Welcome to the Wesgram Online!  

Welcome to our new look. This edition contains important information regarding July 1st changes in PEIA benefits that may impact your practice.  You'll also find updates from other payors, as well as upcoming educational events for both physicians and staff.  

If you need additional information or if you want to join my mailing list, please contact me at the link below.

(information provided by PEIA)

The PEIA Finance Board has adopted benefit changes for Plan Year 2016, which begins on July 1, 2015. The following benefit changes will affect active employees and non-Medicare retirees and their enrolled dependents beginning July 1, 2015:

*           Increase family out-of-pocket maximum for PEIA PPB Plans A and D from 1.5 times               to twice the employee only amount

*           Increase deductible by $25 single and $50 family

*           Increase Primary Care Office Visit copayment from $15 to $20 per visit

*           Increase Specialist Office Visit copayment from $25 to $40 per visit

*           Add $100 copay to deductible and 20% coinsurance for inpatient hospital care

*           Increase outpatient surgery copay from $50 to $100 per procedure

*           Increase emergency room copay to $100 with no discount for medical emergencies

*           Increase generic drug copay for 30-day supply from $5 to $10 and for 90-day supply (maintenance only) from $10 to $20

*           Increase preferred drug copay for 30-day supply from $15 to $25 and for 90-day supply (maintenance only) from $30 to $50

Participants in PEIA's Medical Home Program (MHP) will continue to have a $10 copay per visit.  Participants in PEIA's Comprehensive Care Partnership Program will have no or reduced copays for office visits, as determined in our contract. 

Members of PEIA PPB Plan C, the high deductible health plan, do not pay office visit copays.  Their benefit is deductible and 20% coinsurance.

From the WVSMA--It is important to know that members are not being issued new cards.  Physician practices will need to ensure that you collect the correct copay from the member. 

CoventryCares Update

CoventryCares of West Virginia has scheduled an additional Medicaid Provider Workshop.  The workshop will be held on Wednesday, July 8th in Wheeling, WV, at the Oglebay Park Banquet View Rooms 1 & 2.

 These workshops will provide you and your office staff with valuable information including:

?    Appeal procedures and best practices

?    Case management program information

?    Behavioral Health updates

?    ACA Medicaid membership overview

?    Provider Credentialing/Recredentialing workflows

?    Directprovider.com tutorial

?    Pre-authorization process review

?    Meet & Greet with your local Provider Relations Representative

Registration begins at 8:00am and the Workshop will be from 9:00am - 12:00pm

Attendance is free of charge and breakfast will be provided.

Please RSVP at least 3 days prior to the workshop.  For additional information, please call your provider representative or CoventryCares at  (304) 348-2900.

CoventryCares Provider Manual

The CoventryCares WV 2015 Provider Manual is now available by contacting Provider Relations at 1-888-388-1744. 

CoventryCares reminds physicians of the Pregnancy Risk Screening Instrument (PRSI) that collects information from the plan's pregnant patients.  As of March 15, 2015, providers who submit the form prior to delivery will receive a $20.00 incentive payment for completing the form.  Reimbursement will be sent at the end of each quarter. 

For questions, you may contact your Provider Relations Representative or call 888-388-1744.

Highmark Update

As of June 1, 2015, Highmark policy regarding adding and deleting physicians has been revised.  All changes must now come through Navinet.  You should use the "Provider Maintenance" tab on Navinet to update your practice information.

Also, Highmark is now reimbursing for CPT codes 99417 and 99148

Humana Update

Humana, like other plans, performs audits to ensure that claims they pay were accurately coded and paid to match the services rendered.  The plan uses many resources to ensure that audtis are conducted in a fair manner, including provider agreement language, CMS billing guidelines, CPT and HCPCS system guideline and Humana medical coverage policies and code-editing policies.

The number of audits conducted is determined by the provider's error rate and providers with a low error rate will have a reduced number of audits, while providers with high error rates will have an increased number of audits.

You may access information on the Audit Policies or Processes on their website here. 

Humana's Medical Records Management System allows providers to fax, mail or upload medical records and check the status of requests online.  To access the system, long into www.Humana.com, click "resources", then "medical record management".  If you've not registered for Humana.com, you can follow the instructions and register. 

There has been increased audit activity for claims with Modifier 25. This modifier requires additional documentation.  Humana will also be looking at bilateral modifiers.

 The Health Plan of the Upper Ohio Valley

The Health Plan has posted the seminar slides from their recent provider trainings.  The slides may be viewed at their website, www.healthplan.org

TriCare Military Insurance Update  

Tricare is the insurance for our country's military.  The West Virginia military needs West Virginia physicians to partner and serve our military and their families.

The WVSMA wants to make it easier for you to participate in the TriCare network; therefore, we are providing some easy to understand information about the plan.

First off, in order to participate with TriCare, physicians need only agree to accept assignment (Medicare reimbursement).  They do not need to sign a contract with Health Net Federal Services in order to participate in most TriCare plans.  You can be a non-network physician and see TriCare patients without the hassle of a contract or credentialing.  All that is required is a short provider agreement that states that you will accept military members and their families.

Reimbursement is quick (generally within 8 days if billed electronically) and accurate.  Physicians and staff can be proud that they are caring for the ones who serve our great country. It is important that all staff members know that your practice accepts Tricare, although you may not have a contract through Health Net Federal Services.

Another benefit of participating with TriCare is having a special ombudsman for physicians and patients.  West Virginia's Adjutant General James Hoyer has appointed Toney Colagrosso as Health Benefit Advisor for TriCare.   Toney is available to physicians and patients to ensure that patients receive prompt treatment and care while physicians receive prompt reimbursement for their services.  Toney is approachable and reachable to help your practice.

For more information on how your practice can serve our military members and their families, feel free to contact Toney Colagrosso (toney.colagrosso@us.army.mil) or via phone (304) 552-2938.  You may also contact Barbara Good (Barbara@wvsma.org).

Let's ensure that our military members are taken care of in the best possible way.  Please advise your staff that your practice participates with TriCare!

UnitedHealthcare Update

UnitedHealthcare now has notifications/prior authorizations and referrals online.  If your patient's plan requires a referral, notification or prior auth, you can submit and check the status of these at  UnitedHealthcareOnline.com.

The plan is also now using an option called cloud dashboard where you may submit appeals, even with attachments, online.

The Provider Relations email for UnitedHealthcare is UHC-PA-ProviderRelations@UHC.com.

WVSMA Practice Manager of the Year Award   

Nominate Your Practice Manager Today!

This is your opportunity to show appreciation for your practice manager/administrator and give him/her the recognition and reward they deserve!

The winner will be announced at the Celebration and Gala Dinner Dance on

Friday, August 28, 2015, at The Greenbrier Resort, White Sulphur Springs, WV

Additional information and nomination forms may be found on the WVSMA's website, www.wvsma.org.

Update on Charging for Medical Records   

The WVSMA continues to receive many questions about releasing medical records. Below is information from an earlier Wesgram that gives a very detailed explanation of the way to comply with these requests.

The WV Legislature enacted several laws during the 2014 legislative session that affect your practice.  Below is an update on how to comply with HB4560 The Medical Records Act (codified as an amended form of ?16-29-1 and ?16-29-2 of the Code of West Virginia, 1931).

In short, this Act requires health care providers to provide paper or electronic copies of medical records upon written request by patients or their representatives and allows the provider to charge a fee for doing so.

Here are some specific stipulations regarding the provision of copies:

1.    The patient or representative must make the request to the provider in writing and specify a preference for paper or electronic copies, and whether the copies should be delivered by mail.

2.    The provider shall provide copies to the patient within a reasonable time.

3.    If the patient requests electronic copies and the provider routinely stores records electronically and has the ability to do so, the provider shall furnish copies in an electronic format such as a computer disk, portable memory device, or via email.

4.    If a patient treated for psychiatric or psychological problems requests records, the provider shall furnish a summary of the record, following termination of the treatment program.

5.    In the case of x-ray exams, electrocardiograms, or other diagnostic procedures, the provider need only furnish a copy of the report in order to comply with this article.

6.    Any health care provider who does not comply with this Act shall pay any attorney fees and costs, including court costs, incurred by a patient or his or her representative, in the course of enforcing the Act.

Here are some exceptions to the Act:

1.    Providers are not required, under this Act, to release to a parent or guardian any patient records of diagnosis or treatment of minors for birth control, prenatal care, drug rehabilitation or related services, or venereal disease, without prior written consent from the patient.

2.    The rules defined in this Act do not apply to health care records maintained by health care providers governed by the AIDS-related Medical Testing and Records Confidentiality Act.

3.    The Medical Records Act also does not apply to any records that a court has subpoenaed or otherwise requested.

Here are the rules regarding reimbursement under the Act:

1.    The patient or representative must pay the provider a reasonable fee at the time of delivery of the records.

2.    The fee shall be based on the actual cost of supplies for creating a paper copy or electronic media; the cost of postage if the records are mailed; and the cost of copying the records, if on paper, or transferring the records to electronic media.

3.    If the patient requests or agrees to an explanation or summary of records, the provider may impose a reasonable fee for the cost of labor for preparing the explanation or summary, as well as for postage and supplies.

4.    If the records are stored with a third party, or a third party responds to the request for records in paper or electronic media, the provider may charge additionally for the actual charges incurred from the third party.

5.    The fee for labor for copying shall not exceed $25 per hour (adjusted to reflect the consumer price index for medical care services).  

6.    Providers may not impose a fee on indigent patients or their representatives for social security claims; such patients are limited to one free set of copies per provider.

Although the state law does not stipulate a specific time frame, HIPAA requires that providers act on requests for medical records within 30 days, either by providing access, or by providing a written explanation for delay or denial, in accordance with detailed regulations. At most, providers may be allowed one 30-day extension (see ?164.524).     

WVSMA Provides ICD-10 Educational Opportunities!

The WVSMA is providing many opportunities for you and your staff to prepare for the planned October 1, 2015, ICD-10 implementation date!

The conversion to ICD-10 is a multi-staged process that involves people, processes and

systems. This course addresses specific requirements for clinicians and medical office

professionals. Instruction includes an overview of implementation steps along with code

characteristics and guidelines. Participants will review guidelines and sample crosswalks,

and perform specialty-specific exercises to apply skills.

The West Virginia State Medical Association (WVSMA), in partnership with Practice Management Institute (PMI) is offering ICD-10 training courses in seven different specialties---OB/Gyn, Ophthalmology, Orthopedics, Surgery, Family Practice, Internal Medicine and Cardiology---plus a fullday ICD-10 Coding Workshop. 
 

Participants will  review crosswalk examples and complete practice coding exercises to apply new skills. The workshop also includes general code set training and complete guidelines with ICD -10 CM "hands-on" exercises,   
 

The classes begin on Tuesday, August 11, and continue through Friday, August 14, at the WVSMA in Charleston, WV. You may select the course (s) you wish to take.  If there are additional specialty courses that you would like, please feel free to contact Barbara Good (Barbara@wvsma.org) for assistance in obtaining a course. 

Please register as soon as possible in order to obtain the specialty course of your choice.  

Click here to register for the classes.  

Don't miss out on these great training opportunities!  

(Due to circumstances beyond our control, the ICD-10 Training Course scheduled in Wheeling on July 14 has been canceled) 

Save the Date for the Office Managers Association Conference!

The West Virginia Office Managers Association (OMA) has scheduled their 2015 Educational Conference for Thursday/Friday, October 15th/16th at the Pullman Plaza Hotel in Huntington, WV. 

Watch for additional details and make plans to attend this excellent educational event!

Charleston OMA Chapter Upcoming Meeting

The Charleston Chapter of the OMA has scheduled its next meeting for Wednesday July 29th from 12:00pm to 2:00pm at Thomas Memorial Hospital in Classroom 3. The guest speaker will be from Karen Miller Law Firm, presenting on Employment Law. The idea is to provide tips on what to include and what not to include for employee write ups, dealing with termination, and how to avoid unemployment. 

For additional information, please contact Chelsea Slack (Chelsea.Slack@thspp.com).   

Huntington OMA Chapter Plans Meeting

The Huntington Chapter of the OMA has scheduled a meeting for Wednesday, July 8, 2015.  Please mark your calendars and watch for more information from Stacie Spotloe (vpprstateoma@yahoo.com).