Physician Quality Reporting Initiative (PQRI)
Carolyn Henson, Provider Outreach and Education, gave attendees an update on PQRI. In 2009, a 2.0 percent bonus payment will be available for those who meet the PQRI qualifications. In order to review how you did in 2007, visit here and register. 

E-prescribing
This will be the first year of a five-year program in which physicians who use e-prescribing technology may be eligible for a bonus based on covered services furnished during the reporting year. These incentive payments are available each year of the program (2 percent for 2009-10, 1 percent for 2011-12 and 0.5 percent for 2013).

Starting in 2012, however, a penalty in the form of a percentage reduction in the Medicare physician fee schedule payment applies to physicians who are not successful electronic prescribers (-1 percent in 2012, -1.5 percent in 2013 and -2 percent in 2014).

E-prescribing can provide many benefits for physicians and patients. For example, electronic access to each patient’s prescription history helps physicians avoid prescribing drugs that may result in harmful drug interactions, while electronic transmission eliminates the possibility of medication errors caused by illegible handwriting.

Furthermore, access to insurance and formulary information at the point of care allows physicians to prescribe a covered and affordable drug, requiring fewer trips to the pharmacy.

“Medicare’s Practical Guide to the E-Prescribing Incentive Program” is now available online. The guide explains the e-prescribing incentive program, how eligible professionals can participate, and how to choose a qualified e-prescribing system. Read or print the guide here.

Enrollment
During CY 2008, 94.6 percent of all physicians are billing under Medicare participation agreements. This affords physicians direct payment from the Medicare program and an automatic crossover to a Medigap policy. Medicare fee schedule amounts are 5 percent higher if you participate.

WHAT TO DO
If you choose to be a participant in CY 2009:

• If you are currently participating, no action is needed.
  
• If you are not currently a Medicare participant, complete the blank agreement and mail it (or a copy) to each carrier or A/B Medicare Administrative Contractor (A/B MAC) where you submit Part B claims. On the form show the name(s) and identification number(s) under which you bill.

If you decide not to participate in CY 2009:

• If you are currently not participating, no action is needed.
• If you are currently a participant, write to each carrier or A/B MAC to which you submit claims, advising of your termination effective Jan. 1, 2009. This written notice must be postmarked prior to Jan. 1, 2009.

Modifier 22
Use of Modifier 22 does not prompt a request for medical documentation. For a request for additional medical documentation to be generated, you must complete the NTE segment (loop 2400) in the electronic format. 

This is also known as the electronic notepad and Item 19 on the CMS 1500. These fields will hold 80 characters, including punctuation. An “automated development system” or ADS letter will be sent to the
“pay-to” address for the additional documentation.

Customer Care
When talking to Customer Care, please remember to record the date, time and name of the person with whom you are communicating. This information will be used to trace a call and will aid in education of the Customer Care representative. 

Please complete the Customer Care Survey on this Web site. Scroll to Part B in the business type menu and hit go. After reading and accepting an agreement, the third link under “Resources” in the drop down menu will be the Customer Care Survey.

Local coverage determinations (LCD)
National Government Services (NGS) is aware of the multiple dates of the same LCDs on its Web site. NGS officials are currently working on the problem, and it will be corrected in the near future. 

Web source guide
A new Web site and contact information resource guide was distributed to attendees. This guide will aid in navigating the NGS Web site and also provides important contact information.

Medicare Administrative Contractor (MAC)
At this time the MAC for Indiana has not been awarded, but all awards are expected to be announced by the end of 2009.

EDS
Provider Relations Representative Mona Green announced open enrollment for Hoosier Healthwise. Members can change health plans only at the following times:

• Any time during the first 90 days of enrollment with a new health plan
• Annually during the open enrollment period
• Any time there is “just cause” (for example, quality of care concerns)

• Decatur County Memorial Hospital, 720 N. Lincoln Street, Classroom D, Greensburg, 8:30 a.m. – Noon
  
• St. Vincent Randolph Hospital,
  473 E. Greenville Avenue,
  Conference Room 1,
  Winchester, 1 – 4 p.m.

Care Select
Chris Kern and Kelvin Orr from Care Select reminded attendees that claims have been denied inappropriately for Edit 1049 due to an identified defect with the National Provider Identifier (NPI) implementation.  The Indiana AIM system is now fixed. Providers will need to resubmit their denied claims.

Wards and foster children have been transitioning from Hoosier Healthwise or Traditional Medicaid to Care Select since July 1, 2008.  On Jan. 15, 2009, the state and EDS will  auto-assign the remaining wards and fosters to a PMP and care management organization. 

Over the next six months, CMO representatives will be educating about the wards and fosters transition, providing general Care Select program information, doing site surveys and offering tools like the new quick reference guide.
 
Hoosier Healthwise Program
A new initiative in the care of psychiatric and behavioral health conditions within MDwise will be assuming clinical and financial responsibility for behavioral health services within the networks. This transition is in concert with the intent of the Indiana Office of Medicaid Policy and Planning (OMPP) to move toward more integrated care for Medicaid members. 

On Dec. 31, 2008, the MDwise contract with CompCare will expire and the behavioral health care needs of MDwise Hoosier Healthwise members will be managed and paid for within the MDwise network model.

This represents a significant change in how authorization is obtained and how providers are paid for their services. MDwise believes this will be a less fragmented and more holistic model of care in addressing the physical and behavioral healthcare needs of its members.
As with any new initiative, there will be a time of transition and adjustment to new procedures. MDwise will provide help through this process.

The current CompCare provider network will transition to the MDwise Behavioral Health Network effective Jan. 1, 2009. MDwise is partnering with Behavioral Health Management Inc. (BHMI) to build this network.

BHMI is an administrative organization that represents a consortium of 30 community mental health centers throughout Indiana.

A key BHMI partner, Indiana-based InteCare, is responsible for contracting and credentialing all providers who want to participate in the new MDwise Behavioral Health Netowrk. The network will include hospitals, practice groups and independent behavioral health providers. 

Claims disputes for issues occurring prior to Jan. 1, 2009, will continue to go to CompCare, 3405 W. Dr. Martin Luther King Jr., Ste 101, Tampa, FL 33607. After Jan. 1, 2009, claims disputes will go to MDwise at: MDwise Hoosier Healthwise, P.O. Box 441423, Indianapolis, IN 46244-1423, attention: Grievances and Appeals.

Jeane Maitland of Anthem stated that by Feb. 19, 2009, Anthem’s State Sponsored Business Preferred Drug List will include additional codes requiring prior authorization (PA) for certain critical services for Medicaid program members. Find additional codes under these three existing services:

• Outpatient surgical services delivered in an ambulatory surgical center or outpatient hospital setting
  
• Radiology services—PET/SPECT scans, CTAs and MRIs
  
• Outpatient observation status (in a hospital setting)

• Specialty Drugs Prior Authorization
  Fax: (866) 545-0062
  Phone: (888) 662-0944
  
  

2009 Medicare physician payment rule published in the Federal Register
The AMA advised that on Nov. 19, the Centers for Medicare and Medicaid Services (CMS) published a final rule in the Federal Register on the 2009 Medicare physician payment schedule. It describes numerous changes, including:

• An across-the-board payment update of 1.1 percent as required by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)
  
• A 2 percent  incentive payment for reporting on Physician Quality Reporting Initiative (PQRI) measures
  
• An additional 2 percent incentive payment for electronic prescribing.

In addition, the rule reflects the final phase-in of the most recent update to the geographic practice cost indices (GPCIs), the third year of the transition to revised practice expense relative values, changes in certain relative values due to adoption of RUC recommendations and a shift of the budget neutrality adjustment from the work relative values to the conversion factor.

When the various changes in payment rates for services are combined, those specialties estimated to benefit most, with an average 4 percent increase, include infectious disease specialists, psychiatrists and emergency physicians. They are followed by 2-3 percent increases for anesthesiologists, cardiac surgeons, colorectal surgeons, intensivists, family physicians, gastroenterologists, general surgeons, geriatricians, internists and several others.

Specialties experiencing average decreases of 1-2 percent include allergists, cardiologists, oncologists, and nuclear physicians. No net payment changes are estimated for radiologists, urologists, ophthalmologists and orthopaedic surgeons.

The next meeting is scheduled for
Jan. 16, 2009.