ParaRev Weekly eJournal, January 11, 2023

Quest ion: If a surgeon schedules surgery w it h his pat ient s but t he surgery is done at our facilit y Our facilit y doesn't schedule anyt hing w it h t he pat ient The surgeon?s office sends us a list of pat ient s having Cat aract Surgery at our facilit y 2-3 days prior. Who is t he Convening Provider and w ho is t he co-provider We never t alk t o pat ient s prior t o t hem show ing up on day of surgery.

Answ er: It appears that the surgeon has a surgical suite reserved for a designated period and does their own scheduling within that reserved time frame The surgeon is technically the convening provider as defined: 45 CFR149 610(a)(2)(ii) -Conveninghealth careprovider or conveninghealth carefacility(conveningprovider or convening facility)means the provider or facility who receives the initial request for a good faith estimate from an uninsured (or self-pay) individual and who is or, in the case of a request, would be responsible for scheduling the primary item or service.

As the convening provider, the surgeon?s office should be contacting the facility within one business day of scheduling a patient to request the facility?s charges as a co-provider.

The facility must respond within one business day so the surgeon?s office can issue a GFEto the uninsured patient with all reasonably anticipated charges related to the primary service.

Should an uninsured patient contact the facility directly to inquire about the cost, the facility is obligated to issue the GFEwithin three business days of that inquiry.

The GFEfor each uninsured individual issued by the co-provider to the convening provider must contain the following data elements: 45 CFR149 610(d)Content Requirementsfor Good Faith EstimateInformation Submitted byCo-Providersor Co-Facilitiesto ConveningProvidersor Convening Facilities.

(1) Good faith estimate information submitted to convening providers or convening facilities by co-providers or co-facilities for inclusion in the good faith estimate (described in paragraph (c)(1) of this section) must include:

(i) Patient name and date of birth;

(ii) Itemized list of items or services expected to be provided by the co-provider or co-facility that are reasonably expected to be furnished in conjunction with the primary item or service as part of the period of care;

(iii) Applicable diagnosis codes, expected service codes, and expected charges associated with each listed item or service;

(iv) Name, National Provider Identifiers, and Tax Identification Numbers of the co-provider or co-facility, and the State(s) and office or facility location(s) where the items or services are expected to be furnished by the co-provider or co-facility; and

(v) A disclaimer that the good faith estimate is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services from any of the co-providers or co-facilities identified in the good faith estimate.

ParaRev recommends getting an agreement in writing with the surgeon?s office that clearly identifies them as the scheduling party (convening provider) in the event an uninsured patient files a complaint of non-compliance when they don? t receive a GFE.

CONGRESSDELAYSLAB PAMA REPORTINGTO 2024

Within the Consolidated Appropriations Act of 2023 on December 23, 2022, Congress once again delayed the reporting period for private payer payment data on non-patient lab services. However, the data collection period remains January 1, 2019 through June 30, 2019.

In addition, Congress delayed cuts to lab test reimbursement that would have kicked in on January 1, 2023.

The private payer payment rate reporting requirement applies to ?applicable laboratories?, which includes hospitals which received more than $12,500 in Medicare reimbursement for non-patient lab services (billed on a 14XType of Bill) in the period January-June 2019.(There are additional requirements that define an ?applicable laboratory?, but most are met by hospitals with ?outreach?laboratory services )

The announcement is on the CMSPAMA Regulations webpage: https://www cms gov/medicare/medicare-fee-for-service-payment/ clinicallabfeesched/pama-regulations

ParaRev offers assistance to organizations which meet Medicare?s definition of an ?Applicable Laboratory?definition in preparing Lab PAMA reports. To learn more about which organizations are required to submit the report, or ParaRev's solution to assist with this burdensome project, please reach out to a ParaRev Account Execut ives ? Violet Archuleta-Chiu (violet.archuleta-chiu@corrohealth.com) or Sandra LaPlace (Sandra.laplace@corrohealth.com).

NO SURPRISESACTIDRDISPUTEFEEINCREASED BY 700% IN 2023

The administrative fee for the Independent Dispute Resolution (IDR) process has increased by 700%in 2023 The administrative fee to participate in a dispute related to the No Surprises Act (NSA) ban on balance billing jumped from $50 to $350. Given the significant increase in the fee, many providers may find that disputes are not worth the burden and forgo the process. With the volume of disputes filed in a five-month window exceeding the anticipated yearly volume, one can speculate that CMSis using the fee to alleviate some of the backlog.

In addition to the administrative fee hike, the threshold for the IDRarbitrators?fixed fee was increased to $700 in 2023, an increase of $200 over the 2022 rates. For batched cases, the maximum allowed fee increased from $670 in 2022 to $938 in 2023

Last year was the first year balance billing was banned under the NSA with respect to the following services:

- Emergency services

- Non-emergency items or services furnished by out-of-network (OON) providers at certain in-network health care facilities, and

- Air ambulance services furnished by OON providers of air ambulance services

The OON facilities and providers found themselves disputing reimbursement with health plans rather than balance billing patients The law created a process for providers and insurers to resolve payment disputes by entering into a baseball-style arbitration. When they couldn? t negotiate between themselves, they turned to certified IDRentities to resolve the dispute

The first report published by HHS, DOL, and the Treasury Department reported that over 90,000 disputes were submitted to the federal IDRportal between April 15 and September 30. The report provides some interesting data indicating how the system was overloaded Over 80%of the disputes originated from emergency department visits Only ten provider groups accounted for 75%of the disputes. United Healthcare was involved in 25%of the disputes followed by Aetna with 14% The complete report can be found at this link:

Initial Report on the Independent Dispute Resolution (IDR) Process (cms gov)

RECOVERINGFEES IN THE340B DRUGPROGRAM

In October, 2022, the United States District Court for the District of Columbia ruled in favor of the American Hospital Association who brought suit against the Department of Health and Human Services The court ruled that HHSmust immediately halt the departments?unlawful cuts to outpatient reimbursement rates for the remainder of 2022 for certain hospitals that participate in the 340B Drug Pricing Program. ?The prospective portion of the 2022 reimbursement rate shall be vacated because it is defective and because vacating this portion of the 2022 OPPSRule will not cause substantial disruption,?wrote Judge Rudolph Contreras. ?HHSshould not be allowed to continue its unlawful 340B reimbursements for the remainder of the year just because it promises to fix the problem later.? The AHA in August urged the court to halt the 2022 cuts, explaining that ?each and every passing day? HHScontinues to "underpay for 340B drugs pursuant to this unlawful" policy Judge Contreras has not yet ruled on AHA?s motion to include 2020-2022 reimbursement cuts in AHA?s case, as well as AHA?s motion to repay hospitals for the unlawful cuts since 2018 without penalizing other hospitals AHA?s August brief noted that nothing in the 340B law authorizes HHSto retrospectively take back these funds, and in similar circumstances HHShas never recouped funds already spent without explicit congressional authorization, which does not exist here. As a result of the court order the Centers For Medicare and Medicaid Services (CMS) must revise its methodology for paying 340B hospitals for outpatient drugs and reprocessing claims paid on or before the September 28, 2022 ruling

CMSceased reimbursing 340B hospitals the default ate after it released the 2018 Outpatient Prospective Payment System (OPPS) final rule. That final rule reduced reimbursement rates by 28 5 percent and saved the government about $1 6 billion But the judge was unimpressed and now HHSmust restore full payment to 340B hospitals.

The prospect ive port ion of t he 2022 reim bursem ent rat e shall be vacat ed because it is defect ive and because vacat ing t his port ion of t he 2022 OPPS Rule w ill not cause subst ant ial disrupt ion.

RECOVERINGFEES IN THE340B DRUGPROGRAM

But t here is opport unit y t o recover lost charges from previous claim s

The Ruling At A Glance... And Your Opportunity

- Medicare is under a court order to stop applying the unlawfully discounted rate for 340B drugs on claims processed on and after September 28, 2022

- One MAC,Novitas, has issued instructions to providers to request corrected reimbursement for the claims processed between January 1,2022and September 28,2022by resubmitting claims which billed separately payable drugs with modifier JG

- Other Medicare Administrative Contractors are beginning to issue instructions on claims for dates of service within 2022. Palmetto GBA, as an example, has limited providers resubmission of corrected claims to 1 (one) year from discharge

SHOPPINGAROUND: WHATCONSUMERS SEEIN GOOD FAITH ESTIMATES

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Good Faith Estimates:

Underst anding cost s in advance Get t ing cost est im at es before you get care if you?re

uninsured or self-pay

As of January 1, 2022, if you?re uninsured or don? t plan to submit your claim to your health plan, health care providers and facilities must provide you with a ?good faith estimate?of expected charges before you get an item or service The good faith estimate isn? t a bill

Providers and facilities must give you a good faith estimate if you ask for one, or when you schedule an item or service. It should include expected charges for the primary item or service you?re getting, and any other items or services provided as part of the same scheduled experience

For example, if you?re getting surgery, the good faith estimate could include the cost of the surgery, any lab services or tests, and the anesthesia used during the operation. But in some instances, items or services related to the surgery that are scheduled separately, like pre-surgery appointments or physical therapy in the weeks after the surgery, might not be included in the estimate.

In 2022, the estimate isn? t required to include items and services provided to you by another provider or facility, but you can ask these providers or facilities for a separate estimate. In 2023, the provider or facility will be required to provide co-provider or co-facility cost information

Not e: You could be charged more than the estimate if you get additional items or services during your visit or procedure that your doctor didn? t anticipate

SHOPPINGAROUND: WHATCONSUMERS SEEIN GOOD FAITH ESTIMATES

What t o expect from a good fait h est im at e

Providers and facilities must give you:

- Your good faith estimate before an item or service is provided, within certain time frames

- An itemized list with specific details and expected charges for items and services related to your care

- Your good faith estimate in writing (paper or electronic) Note: A provider or facility can discuss the information included in the estimate over the phone or in person if you ask

- Your estimate in a way that?s accessible to you

Need help?View an example of what a good faith estimate may include (PDF) or a detailed explainer on the good faith estimate (PDF)

Disput ing charges higher t han t he est im at e

Once you get your good faith estimate from your provider or facility, keep it in a safe place so you can compare it to bills you get later

If you get the bill and the charges are at least $400 above the good faith estimate, you may be eligible to start a patient-provider dispute Learn more about the patient-provider dispute resolution process, including eligibility requirements View examples of good faith estimates that do and don't qualify for the dispute process. (PDF)

Insurance ID cards

Starting in 2022, new pricing information will be shown on any physical or electronic insurance identification card (ID) provided to you. This will include:

- Applicable deductibles

- Applicable out-of-pocket maximum limits

- A telephone number and website where you can get help or more information

A health plan may provide additional information on their website that you can access through a Quick Response code (commonly referred to as a QRcode) on a physical ID card, or through a hyperlink on a digital ID card.

SHOPPINGAROUND: WHATISA GOOD FAITH ESTIMATE?

what t heconsumer sees r egar dinggoodfait hest imat es

If you don? t have health insurance or you plan to pay for health care bills yourself, generally, health care providers and facilities must give you an estimate of expected charges when you schedule an appointment for a health care item or service, or if you ask for an estimate.

This is called a ?good faith estimate.?A good faith estimate isn? t a bill The good faith estimate shows the list of expected charges for items or services from your provider or facility. Because the good faith estimate is based on information known at the time your provider or facility creates the estimate, it won? t include any unknown or unexpected costs that may be added during your treatment.

Generally, the good faith estimate must include expected charges for:

- The primary item or service

- Any other items or services you?re reasonably expected to get as part of the primary item or service for that period of care

The estimate might not include every item or service you get from another provider or facility, even if some items or services may seem connected to the same service For example, if you?re getting surgery, the good faith estimate could include the cost of the surgery, anesthesia, any lab services, or tests In some cases, items or services related to the surgery that are scheduled separately, like certain pre-surgery appointments or physical therapy in the weeks after the surgery, might not be included in the good faith estimate. You?ll get a separate good faith estimate when you schedule those items or services with the provider or facility, or if you ask for it.

- After you schedule a health care item or service If you schedule an item or service at least 3 business days before the date you?ll get the item or service, the provider must give you a good faith estimate no later than 1 business day after scheduling If you schedule the item or service ORask for cost information about it at least 10 business days before the date you get the item or service, the provider or facility must give you a good faith estimate no later than 3 business days after you schedule or ask for the estimate

- That includes a list of each item or service (with the provider or facility), and specific details, like the health care service code

- In a way that?s accessible to you, like in large print, Braille, audio files, or other forms of communication

2023 OPPSUPDATE: INPATIENTONLY CHANGES

In the 2023 OPPSFinal Rule, Medicare added nine codes to OPPSAddendum E, the ?Inpatient only?list. Medicare will not cover these services when billed on an outpatient claim except if the patient expires before admission to inpatient status or when the provider transfers the patient to another facility.

2023 Inpatient Only Procedures Addendum Emay be located by searching ?2023?in the Advisor tab of the PARA Dat a Edit or (PDE).

The nine newly added Inpatient Only HCPCSprocedures are identified with the letters ?NC?in the column labeled ?N?(Change Indicator) as shown below:

Medicare provides guidance on these exceptions in the Medicare Claims Processing Manual, Chapter 4 ?Part B Hospital, Paragraph 180.7 ? Inpatient-only Services: https://www cms gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04 pdf

?There are two exceptions to the policy of not paying for outpatient services furnished on the same day with an ?inpatient-only?service that would be paid under the OPPSif the inpatient service had not been furnished:

Except ion 1:If the ?inpatient-only?service is defined in CPT to be a ?separate procedure?and the other services billed with the ?inpatient-only?service contain a procedure that can be paid under the OPPSand that has an OPPSSI=Ton the same date as the ?inpatient-only? procedure or OPPSSI = J1 on the same claim as the ?inpatient-only?procedure, then the ?inpatient-only?service is denied but CMSmakes payment for the separate procedure and any remaining payable OPPSservices. The list of ?separate procedures?is available with the Integrated Outpatient Code Editor (I/OCE) documentation. See http://www cms gov/Medicare/Coding/OutpatientCodeEdit/

Except ion 2:If an ?inpatient-only?service is furnished but the patient expires before inpatient admission or transfer to another hospital and the hospital reports the ?inpatient only?service with modifier ?CA?, then CMSmakes a single payment for all services reported on the claim, including the ?inpatient only?procedure, through one unit of APC5881, (Ancillary outpatient services when the patient dies.) Hospitals should report modifier CA on only one procedure.?

CMSsummarized the CY2023 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule changes in its Newsroom Fact Sheet available through the following link: https://www cms gov/newsroom/ fact-sheets/cy-2023-medicare-hospitaloutpatientprospective-payment-systemand-ambulatory-surgical-center-2

PARA YEAR-END HCPCSUPDATEPROCESS

As usual, clients will be fully supported with information and assistance on the annual CPT® HCPCScoding updates for calendar year 2023.

The PARA Dat a Edit or (PDE) contains a copy of each client chargemaster; we use the powerful features of the PDEto identify any line item in the chargemaster with a HCPCScode assigned that will be deleted as of December 31, 2022.

ParaRev will not review chargemasters loaded into the PDEolder than 12 months For this reason, it is important that clients check to ensure that a recent copy of the chargemaster has been supplied to ParaRev for use in the year-end update.

ParaRev will produce Excel spreadsheets of each CDM line item, as well as our recommendation for alternate codes, in three waves as information is released from the following sources:

- The American Medical Association?s publication of new, changed, and deleted CPT® codes; this information is released in Sept em ber of each year ParaRev will produce the first spreadsheet of CPT® updates for client review in Oct ober 2022

- Following the release of Medicare?s 2023 OPPSFinal Rule, typically in early Novem ber; ParaRev will perform analysis and produce the second spreadsheet to include both the CPT® information previously supplied, as well as alpha-numeric HCPCSupdates (J-codes, G-codes, C-codes, etc ) from the Final Rule Clients may expect this spreadsheet to be available in Novem ber 2022

- Following the publication of Medicare?s 2023 Clinical Lab Fee Schedule (CLFS) ? typically published in late Novem ber, ParaRev will prepare a final spreadsheet to be available in Decem ber 2022 This final spreadsheet ensures that ParaRev shares any late-breaking news or coding information, although we expect the December spreadsheet to be very similar to the November edition.

Clients will be notified by email as spreadsheets are produced and recorded on the PARA Dat a Edit or ?Admin?tab, under the ?Docs?subtab. When the code maps are ready, the 2023 spreadsheet will appear just as they did in 2022:

In addition, ParaRev consultants will publish concise papers on coding update topics in order to ensure that topical information is available in a manner that is organized and easy to understand ParaRev clients may rest assured that they will have full support for year-end HCPCScoding updates to the chargemaster

FORYOURINFORMATION

Theprecedingmaterialsare for instructional purposesonly. Theinformation ispresented "as-is"and to the best of ParaRev?s knowledgeisaccurate at thetime of distribution. However, dueto theever changing legal/regulatorylandscapethisinformation issubject to modification, asstatutes/laws/regulationsor other updatesbecomeavailable.

Nothingherein constitutes, isintended to constitute, or should berelied on as, legal advice ParaRev expressly disclaimsanyresponsibilityfor anydirect or consequential damagesrelated in anywayto anythingcontained in thematerials, which areprovided on an ?as-is?basisand should beindependentlyverified beforebeing applied.

You expresslyaccept and agree to thisabsoluteand unqualified disclaimer of liability.Theinformation in this document isconfidential and proprietaryto ParaRev and isintended onlyfor thenamed recipient. No part of thisdocument maybereproduced or distributed without expresspermission. Permission to reproduce or transmit in anyform or byanymeanselectronicor mechanical, includingpresenting, photocopying, recording and broadcasting, or byanyinformation storageand retrieval system must be obtained in writingfrom ParaRev. Request for permission should be directed to sales@pararevenue.com.

ParaRev is excited to announce we have joined industry leader CorroHealt h to enhance the reach of our offerings! ParaRev services lines are additive in nature strengthening CorroHealt h?s impact to clients?revenue cycle. In addition, you now have access to a robust set of mid-cycle tools and solutions from CorroHealt h that complement ParaRev offerings

In terms of the impact you?ll see, there will be no change to the management or services we provide The shared passion, philosophy and cultures of our organizations makes this exciting news for our team and you, our clients

While you can review the CorroHealt h site HERE, we can coordinate a deeper dive into any of these solutions Simply let us know and we?ll set up a meeting to connect.

As always, we are available to answer any questions you may have regarding this news We thank you for your continued partnership