CorroHealth Weekly eJournal, August 2, 2023

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DMEIn The Emergency Department

What Is Billable?

Changing Payer Behavior Successful Strategies

It 's Been A Year. Have You Felt The Impact?

DHShas released its first annual report on how the No Surprises Act is impacting health care markets, and the results are both surprising and expected.

Among the crucial findings are the decrease and concentration of out-of-network billing, both claims and the total amount associated with those claims; trends regarding changes in hospital ownership; and horizontal consolidation and pass-through costs to consumers

Join us as we analyze the findings and what they mean to the industry going forward We will also discuss the key factors that play a role in the DHS?evaluation of NSA and what they might mean for market trends, consolidation, and out-of-network billing.

About Barbara Johnson, BSN, RN ?Senior Revenue Cycle Consultant

Leading the series is CorroHealth?s resident subject matter expert, Barbara Johnson, BSN, RN ? Senior Revenue Consultant. As a registered nurse Johnson worked in emergency medicine before transitioning into nursing administration She entered the specialty of Revenue Integrity as a nurse auditor where she expanded her knowledge of coding and revenue cycle compliance through membership in AAPCand HFMA Today, she is CorroHealth?s leading subject matter expert on NSA.

Did You Miss An Episode?

You can cat ch up here!

Episode1 Episode2 Episode3

CorroHealth?s ?No Surprises Act and Price Transparency, a New Monthly Series?was created to provide attendees with clarity around No Surprises Act, to answer questions, and get you on the best path for success The series also clarifies payers?increased role in the process, the status of impactful legislation, and the processes providers should follow to comply

For More Details About NSAAnd Other Services From CorroHealth,

Contact Your State's Account Executive.

DME In The Emergency Department

Quest ion:

For patients who are seen in the Emergency Department, are we allowed to provide them with DMEitems at no charge?For example, can we distribute items such as crutches, boots, neck collars, etc, if we do not have a DMElicense? Are we allowed to bill for for these items if we do not have a DMElicense?Does a DMEprovider actually have to be the one providing these items in order to bill?

Answ er:

The facility can dispense crutches to an ED patient without being a DMEprovider if the crutches are provided incident to other medically necessary outpatient services While they can be dispensed, the facility cannot bill for those crutches

A report pulled from the DMEselection under the Calculator tab of the PDEproduces a report that indicates the crutches are not billable by an OPPS facility. Whether the patient is under a plan of care established by a provider who practices at the same clinic

An OPPShospital is not required to enroll with Medicare as a DMEsupplier to obtain reimbursement for Prosthetics and Orthotics reported on outpatient claims. I have attached a paper that discusses billable DMEand how to bill for those items

CMS Proposes Remedy to 340BReimbursement Cuts

On July 7, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule to remedy $7.8 billion dollars in underpayments affecting 1,600 OPPShospitals which reported the JG modifier on expensive drugs acquired under 340B program between 1/1/2018 and 9/28/2022.

The discounting formula applied by CMSduring that period was deemed illegal by the Supreme Court of the United States in June of 2022; part of the court?s decision directed CMSto propose a remedy for the underpaymentsThe proposed remedy/rule Is open for public comment until September 11, 2023

A CMSFact Sheet on the proposal is available at the following link; a hyperlink to the full text of the proposed rule is found within the Fact Sheet:

Hospital Outpatient Prospective Payment System: Remedy for the 340B-Acquired Drug Payment Policy for Calendar Years 2018-2022 Proposed Rule (CMS1793-P)

In the rule, CMSproposes a lump-sum payment to each affected OPPShospital to correct for any claims which remain underpaid The lump sum would include both Medicare?s share and that portion of the reimbursement which would have been attributed to patient coinsurance, had each claim been re-adjudicated

Since Medicare will cover that coinsurance, hospitals would be prohibited from billing beneficiaries for coinsurance on the corrected transactionsCertain 2022 claims which were submitted for reprocessing have already been re-adjudicated, and therefore will not be included in the lump sum payment Presumably, the patient liability generated by the corrected payments on those claims will not be covered by Medicare

If Medicare finalizes the lump sum payment proposal in its present form, Medicare plans to impose reductions to reimbursement in other areas of OPPSin order to maintain budget neutrality. For example, the overall APCconversion factor could be reduced for several years, until the lump sum payments are offset from future OPPSexpenditures (Since Critical Access Hospitals were not subjected to the discounted OPPSpayment, the remedy does not apply to CAHs )

The final rule will be issued following the public comment period, coinciding with the release of the Calendar Year CY2024 OPPS/ASCFinal Rule in Fall 2023 (usually in early November )

OPPS-paid hospitals which submitted claims with the JG modifier, indicating a 340B purchased drug, may identify the amount of the proposed lump sum payment within the downloads section at the following website, Addendum AA:

https://www.cms.gov/medicare/medicare-fee-service-payment/hospitaloutpatientpps/ hospital-outpatient-regulations-and/cms-1793-p

Background

The 340B program allows participating hospitals and providers to buy certain drugs at discounted prices

Before 2018, Medicare payment rates for these drugs in outpatient hospitals were generally based on the average sales price (ASP) plus 6%. In 2017, CMSadjusted the payment rate for 340B drugs to ASPminus 22.5%to reflect better the actual costs for hospitals acquiring these drugs This rate was in effect from 2018 to the third quarter of 2022 To meet the budget neutrality requirements set by law for the OPPS, CMSincreased payments to all hospitals, including 340B hospitals and non-340B hospitals, for non-drug items and services This increase in payments was implemented from CY2018 to CY2022

The Supreme Court ruled in June 2022 that the payment rates for 340B-acquired drugs were unlawful because HHSdid not survey hospitals' acquisition costs as required by the statute.

In September 2022, the District Court for the District of Columbia vacated the future payment rate cuts for 340B-acquired drugs. As a result, claims for these drugs on or after September 28, 2022, were paid at the ASP plus a 6%default rate

CMSset a general payment rate of ASPplus 6%for drugs acquired through the 340B program in the 2023 OPPS/ASCfinal rule CMSreduced payments for non-drug items and services by 3.09%in 2023 to maintain budget neutrality. CMSannounced in the 2023 OPPS/ASCfinal rule that it would address the remedy for 340B drug payments from 2018-2022 before the release of the 2024 OPPS/ASCproposed rule

Proposed Rem edy

CMSestimates that certain providers received $10.5 billion less in 340B drug payments from 2018 to the third quarter of 2022 due to the invalidated policy.

Some 2022 claims for 340B drugs have already been paid at the higher default rate, resulting in $1 5 billion of the owed $10 5 billion already being paid

For the remaining $9 billion owed to affected providers, CMSproposes to make a one-time lump-sum payment to each affected hospital The proposed rule calculates the amounts owed to an estimated 1,600 affected 340B participating hospitals.

CMS PROPOSESREMEDY TO 340B REIMBURSEMENTCUTS

Beneficiary Copaym ent s

About 20%of the payments affected hospitals did not receive due to the 340B payment policy comprised of beneficiary copayments Providers will not bill beneficiaries for cost sharing To account for the difference, Medicare plans to include the beneficiary cost-sharing within the one-time lump sum payments

Prospect ive Offset for Higher Paym ent s for Non-Drug It em s and Services (2018-2022)

CMSproposes to maintain budget neutrality by making a corresponding offset for the increased payments made for non-drug items and services from 2018-2022. CMSestimates that hospitals were paid $7.8 billion more for non-drug items and services during this period due to the 340B payment policy

To achieve budget neutrality, CMSproposes to reduce future payments for non-drug items and services by decreasing the OPPSconversion factor by minus 0 5%starting in 2025 According to the proposed rule:

?We are adjusting payments prospectively in order to provide a remedy for a previous unlawful payment decision And precisely because that previous payment decision itself followed budget neutrality principles; it provided unwarranted payments to some at the same time it improperly took payments from others.In applying budget neutrality principles to this remedy, we seek to rectify this imbalance and restore matters as closely as possible to where they would have been absent the policy the Supreme Court determined to be unlawful.We solicit comments from the public on our proposed interpretation of our statutory budget neutrality obligations, equitable payment authorities, and recoupment authority

?? We propose to, beginning in CY2025, reduce all payments for non-drug items and services to all OPPSproviders, except new providers as defined later in this section, by 0 5 percent each year until the total offset is reached (approximately 16 years) ? ?

This adjustment will continue until the full $7 8 billion is offset, which CMShas estimated will take approximately 16 years The proposed offset may slightly decrease beneficiary co-payments for non-drug items and services Providers that enrolled in Medicare after January 1, 2018, and did not fully benefit from the increased payments for non-drug items and services from 2018-2022, would be excluded from the prospective rate reduction.

CMS PROPOSESREMEDY TO 340B REIMBURSEMENTCUTS

Lymphedema

Billing

Quest ion:

Can you help confirm if we are billing for lymphedema management correctly?This is our current practice: When both the compression wrap and the manual lymphatic drainage 97140 are performed on the same extremity, we charge only 29581 for the therapy done on the separate extremity than what was wrapped. However, we saw some literature that states we may change manual therapy and compression wraps on the same extremity now Can you confirm this?We want to make sure we are not under billing or over billing for this service, and are being consistent between therapists.

Answ er:

A Medicare edit prevents 29581 from being reported on the same claim without a modifier

In many cases, lymphatic drainage is necessary before compression systems are applied

The Medicare NCCI 2023 Coding Policy Manual ? Chapter 4 states a modifier may be necessary when manual therapy techniques (97140) are performed as a separate and distinct procedure from the multi-layer compression application (29581) An X{EPSU) or -59 modifier may be appended if documentation supports the medical necessity of both procedures

LYMPHEDEMA BILLING

The guidance offered in Noridian?s A52959 Billing and Coding: Lymphedema Decongestive Treatment is valid for all Medicare regions

On November 11, 2014, The AMA published Errata and Technical Corrections ? CPT® 2015, which removed the exclusionary parenthetical statement as follows:

STRATEGIESTO CHANGEPAYERBEHAVIOR

Exploring Successful Strategies To ChangePayer Behavior

While many hospitals are operating in negative margins, payers are bringing in record revenues and profit margins. And healthcare organizations have fallen into a pattern of not fighting or simply accepting many denials, much to their financial detriment

At Becker?sHospital Review?s2023 Annual Meeting, in a workshop sponsored by CorroHealth, Jay Ahlmer, president of Corro Clinical, and Jerilyn Morrissey, MD, chief medical officer for CorroHealth, shared insights and tactics into how to change payer behaviors to help hospitals and healthcare systems better recoup money

Three key takeaways were:

1. Payers are doing everything they can to increase profit margins, even as hospitals struggle Payers?financial performance has continued to improve year after year Meanwhile, provider organizations are struggling financially, and each year have to work harder to achieve the same level of reimbursement as the year before, particularly for Medicare Advantage programs

With large marketing budgets, payers are focused on capturing market share by signing on new members and are working to improve revenue per member Payers invoke terms and initiatives such as ?frictionless healthcare?and ?frictionless billing.?

Being ?frictionless?may sound great, but it is code for increasing margins by lowering administrative and medical costs, in some instances creating disadvantages for providers. ?When payers think of frictionless healthcare, they think of ways to get to the end result, which is maximizing their profit margin with a lot less hassle,?Dr. Morrissey said. ?In many ways, the payer and provider relationship is a zero-sum game,?Mr. Ahlmer said. ?A substantial amount of the payer?s profits come from limiting their payments for hospital services ?

2 To change the status quo, provider organizations must learn to influence payers to change their behaviors ?Hospitals don? t have to simply accept the role of victim in payers? pursuit of ever increasing profits. There are strategies and tactics that can be deployed to establish new expectations and boundaries with payers to create a more sustainable partnership,?Mr Ahlmer said

EXPLORINGSUCCESSFUL STRATEGIESTO CHANGEPAYERBEHAVIOR

The payer-provider relationship needs transparency from both sides and balance among everyone?s motivating factors. After that, provider organizations can benefit from taking these three steps to prepare to change payer behavior

- Get your housein order.?It?s almost impossible to establish a payer strategy if the staff is not on board and is following the signals from the payer?s influence,?such as not appealing any but the most obvious denials, Mr Ahlmer said

- Hold accountabilitiesand enforceyour rights.Exercise the rights available in contracts and remember that it?s ok to get a denial and push for the right status, such as inpatient versus outpatient ?What are other options beyond the individual transaction, because we can get buried in the day-to-day transactions??Mr Ahlmer asked

- Escalatepayer issuesto changepayer behaviors. Using joint operating committees or executive escalation can help when other tactics fail or using arbitration and even lawsuits.

3 CorroHealth has helped numerous health systems achieve sustained results in changing payer behavior

For example, three midwestern health systems in the same market were facing an unsustainable financial situation due to adverse payer relationships. Attempts to remove friction in the authorization and denials process had failed and reimbursement was significantly reduced, with no clear resolution

Optimizing overturn rates left many denials underpaid And, prioritizing accounts receivable days and write-offs allowed payers to issue denials and not be held accountable.Working with CorroHealth, these health systems developed a strategy that included collaborating, measuring their efforts and partnering with local leaders to influence change Ultimately, one system, with more aggressive appeals, was able to increase their net inpatient payment rate from a low of 50 percent to 72 percent. That led to payment improvement of $16 million for Medicare Advantage patients

- Health systems are facing tighter-than-ever financial dynamics And payers have a great deal of power But with the right strategy and a knowledgeable partner, health systems can retrain payers and improve their fortunes, especially to denials.

Back-Dating IP Orders

Quest ion:

Our URdepartment has posed a question regarding the following scenario for commercial payers A patient is admitted as Observation for one night URcatches the next day that they actually meet IPcriteria and updates them to IPstatus for day two. The patient then discharges the following day.

We are left with a patient with one night of observation and one night of inpatient. Are we legit in changing the initial order of observation to IPfor the entire stay?

Answ er:

Admission orders may be back-dated The admission and date must match the physician's order. While we acknowledge your question in regards to commercial payers, we refer you to the Medicare Beneficiary Policy Manual, Chapter 2: Page 16B Inpatient Order:

The Medicare Conditions of Participation (CoP) -Hospital Inpatient Admission Order and Certification offers almost identical verbiage:

CorroHealt h invit es you t o check out t he m lnconnect s page available from t he Cent ers For Medicare and Medicaid (CMS) It 's chock full of new s and inform at ion, t raining opport unit ies, event s and m ore! Each w eek PARA w ill bring you t he lat est new s and links t o available resources Click each link for t he PDF!

Thursday, July 27, 2023

New s

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CMSContinues Work on Behavioral Health

- Discarded Drugs and Biologicals: Updated FAQs on JW & JZ Modifiers

- Expanded Home Health Value-Based Purchasing Model: July 2023 Interim Performance Reports

- Subsequent Annual Wellness Visits: Comparative Billing Report in July

- Medicare Ground Ambulance Data Collection System: Submit Comments by September 11

-

Clinical Laboratories: New Diagnostic Tests & Reporting Reminder

- Viral Hepatitis: Talk with Your Patients about Shots & Screenings

Claim s, Pricers, & Codes

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HCPCSApplication Summaries & Coding Decisions: Drugs & Biologicals

From Our Federal Part ners

- Biosimilars: Free Continuing Education Courses, Videos, & Resources from FDA

t r ans mit t al s

Therew as1new or revised Transmittal released thisw eek.

To go to thefull Transmittal document simply click on thescreen shot or thelink.

TRANSMITTAL R12122CPTRANSMITTAL R12127PI

m edl ear ns

Therew ereNOnew or revised MedLearnsreleased thisw eek.

To go to thefull Transmittal document simply click on thescreen shot or thelink.

Theprecedingmaterialsare for instructional purposesonly. Theinformation ispresented "as-is"and to thebest of CorroHealth'sknowledgeisaccurateat thetimeof distribution. However, due to the ever-changinglegal/regulatory landscape, thisinformation issubject to modification asstatutes, laws, regulations, and/or other updatesbecome available. Nothingherein constitutes, isintended to constitute, or should berelied on aslegal advice. CorroHealth expresslydisclaimsanyresponsibilityfor anydirect or consequential damagesrelated in anywayto anything contained in thematerials, which areprovided on an "as-is"basisand should beindependentlyverified before beingapplied. You expresslyaccept and agree to thisabsoluteand unqualified disclaimer of liability. The information in thisdocument isconfidential and proprietaryto CorroHealth and isintended onlyfor thenamed recipient. No part of thisdocument maybereproduced or distributed without expresspermission. Permission to reproduceor transmit in anyform or byanymeanselectronicor mechanical, includingpresenting, photocopying, recording, and broadcasting, or byanyinformation storageand retrieval system must beobtained in writingfrom CorroHealth. Request for permission should bedirected to Info@Corrohealth.com.