impossible situation.”

Using generic video conferencing software helped her see her patients when they could not come to her office, but it left a lot to be desired. Some patients had trouble logging in, and limitations on meeting times caused headaches for the therapist and her patients. She needed an application that would ensure flexibility, a means to help her patients access care and HIPAA compliance.

The ABILITY telehealth application provided the safe environment that counseling patients need to share intimate details about their lives in a virtual space.

Theodore quickly discovered that telehealth was more than a stop-gap service in a pandemic. It was a means to expand access to her patients. Licensed in New York and California, Theodore can now serve patients across the country from her L.A. office. “Patients love it,” she explains in a recent case study. “I practice in Los Angeles, where driving and parking can be a massive headache. Telehealth appointments remove that barrier to care.”

ABILITY Virtual Care has also helped the practice resolve another issue with patient access: radius of care. Insurers often refer patients who live 50-100 miles away from the practice. Before adopting ABILITY Virtual Care, that commute would be practically impossible for patients in need of one or more appointments per week. With an innovative telehealth application designed specifically for healthcare, the practice can now help patients who were physically beyond its reach before.

How can the right telehealth software help your practice better serve your patients? Schedule a demo today to see ABILITY Virtual Care in action.

 

ABILITY and design® and ABILITY® are trademarks of ABILITY Network, Inc.

Medicare simplifies home health claims, phasing out RAPs

The Centers for Medicare & Medicaid Services (CMS) announced that its phase-out of requests for anticipated payments (RAPs) will be complete in 20221, simplifying the process of billing home health care delivered to Medicare patients by Home Health & Hospice Medicare Administrative Contractors (MACs). Instead of the RAP, home health agencies (HHAs) will submit a one-time notice of admission (NOA) to mark the beginning of a period of care.

Understanding the change

When billing Medicare contractors for home health care, HHAs currently have to submit one RAP for every 30-day period of care (POC) for the duration of the patient’s episode of care. With the full phase-out of RAPs, HHAs will begin submitting NOAs when billing Home Health & Hospice MACs. CMS will require HHAs to submit one NOA for any series of HH POCs, beginning with admission and ending with patient discharge. The NOA will cover contiguous 30-day periods of care. If a patient is discharged from home health care but later qualifies for home health services, the provider will have to submit a new NOA.

Billing with NOAs

Under the change, HHAs must submit a NOA within the first five days of a period of care using TOB 32A. After the NOA has been submitted, HHAs will use TOB 329 to report POC. As of Jan. 1, 2022, TOB 329 will be reclassified to an original claim from an adjustment. HHAs are able to submit NOAs to Home Health & Hospice Medicare Administrative Contractors by mail, Electronic Data Interchange or Direct Data Entry. When submitting NOAs through an Electronic Data Interchange, HHAs will need to submit additional data beyond the requirements of the NOA to satisfy CMS transaction standards.

ABILITY has adapted its applications to accommodate the billing change. As ABILITY EASE Medicare has done with hospice notice of election (NOE) claims, the application now allows users to submit NOAs in bulk through batch submissions. That allows providers to submit their NOAs on time to reduce timely filing penalties.

For patients who are already enrolled in home health care as of Jan. 1, 2022, HHAs must submit a one-time NOA listing an artificial admission date with the period of care beginning in 2022.

CMS will implement a reduction in payment for non-timely NOA submission. Payments will be reduced by 1/30 of the wage rate for each day past the five-day filing window that the NOA is late. If an HHA does miss the filing deadline, they are able to request an exception from CMS to avoid the reduction in payment.

Discover how ABILITY EASE Medicare can assist your agency today.

 

1. “Replacing Home Health Requests for Anticipated Payment (RAPs) with a Notice of Admission (NOA) – Manual Instructions.” MLN Matters, June 9, 2021. www.cms.gov/files/document/mm12256.pdf

ABILITY and design®, ABILITY® and ABILITY EASE® are trademarks of ABILITY Network, Inc.

pdpm calculator

Understanding PDPM & the ABILITY CAREWATCH PDPM Calculator

How is PDPM calculated?

 

The ABILITY CAREWATCH PDPM calculator uses the payment for each component and is calculated by multiplying the case-mix index (CMI) that corresponds to the patient’s case-mix group (CMG) by the wage adjusted component base payment rate, then by the specific day in the variable per diem adjustment schedule when applicable. The payments for each component are then added together along with the non-case-mix component payment rate to create a patient’s total SNF  Prospective Payment System (PPS) per diem rate under the PDPM.

Find out how ABILITY can help you successfully navigate PDPM. Contact us for a demo.

PDPM Calculator

What is PDPM?

The Patient-Driven Payment Model (PDPM) is the official model as indicated by CMS effective October 1, 2019, for the case-mix classification system for classifying skilled nursing facility (SNF) patients in a Medicare Part A covered stay into payment groups under the SNF Prospective Payment System. PDPM replaced the Prospective Payment System (PPS).

According to CMS, PDPM eliminates the incentive to provide unnecessary or ineffective therapy, and classifies residents into payment groups based on specific, data-driven characteristics while simultaneously reducing administrative burden on SNF providers.

 

What does PDPM do?

PDPM determines Medicare payments based on a resident’s conditions and care needs, as opposed to the previous Resource Utilization Group (RUG-IV) system that primarily focused on the therapy minutes provided.

 

What determines payment?

There are six clinical components that determine payment

Five are case-mix adjusted components:

  1. Physical therapy (PT)
  2. Occupational therapy (OT)
  3. Speech-language pathology (SLP)
  4. Non-therapy ancillary (NTA)
  5. Nursing

The final component is not case-mix-adjusted and covers SNF resources that do not vary according to patient characteristics. Patient characteristics are used to determine classification into a case-mix group (CMG), and these CMGs drive payment.

 

How to use PDPM?

The new PDPM system tapers rates for PT and OT over time. To succeed under PDPM, providers need to identify new opportunities for reimbursement. The new reimbursement structure incentivizes caring for medically-complex patients requiring nursing and non-therapy ancillary services. But to be successful in taking on more complex cases, it’s imperative to ensure staff is trained for the challenge.

 

Tips for Navigating PDPM

  • Assess the information you’re getting from the discharging hospital today and determine if you’re currently getting the appropriate diagnosis codes and surgical procedure history to support the coding of the five-day PPS assessment.
  • The newly created Interim Payment Assessment (IPA) has its own item set. A facility will be able to obtain a projected billing code prior to doing the MDS.

Additional PDPM Resources:

 

 

Close the gaps between your claims data, insights and actions

Think about a claims- or billing-related issue that you face on a regular basis. Denials. Audits and appeals. Missing reimbursements. Now, what do you need to tackle any of those problems?

You need to know they are happening, and you need the data and insights to resolve them — fast.

If you’re using multiple claims management systems, it’s probably not a simple process to compile the data you need to manage cash flow projections or gather the information necessary to resolve many common claims and eligibility issues.

Regardless of how big or small an issue is, you need data and analytics to understand the challenge, find a solution and take action. With ABILITY, all of that information is available in one place, whether you are looking for real-time visibility of payments from a certain commercial payer or need automated alerts of ADRs and RAC audits.

Working together to create a powerful, integrated experience, ABILITY EASE All-Payer and ABILITY EASE Medicare deliver the market’s first all-payer dashboard that integrates both government and commercial claims workflows and access. With a single view of all transactions, you can maximize efficiency, save time and speed up reimbursements. Here’s how:

  • One application to view all claims transactions. Log in once and get the all-payer reports and data you need to keep claims – and reimbursements – moving.
  • True integration. Billers can write directly from the clearinghouse into DDE, saving time and eliminating waiting periods.
  • Customizable dashboards that highlight essential next steps. Get at-a-glance insight into your most important KPIs, the claims that need your attention, any factors that are lengthening days in A/R, and more.
  • Up-to-date payment details. Analyze detailed reimbursement data, including remit status, A/R aging, finalized claims and adjustment rates.
  • Custom reports in a few clicks. Simply select criteria to drill down to almost any level of detail about Medicare, Medicaid and commercial payer claims.

If you’re looking to trim the time and headaches currently associated with cobbling together revenue cycle reports from multiple sources, discover how ABILITY’s integrated approach can make a difference in reporting and reimbursements.

ABILITY and design®, ABILITY® and ABILITY EASE® are trademarks of ABILITY Network, Inc.

3 benefits you’re missing out on if you’re still using multiple claims management systems

We live in a world where technology seems to connect just about everything. At home, we ask Google to turn on the lights and wake up our kids. On the way to work, we ask Siri to place our favorite drive-through order from Starbucks. Our personal lives are jam-packed with a wide range of sophisticated devices and services that are all connected, each making life a little bit easier.

So, doesn’t it feel strange to sit down to work and have to log on to multiple claims systems or portals, remember several usernames and passwords, and toggle between tabs and screens? Haven’t we moved beyond such cumbersome, outdated, disparate workflows? Truth is, work applications should be as seamless and connected as the apps we use in our personal lives.

Working together to create a powerful, integrated experience, ABILITY EASE All-Payer and ABILITY EASE Medicare deliver the market’s first all-payer system that integrates both government and commercials claims workflows and access. As a single, connected platform, it transforms your revenue cycle management to maximize efficiency, save time and lead to quicker turnarounds for reimbursement.

If you’re still using multiple claims management systems, you are probably missing out on:

1. Single sign-in access to all payers

A single platform integrates clearinghouse functionality, direct payer connections and DDE-scraping technology, allowing providers of any size to manage every claim from every payer, across all locations. That means that employees only need to log in once to submit, edit, track and manage all claims. No more passwords to remember, switching between screens, or wasting time logging in and out of sites.

2. Gold-standard clean claims

The cost of reworking denied claims is often a significant percentage of an organization’s revenue cycle expenses. And, as many as 60% of claim denials are never even corrected and re-submitted for reimbursement!1

With a single platform featuring robust scrubbers with the most up-to-date CMS and commercial payer rulesets, plus facility-specific, customizable rules, organizations can achieve a 99% or greater clean claims rate.2

3. Fast & simple claims resolution

If a claim is rejected by a payer, resolution, resubmission and turnaround times can really hamper time-to-reimbursement.

When billers only need to focus on a single dashboard for all claims management, it’s easy for them to see the claims issues that require immediate attention. Click-to-fix corrections and direct resubmissions (in other words, no Medicare waiting period) ensure that mistakes don’t impact your bottom line.

It’s time to stop jumping between applications and realize the productivity boost and time savings of a one-stop, all-claims platform. Discover how ABILITY’s integrated approach can transform your revenue cycle.

 

1. “Why getting claims right the first time is cheaper than reworking them,” Timothy Mills, Physician’s Practice, September 9, 2019, https://www.physicianspractice.com/view/why-getting-claims-right-first-time-cheaper-reworking-them

2. ABILITY internal reporting, ABILITY EASE All-Payer, November 2020

ABILITY and design®, ABILITY® and ABILITY EASE® are trademarks of ABILITY Network, Inc.

How SNFs use technology to increase efficiency and improve resident experience

Skilled nursing facilities have been using ABILITY applications for more than a decade to increase efficiency, improve resident outcomes, ease reporting compliance and maximize reimbursements. ABILITY Network President and General Manager Bud Meadows recently provided insight in an interview with Skilled Nursing News as to how ABILITY has worked to understand the operations and needs of SNFs to create products that automate and ease clinical and administrative processes.

Meeting the administrative and clinical needs of SNFs

ABILITY has come a long way since its original platform, which simply connected providers to Medicare. Through evaluations of those transactions, it expanded to clinical and administrative areas that have made it a leader among skilled nursing facilities. With well-honed discipline, project management, distribution, development and support, ABILITY created a scalable system to support SNFs of all sizes. Today, our applications are used by more than 50,000 healthcare facilities.

Simplifying workflows

ABILITY understands that the SNF workflow doesn’t happen in isolation; residents most often present from hospitals that have separate workflows. By understanding the processes involved with SNF admissions, ABILITY automates the manual processes involved to make the transition from a hospital to a SNF simpler and more efficient. Because the administrative and clinical processes play a role in the quality of patient care, ABILITY applications automate both workflows.

Post-acute focus

Though ABILITY supports Medicare providers of all types, it maintains a special focus on post-acute facilities through applications that complement EHRs. Through that focus, ABILITY has forged meaningful partnerships with post-acute providers, enabling the development of products that meet the needs of those facilities.

Overcoming the challenges of the COVID pandemic

With the outbreak of the COVID pandemic, skilled nursing facilities faced a heightened need for infection monitoring and reporting. ABILITY INFECTIONWATCH became a go-to tool for tracking during the public health emergency. The application allows for easy reporting of COVID tests, cases and vaccinations. ABILITY INFECTIONWATCH – as well as ABILITY CAREWATCH – also allow facilities to track and manage quality measures for quicker identification of PDPM components to better capture revenue opportunities.

To gain more insight into how ABILITY supports SNFs, read the full Skilled Nursing News article.

 

ABILITY and design®, ABILITY®, ABILITY INFECTIONWATCH® and CAREWATCH® are trademarks of ABILITY Network, Inc.