Colorado
Insurance Information
January
14, 2008 - SPECIAL BULLETIN
UPDATED FEES for
Colorado Medicare 1-14-08
Noridian Administrative Services, LLC
(NAS) announces the new, revised 2008 Medicare Physician Fee Schedule
(MPFS) state specific files for the last two NAS administered states
were posted to the NAS web site on Friday, January 11, 2008. With the
posting of the Alaska and Colorado data on January 11, 2008, NAS has
completed the public release of the new rates mandated by the Medicare,
Medicaid and SCHIP Extension Act of 2007. The President signed the
legislation on December 29, 2007 mandating the replacement of the
scheduled 10.1 percent reduction in the Medicare Physician Fee Schedule
(MPFS) conversion factor with a 0.5 percent increase for dates of
service beginning January 1 through June 30, 2008. Physicians do not
need to take any additional action in order for their MPFS claims to be
paid at the new rate that reflects the 0.5 percent increase in the
conversion factor. NAS is able to process claims for services paid
under the MPFS that contain dates of service January 1, 2008 and after
with the new 2008 rates. No adjustments should be necessary.
2008 COLORADO
Medicare Fee Schedule Effective 1-1-08 to 6-30-08
| Procedure |
PAR amount
|
NONpar amount
|
Limting Charge
|
98940
|
$23.92
|
$22.72
|
$26.13
|
98941
|
$33.07
|
$31.42
|
$36.13
|
98942
|
$43.26
|
$41.10
|
$47.27
|
Amounts payable at 80% after deductible - $135 for 2008.
Direct Link to fees on-line:
https://www.noridianmedicare.com/p-medb/news/fees/2008/fee_schedule.html
(be sure to click COLORADO fees)
Remember: use the AT modifier on all non-maintenance treatment
Implications of SB79 Standard Contract Bill
SB 79 will reduce
administrative costs
associated with processing multiple payer contracts, all of which have
different language and conditions. It
ensures that all contracts are drafted in plain language and use set of
terms. The bill requires payers to notify
providers of changes and updates to their contracts.
Previously, payers might make changes which
providers might to be aware of, and those added conditions had a
negative
impact. If someone from the office did
not regularly check a payer’s web site, they would be unaware of
material
changes to their contract. After January
1, 2008, providers are no longer obligated to accept unilateral changes
made by
the plans during the term of their contract. This
will bring transparency to the contracting
process. It
eliminates “contracts of
adhesion” that all doctors are required to sign when they join a
managed care
network. The law will eliminate “phantom” networks, stop
retroactive
contract changes, require that a copy of the fee schedule be attached
to the
contract, and provide other helpful contractual provisions that will
allow you to
evaluate whether to sign the contract or get out of the network.
SB 79, as set forth in the
bill summary,
requires any
person or
entity contracting with a health care provider on or after
January 1, 2008, to use
a standard form contract . Requires each contract to include a summary
disclosure form that contains:
- Compensation and payment
terms that are sufficient for the health care provider to identify the
compensation for health care that is provided that shall include a fee
schedule;
- The duration of the
contract and reasonable termination terms;
- The identity of the
claims processors;
- Dispute resolution terms;
and
- The subject and order of
an addenda, if applicable.
Requires the person or
entity to identify a program
used to review, monitor, evaluate, or assess the health care services
provided.
Exempts a person or entity from providing a fee schedule to a provider
if the
fee schedule is for dental services whose providers include licensed
dentists,
and the fee schedule is based on fees filed by the dental provider and
is
revised periodically.
Requires the person or
entity to state how a
completed claim was adjudicated and any outstanding balance owed.
Requires the
payment and compensation terms to be disclosed in writing when a
contract is
proposed by the person or entity. Allows
a material change to a contract only if the change is provided in
writing 90
days prior to the change. Allows a contract to be terminated by either
party if
there is written objection to the change, unless the objection is to an
addition of a new category of coverage. Prohibits a person or entity
from
assigning, allowing access to, selling, renting, or giving the rights
to the
provider's services unless specific conditions are met. Prohibits a
contract
from requiring a waiver of the provider's legal rights as a condition
of
entering into the contract. Allows a
health care provider to decline services to new patients upon 60 days'
notice.
Allows for termination of a contract without cause
by either party if the
contract is for less than 2
years, otherwise requires the termination without cause terms to be
specified
in the contract. Exempts certain entities from the requirement of using
the
contract. Allows a contract to include
an agreement for binding arbitration.
Requires the availability
of private rights of
action, equitable relief, reasonable attorney fees when the provider is
the
prevailing party in an action, and the option to introduce prior
arbitration
awards regarding a violation.
Resources
regarding the
new
Colorado
TORT auto insurance
system effective
July 1, 2003
The Colorado Chiropractic
Association (CCA) would like to
demonstrate that since the sunset of PIP in July 2003, there has been a
significant increase in the number of patients unable to pay for
treatment,
resulting in a decrease in patient recovery (due to patients’ inability
to pay)
and increased financial losses for Colorado Doctors of Chiropractic.
2005
Colorado Auto Insurance TORT Survival Guide
For CCA Members ONLY!
Purchase
the CCA's TORT
Revisited video (recorded 2-12-04) & notes:
Download the
TORT video order form from the CCA Members Only page
Colorado
Division of Insurance Web Site:
The Road
to Tort
by Richard Keuhn, DC,
2003 CCA Legislative Committee Chair
Colorado no-fault insurance began in the early 1970s as a tactic to
discourage lawsuits by providing guaranteed medical benefits for
injured parties. The rationale for this was based on the fact
that in a “tort” system each insurance carrier would typically
represent insureds who were at-fault 50% of the time and victimized 50%
of the time so liability settlements averaged out over time with
minimal financial implications. However, the insurance carriers
considered a “no-fault” system as an opportunity to eliminate or
minimize legal fees and costs by reducing lawsuits in exchange for
guaranteed medical benefits. This system worked well in Colorado
for nearly 30 years and could have been continued as a sound public
policy with proper reforms but the system was not modernized or updated
adequately causing huge political pressure for more dramatic
changes. The no-fault statute expired in 2001 but was renewed for
one year in 2001 and again for another year in 2002. This led to
the bitter battles and drastic changes in 2003 that led to our
transition to tort.
Many Colorado consumers and health care professionals are dismayed by
the changes to “tort” because of the uncertainty regarding payment of
medical expenses, delays in payment and negotiation of fees based upon
settlements. However, the end result could have been much worse
as the proposed “PIP reforms” were even worse public policy than our
current tort system. For instance, the final “compromises”
presented by the conference committee (the voice of Republican
leadership) would have allowed insurance carriers to sell PIP benefits
that excluded chiropractic, massage therapy, physical therapy,
acupuncture, and occupational therapy. In essence, the “reforms”
proposed in the following summary of bills would have guaranteed a
medical monopoly, discriminated against all non-allopathic providers
and unreasonably restricted consumer freedom of choice in health
care. The CCA supported tort as a better choice than “ridiculous
PIP reform” because our number one priority prior to the 2003
legislative session was “direct patient access to chiropractic
care.” While some may argue about the extent of such access
under tort, the truth is that the other choices were much worse.
It is also important to put the extent of our accomplishments in
perspective. HB 1225 was the primary proposal for PIP
reform. It was developed by a secretive committee appointed by
the governor, the automobile insurance industry and other key business
representatives under the umbrella of the Colorado Association of
Commerce and Industry. The CCA tried repetitively to be a part of
this process and in fact testimony in the 2003 House Business Affairs
Committee revealed that several types of health care providers were
excluded from this process causing some dissension among key
legislators. Regardless, it is amazing the impact that health
care providers and their patients had during the 2003 legislative
session especially when you realize that we battled against the
Hospital Association, the health insurance carriers, the entire
business community and the Colorado Medical Society supported by
republican leadership from the governor’s office down through House
leadership. Ironically, the governor had to “cut a deal” to get
his own bill out of a committee chaired by the sponsor of the bill and
with the largest partisan majority of all the committees! And
that was only the beginning! There were hearings with so much
overflow attendance that they had to be moved and patrolled by the
Sergeant of Arms. There was such controversial testimony that
observers could barely control their outbursts. There was
unprecedented intimidation on the House Floor including a historic
“call vote” with Republican leadership badgering House members who
wouldn’t “fall in line.” There were tricks and shenanigans with
the “Committee of the Whole Report” to confuse and manipulate
votes. We even had the votes on the House floor to amend their
bill in such a way to preserve the fundamental structure of PIP, but a
brief lapse by a key legislator caused this amendment to fail.
The net result is that we have a new automobile insurance system in
Colorado. It is not necessarily “good” or “bad” in itself.
It just is! It is a system that has been in place in 37 other
states. We have significantly higher liability limits ($25,000
bodily injury) than many other states that are stuck with $10,000
limitations. We preserved direct access of patients to
chiropractic treatment which was our primary goal. We have a
strong organization that has developed a greater and greater influence
in the political process. As a resilient group of ethical health
care practitioners dedicated to delivering quality chiropractic care
AND receiving fair reimbursement for those services, we cannot only
survive but thrive in a tort system. We are and should continue
to be an integral aspect of health care for motor vehicle accident
injuries. However, it is critical that we remember that the rules
have changed and it is up to individual doctors and our state
association to learn the rules, develop strategies to excel in this new
system and foster relationships with other professionals with the same
commitment to serving injured parties. (end)
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2007
Medicare
Fee Schedule
If you have
any COLORADO Medicare questions, please contact CCA President Dr. Hal
Lease who serves as Colorado’s
chiropractic representative on Noridian Medicare’s Carrier Advisory
Committee. Dr. Lease may be reached at (719) 324-5242 or hal@jlm.com.
For a Colorado Medicare Fee
Schedule, please see the CCA
Members Only page OR visit Noridian's
Web Site.
<>
Posted
5-23-07: Guidance on Compliance with the HIPAA National
Provider Identifier (NPI) Rule
AFTER THE MAY 23, 2007, IMPLEMENTATION DEADLINE BACKGROUND
<>
To improve the efficiency and effectiveness
of the health care system, Congress enacted the Health Insurance
Portability and Accountability Act (HIPAA) of 1996, which included a
series of “administrative simplification” provisions that required the
Department of Health and Human Services (HHS) to adopt national
standards for electronic health care transactions and code sets and
identifiers to be used in those transactions. The final rule adopting
the NPI as the standard unique health identifier for health care
providers was published on January 23, 2004, and became effective on
May 23, 2005. All covered entities must be in compliance with the NPI
provisions by May 23, 2007, except for small plans, which must be in
compliance by May 23, 2008.
Compliance means in part that the NPI must be
used by covered entities to identify providers on all HIPAA covered
transactions that call for health care provider identifiers. Covered
transactions that require a health care provider’s identifier that are
transmitted containing only legacy identifiers (identifiers in use
today) or containing both legacy identifiers and NPIs would be
noncompliant. The NPI final rule is clear: May 23, 2007 is the
final deadline for covered entities, other than small plans, to comply
with HIPAA’s NPI provisions. After that date, covered entities,
including health plans (other than small health plans), may not conduct
noncompliant transactions. With the May 2007 deadline just ahead, HHS
has received a number of inquiries expressing concern over the health
care industry’s state of readiness.
In response, the Department believes it is
particularly important to outline its approach to enforcement of
HIPAA’s NPI provisions. The Department will continue to provide
technical assistance to the industry and issue guidance on the NPI
provisions and compliance requirements.
ENFORCEMENT APPROACH
The Secretary has delegated to the
Administrator of the Centers for Medicare & Medicaid Services (CMS)
authority to enforce the electronic transactions, code set, security,
and identifier provisions (i.e., non-privacy administrative
simplification provisions) of HIPAA. CMS will focus on obtaining
voluntary compliance and use a complaint-driven approach for
enforcement. When CMS receives a complaint about a covered entity that
appears to allege a failure to comply with a non-privacy administrative
simplification provision of HIPAA, it will notify the entity in writing
that a complaint has been filed. Following notification from CMS, the
entity will have the opportunity to 1) demonstrate compliance, 2)
document its good faith efforts to comply with the standards, and/or 3)
submit a corrective action plan.
GOOD FAITH POLICY
CMS’s approach will utilize the flexibility
granted in section 1176(b) of the Social Security Act to consider good
faith efforts to comply when assessing individual complaints. Under
section 1176(b), HHS may not impose a civil money penalty where the
failure to comply is based on reasonable cause and is not due to
willful neglect, and the failure to comply is cured within a 30-day
period. HHS has the authority under the statute to extend the period
within which a covered entity may cure the noncompliance “based on the
nature and extent of the failure to comply.” CMS recognizes that
transactions often require the participation of two covered entities,
each of whom is required to comply with HIPAA, and that noncompliance
by one covered entity may put the second covered entity in a difficult
position. CMS also understands that if one of the covered entities is a
small health plan, which has a May 23, 2008 compliance date, compliance
by the covered trading partner may be especially challenging.
Therefore, during the 12 month period immediately following the May 23,
2007 compliance date for all covered entities other than small health
plans, CMS intends to look at both covered (non-small health plans)
entities’ good faith efforts to come into compliance with the NPI
standards in determining, on a case-by-case basis, whether reasonable
cause for the noncompliance exists and, if so, the extent to which the
time for curing the noncompliance should be extended. For a 12
month period after the compliance date (i.e., through May 23, 2008),
CMS will not impose penalties on covered entities that deploy
contingency plans (in order to ensure the smooth flow of payments) if
they have made reasonable and diligent efforts to become compliant and,
in the case of health plans (that are not small health plans), to
facilitate the compliance of their trading partners. Specifically, as
long as a health plan (that is not a small health plan) can demonstrate
to CMS its active outreach/testing efforts, it can continue processing
payments to providers. In determining whether a good faith effort has
been made, CMS will place a strong emphasis on sustained actions and
demonstrable progress. We limit the period during which covered
entities may deploy contingency plans to allow additional time to carry
out needed testing and other activities without payment disruption,
while providing a clear ending date for those activities. A covered
entity may end its contingency plan at any time prior to May 23, 2008,
but cannot continue it after that date. Indications of good faith might
include, for example, such factors as:
• Increased external testing with trading
partners.
• Lack of availability of, or refusal by, the
trading partner(s) prior to May 23, 2007 for health plans (other than
small health plans) to test the transaction(s) with the covered entity
whose compliance is at issue.
• In the case of such a health plan,
concerted efforts in advance of the May 23, 2007 and continued efforts
afterwards to conduct outreach and make testing opportunities available
to its provider community.
• For a health care provider, having obtained
an NPI and having the ability to use it on HIPAA transactions.
While there are many examples of complaints
that CMS may receive, the following is one example that illustrates how
CMS expects the process to work. Example: A complaint is filed against
a health plan (that is not a small health plan) solely because it
accepts and processes transactions containing both legacy identifiers
and NPIs while working to help its provider trading partners achieve
compliance. In this situation, CMS would 1) notify such a plan of the
complaint, 2) based on the plan’s response to the notification,
evaluate the plan’s efforts to help its noncompliant providers come
into compliance, and 3) if it is determined that the plan had
demonstrated good faith and reasonable cause for its non-compliance,
not impose a penalty for the period of time CMS determines is
appropriate, based on the nature and extent of the failure to comply.
For example, CMS would examine whether the
health plan (that is not a small health plan) undertook a course of
outreach actions to its trading partners on awareness and testing, with
particular focus on the actions that occurred prior to the May 23, 2007
NPI compliance date. Similarly, health care providers should be able to
demonstrate that they took actions to become compliant prior to the May
23, 2007 NPI compliance date, including obtaining an NPI. If CMS
determines that reasonable and diligent efforts have been made, the
cure period for noncompliance would be extended at the discretion of
CMS. Furthermore, CMS will continue to monitor the covered entity to
ensure that their sustained efforts bring progress towards compliance.
If continued progress is not made, CMS will step up their enforcement
efforts towards that covered entity. Organizations that have exercised
good faith efforts to correct problems and implement the changes
required to comply with HIPAA should document such efforts in the event
of a complaint being filed. This flexibility will permit health plans
to mitigate unintended adverse effects on covered entities’ cash flow
and business operations during the 12 month transition to the NPI
standards, as well as on the availability and quality of patient care.
WORKING TOWARD COMPLIANCE
In the few remaining months before the May
23, 2007 deadline for all covered entities other than small health
plans, HHS encourages those covered entities to intensify their efforts
toward achieving compliance with the NPI requirements. In addition, HHS
encourages health plans that are not small health plans to assess the
readiness of their provider communities to determine the need to
implement contingency plans to maintain the flow of payments while
continuing to work toward compliance. Although compliance with the NPI
is a huge undertaking, the result will be greatly enhanced electronic
communication throughout the health care community. Successful
implementation will require the attention and cooperation of all health
plans and clearinghouses, and of all providers that conduct electronic
transactions. HHS plans to reassess industry readiness on the May 23,
2007 compliance date, and throughout the 12 month contingency plan
period.
Posted
5-24-07 More on NPI: Get It. Share It. Use It.
The
NPI Compliance Deadline is Here!
At this point, any
covered entity that is noncompliant, and has not implemented a
contingency plan, is at risk for enforcement action. Please review the April
2, 2007 CMS “Guidance
on Compliance with the HIPAA National Provider Identifier (NPI) Rule.”
As this guidance pertains
to claims transactions, it means that:
1. Providers must have and
use their NPI;
2. Clearinghouses must
accept and use NPIs; and
3. Health plans must accept
and send NPIs in claims transactions.
Providers should be:
1. Aware of contingency
plans for any health plans they bill. Contingency plans may differ by
health plan.
2. Aware that health plans
may lift their contingency plans (and require an NPI on claims or other
HIPAA transactions) any time before May 23, 2008.
3. Working with vendors and
clearinghouses with whom they contract, to make sure the NPI is being
passed to health plans.
4. Paying close attention to
how and when health plans will be testing implementation of the NPI.
5. Aware that, for those
health plans that did not establish a contingency plan, providers are
required to use their NPIs now. This means that if you are not using
your NPI, your claim may be rejected or denied.
New
Tip Sheet Available
A Tip sheet entitled What
the “Guidance on Compliance with the HIPAA National Provider Identifier
(NPI) Rule” Means for Health Care Providers is now available at http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/ContingencyTipSheet.pdf
This product provides
helpful steps for providers based on the contingency guidance released
on April 2, 2007. This guidance does not mean that providers have an
extra year to get an NPI, so please view the Tip Sheet for additional
information.
Reminder
– Sharing
NPIs
Once
providers have received their NPIs, they should share them with other
providers with whom they do business, and with health plans that
request them. In fact, as outlined in current regulation, providers who
are covered entities under HIPAA must share their NPIs with any
entities that request them for use in
standard transactions -- including those who need to identify ordering
or referring physicians/providers. Providers should also consider
letting health plans, or institutions for whom they work (e.g. a large
hospital system), share
their NPIs for them.
When
to Contact the NPI Enumerator for Assistance
Providers
should remember that the NPI Enumerator can only
answer/address the following types of questions/issues:
- Status of
an NPI application, update, or deactivation
- Forgotten/lost
NPI
- Lost NPI
notification letter
- Trouble
accessing NPPES
- Forgotten
password/User ID
- Need to
request a paper application
·
Need clarification on
information that is to be supplied in the NPI application
Providers
needing this type of assistance may contact the enumerator at
1-800-465-3203, TTY 1-800-692-2326, or email the request to the NPI
Enumerator at CustomerService@NPIenumerator.com .
Resources for other kinds
of questions can be found at the end of this document.
Please
Note: The NPI Enumerator’s operation is closed on federal holidays. The
federal holidays observed are: New Year's Day, Independence Day,
Veteran’s Day, Christmas Day, Martin Luther King's Birthday,
Washington's Birthday, Memorial Day, Labor Day, Columbus Day, and
Thanksgiving.
Important
Information for Medicare
Fee-For-Service (FFS) Providers
Testing
Medicare Claims
To date,
Medicare has encouraged providers to submit both an NPI and a legacy
identifier on claims. Medicare is now asking that submitters send a
small number of claims using only the NPI. If no claims are rejected,
the submitter can gradually increase the volume. If any claim is
rejected, the NPI should be verified to make sure it was entered
correctly. If the NPI is correct, then data in either NPPES or Medicare
provider files should be corrected. The
following fields in your NPPES and/or 855 provider enrollment record
should be validated:
§ EIN (for organization
providers)
§ Other Provider
Identification Numbers. This is where providers, when they apply for
their NPIs, list the Medicare legacy identifier(s) that needs to be
linked to the NPI.
§ Practice Location Address
§ Master Address (from
provider enrollment records)
§ Other Address (from
provider enrollment records)
§ Legal Name or Legal
Business Name
Once this has been done,
test again with a small number of claims. This process will help
establish confidence that your claims will be paid. It is critical that
you start testing with your NPI now.
While
Medicare FFS has announced its contingency plan, it is committed to
ending the contingency plan as soon as possible.
Reminder
-
Medicare FFS Contingency Plan Announced on April 24th
View the
associated Change Request at http://www.cms.hhs.gov/transmittals/downloads/R1227CP.pdf, as well
as the related MLN Matters article at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5595.pdf on the CMS website. These
materials were recently revised; please be sure to visit the links
above for the latest information.
Reminder - NPI
MLN Matters Articles
There are
many MLN Matters articles dealing with various topics of NPI relative
to the Medicare program. These MLN articles are available at
http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/MMArticles_npi.pdf
Additional
Information
As always, more
information and education on the NPI can be found at the CMS NPI page www.cms.hhs.gov/NationalProvIdentStand on the CMS website.
Providers can apply for an NPI online at https://nppes.cms.hhs.gov or can call the NPI
enumerator to request a paper application at 1-800-465-3203.
Getting
an NPI is free - not having one can be costly.
Lucretia James
Centers for Medicare
& Medicaid Services
Region VIII
1600 Broadway, Suite 700
Denver, CO
80202
(303) 844-1568
lucretia.james@cms.hhs.gov
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Complete Chiropractic
Guide to Workers Comp available
on CCA's Members Only page
Work
Comp Guidelines
The CCA
reviewed proposed guidelines and provided oral and written testimony to
the Colorado Division of Workers Comp during an open meeting on March
6, 2007. CCA 1st Vice President James
Farrell presented rationale for preserving a flexible
number of allowable chiropractic adjustments. The complete 6-page
report is available as a PDF file on the CCA’s Members Only page under “Work Comp
Report 3-6-07” OR CLICK HERE .
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8751
East Hampden
Avenue #B-7 | Denver, Colorado 80231-4929
Phone:
303-755-9011
or 800-829-0339 | Fax: 303-755-1010
E-Mail:
cca@coloradochiropractic.org
Colorado
Chiropractic
Association
The
voice of
Colorado chiropractic since 1917.
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