Filtered by category: Insurance News Clear Filter

Have You Been Negatively Affected by United Healthcare/Optum Practices?


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NYSCA & Council Respond to NYS WCB Proposed Medical Fee Schedule Discussion Document


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MLN Connects Upcoming Calls: Transitioning to ICD-10

Wednesday, November 5; 1:30-3pm ET

To Register: Visit MLN Connects™ Upcoming Calls. Space may be limited, register early.
HHS has issued a rule finalizing October 1, 2015 as the new compliance date for health care providers, health plans, and health care clearinghouses to transition to ICD-10. During this MLN Connects National Provider Call, CMS subject matter experts will discuss ICD-10 implementation issues, opportunities for testing, and resources. A question and answer session will follow the presentations.

  • Final rule and national implementation
  • Medicare Fee-For-Service testing
  • Medicare Severity Diagnosis Related Grouper (MS-DRG) Conversion Project
  • Partial code freeze and annual code updates
  • Plans for National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs)
  • Home health conversions
  • Claims that span the implementation date
Target Audience: Medical coders, physicians, physician office staff, nurses and other non-physician practitioners, provider billing staff, health records staff, vendors, educators, system maintainers, laboratories, and all Medicare providers.

Continuing education credit may be awarded for participation in certain MLN Connects Calls. Visit the Continuing Education Credit Information web page to learn more.


"Medicare Appeals Process" Fact Sheet — Revised

The “Medicare Appeals Process” Fact Sheet (ICN 006562) was revised and is now available in a downloadable format. This fact sheet is designed to provide education on the five levels of claim appeals in Original Medicare (Medicare Part A and Part B). It includes details explaining how the Medicare appeals process applies to providers, participating physicians, and participating suppliers, in addition to including more information on available appeals-related resources.

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CMS Announces 2013 PQRS Incentive Payments are Now Available


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Court Rules in Favor of Class Standing in United Healthcare/Optum Lawsuit


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Workers Compensation Update: Form HP-1 Revised

As part of the Workers' Compensation Board’s effort to improve service and increase efficiency in the unpaid medical bill(s) process, Form HP-1, Health Provider's Request for Decision on Unpaid Medical Bills(s), has been revised. Form HP-1 now directs that the form is sent to the following addresses as appropriate.

When requesting an Administrative Award, Form HP-1 should be sent to the Board’s Centralized Mailing Address:
New York State Workers' Compensation Board
PO Box 5205
Binghamton, NY 13902-5205
When requesting Arbitration, Form HP-1 and a check for the processing fee should be sent to:
New York State Workers' Compensation Board
Medical Director's Office/Finance
328 State Street
Schenectady, NY 12305
The revised Form HP-1 with the new addresses may be obtained at the Board's website here or by following the link "Forms" at the top of the home page.

Please contact the Board at 1-800-781-2362 with any questions regarding Form HP-1. Thank you for your cooperation.

Robert E. Beloten, Chair



NYS WCB Proposes New Fee Schedule


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NYS WCB Chair Proposes Non-Acute Pain Medical Treatment Guidelines


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Important Deadlines Approaching for EHR Incentive Program


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New PQRS Frequently Asked Questions Now Available


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Learn More about the New Remittance Advice Codes for PQRS Claims-Based Reporting


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Medicare to Remove 2% Reduction

Some good news on the Medicare front:

We have been informed that effective July 1, 2014 the 2% reduction for codes 98940, 98941 and 98942 will be eliminated. As you will recall, this 2% reduction was put in place as a result of the demonstration project that was determined not to be cost neutral. This will be removed effective July 1.

Respectfully submitted,
Mariangela Penna DC
NY CAC Representative


Urgent Medicare Bulletin: Service-Specific Prepayment Reviews of Chiropractic Services


Attention Services for Jurisdiction K Part B Chiropractic Providers in Connecticut and New York

National Government Services will be conducting service-specific prepayment reviews on CPT code 98940 in the Queens, NY area and CPT Code 98941 in CT and the upstate and downstate NY areas.

A prepayment review consists of a medical review of claims prior to payment. Request for records are most frequently electronically generated and referred as ADS letters. Please note that when medical records are requested for chiropractic services, it is necessary to submit all the specific documentation as notated in the ADS, which would include but is not limited to:
  • Services up to three (3) months prior to and including the date(s) of service in question
  • Advance Beneficiary Notice of Noncoverage
The primary focus of the audits will be to better identify common billing errors, develop educational efforts, and prevent improper payments. Providers will be receiving ADSs asking for documentation to support the service billed. Medical Review encourages providers to respond with the requested documentation in a timely manner to expedite adjudication of these claims.

Providers can assist in this process by:
  • Reviewing all contractor publications and LCDs
  • Understanding Medicare coverage requirements
  • Ensuring office staff and billing vendors are familiar with claim filing requirements
  • Performing self-audits of medical records against billed claims using coverage criteria, LCD, and coding guidelines
  • Responding to request(s) for records in a timely manner (CMS requires that providers respond to an ADS within 30 days of the request)
  • Ensuring documentation is legible and demonstrates that the patient’s condition warrants the services being reported and billed
Reports show that from June 2013 through March 2014, the average error rate for CPT code 98941 was:
Connecticut - 81.0
Downstate, NY area - 81.1
Queens, NY area - 91.2
Upstate, NY area - 76.6


EHR Incentive Program Eligible Professionals: Hardship Exception Applications due July 1

Are you a Medicare provider who was unable to successfully demonstrate meaningful use for 2013 due to circumstances beyond your control? CMS is accepting applications for hardship exceptions to avoid the upcoming Medicare payment adjustment for the 2013 reporting year. Payment adjustments for the Medicare EHR Incentive Program will begin on January 1, 2015 for eligible professionals. However, you can avoid the adjustment by completing a hardship exception application and providing supporting documentation that proves demonstrating meaningful use would be a significant hardship for you. CMS will review applications to determine whether or not you are granted a hardship exception. CMS has posted hardship exception applications on the EHR website for: Applications for the 2015 payment adjustments are due July 1, 2014 for eligible professionals. If approved, the exception is valid for one year.

New Hardship Exception Tipsheets
You can also avoid payment adjustments by successfully demonstrating meaningful use prior to the payment adjustment. Tipsheets are available on the CMS website that outline when eligible professionals must demonstrate meaningful use in order to avoid the payment adjustments.

Want more information about the EHR Incentive Programs?
Make sure to visit the Medicare and Medicaid EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs.


Stage 2 Meaningful Use Requirements, Reporting Options, and Data Submission Processes for Eligible Professionals — Registration Now Open


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New Fact Sheet Available on How to Avoid the 2016 PQRS Payment Adjustment

Are you an eligible professional or part of a group practice participating in PQRS this year? If so, you must satisfactorily report data on quality measures during 2014 to avoid the 2016 payment adjustment.

Review the new fact sheet for guidance on how to avoid the 2016 PQRS Payment Adjustment.

Avoid the 2016 Payment Adjustment
You can avoid the 2016 payment adjustment by meeting one of the following criteria during the one-year 2014 reporting period (January 1–December 31):

If Participating as an Individual Eligible Professional
  • Meet the criteria for satisfactory reporting adopted for the 2014 PQRS incentive.
OR If Participating as a Group Practice
  • Meet the Group Practice Reporting Option (GPRO) requirements for satisfactory reporting.
  • Participate in PQRS via qualified registry reporting and report at least three measures covering one NQS domain for at least 50 percent of your group practice’s Medicare Part B FFS patients.
Want more information about PQRS?
Please visit the CMS PQRS website:


Reminder on the Appeals Process and Ways to Avoid Appeals

If an initial claim determination results in a denial, providers, participating physicians, and other suppliers have the right to appeal the decision. National Government Services has seen an increase in the number of claims submitted to Medicare Part B Appeals for review and may cause a delay in receiving your decision. We are processing appeal and reopening requests in an efficient manner and working diligently to resolve these issues expeditiously. Our goal is to minimize disruption to the provider/supplier and beneficiary community. You will receive a decision as soon as possible; we appreciate your patience during this period.

Important Information
  • Do not submit a duplicate appeal.
  • If you are a current NGSConnex user, you can check the status of your appeal at Please note: do not resubmit the appeal when using NGSConnex.
  • The appeals process, levels of appeal, documentation, and recommended forms can be found on our Web site under Review Process > Appeals.
  • A local coverage determination (LCD) is a decision a Medicare contractor will make to cover a particular item or service. A majority of appeal requests are the result of the initial claim not following the LCD. It is important to become familiar with LCDs and national coverage determinations (NCDs).
  • LCDs contain information to indicate medically reasonable and necessary documentation and should be used as an administrative and educational tool to assist with submitting correct claims for payment. LCDs are located on our Web site in the Medical Policy Center.
  • The Centers for Medicare & Medicaid Services Internet-Only Manual Publication 100-03, Medicare National Coverage Determinations (NCD) Manual describes whether specific medical items, services, treatment procedures, or technologies can be paid for under Medicare. All decisions that items, services, etc. are not covered are based on Section 1862(a)(1) of the Act unless otherwise specifically noted. More information on NCDs can be found on the Medicare Coverage Determination Process page on the CMS Web site.
  • Not all covered Medicare services are subject to either an LCD or NCD.
Below is a list of LCDs causing the increased number of appeals to National Government Services. Please use the links to become familiar with the policy and avoid future appeals.


New EHR Incentive Programs Tipsheet for Eligible Professionals Practicing in Multiple Locations

Are you an eligible professional practicing in multiple locations? Review the new Multiple Locations Tipsheet for information on how to successfully demonstrate meaningful use in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. The tipsheet includes guidance on determining if a location is equipped with certified EHR technology, calculating patient encounters, and what to do when different menu objectives and clinical quality measures (CQMs) are chosen across locations.

Guidance for Multiple Locations
Here are some key points to keep in mind if you are practicing in multiple locations:
  • To demonstrate meaningful use, 50 percent of patient encounters must take place at locations with certified EHR technology during the reporting period. 
  • A location is equipped with certified EHR technology if you have access to the certified EHR at the beginning of the EHR reporting period. 
  • You can add numerators and denominators from each certified EHR system for an accurate total. 
  • You should report on menu objectives and CQMs from the location with the most patient encounters if different locations chose different measures.
For More Information
Visit the CMS EHR Incentive Programs website for more resources to help you successfully participate.


EHR Incentive Programs: Learn More about the Batch Reporting Option for 2014

Are you part of a group practice with multiple eligible professionals or part of a system of eligible hospitals participating in the Medicare Electronic Health Record (EHR) Incentive Program? If so, you now have the option to submit your attestations through the batch reporting method. The batch reporting method – or attestation batch upload – is a new reporting method for 2014 that allows you to upload and submit attestations for multiple eligible professionals or eligible hospitals. You can submit your attestation with other members of your medical group or hospital system in a single file through the CMS Registration and Attestation System, while still tracking each eligible professional’s and eligible hospital’s individual meaningful use data. Providers in Stage 1 or Stage 2 of meaningful use can submit their attestation through batch reporting with 2014 certified EHR technology.

Please note: While batch reporting provides groups with the ability to submit attestations together, incentive payments are distributed to each eligible professional or eligible hospital. Providers participating in the Medicaid EHR Incentive Program should check with their state to determine if batch reporting is available.

What measures can you submit with batch reporting?
You can submit the following measure combinations through batch reporting:
  • Core measures and menu measures 
  • Core measures, menu measures, and clinical quality measures 
  • Clinical quality measures only
Helpful resources
For more information on submitting your groups’ attestations using the batch reporting method, review the new Batch Reporting User Guide. You may also visit the Attestation Batch Upload Page to view the batch templates and sample batch attestations.

Want more information about the EHR Incentive Programs?
Make sure to visit the Medicare and Medicaid EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs.