2017 Blue's Tour Presented by: Blue Cross and Blue Shield of Kansas - PowerPoint PPT Presentation

2017 Blue's Tour Presented by: Blue Cross and Blue Shield of Kansas

Presenters Include: Sally Stevens Institutional Provider Consultant, Southern Kansas Cindy Garrison Institutional Provider Consultant, Northern Kansas Jessica Moore Institutional Education and Communication Coordinator Marie Burdiek EDI Account Representative

Agenda  BCBSKS Institutional Policy and Procedure Changes  Quality-Based Reimbursement Program (QBRP) Updates  Updates and Reminders  Top Denials  Self Service Tools  EDI Updates

Presented by: Sally Stevens Institutional Provider Consultant

2018 Summary of Changes  The following is a summary of the changes to the BCBSKS Institutional Policies and Procedures for 2018. Deleted wording is noted in brackets [ italicized ].  New verbiage is identified in bold . Language moved within the document is noted as underlined.  With the redesign of our Policies and Procedures for 2018, two new sections have been added (Claims and Credentialing). Sections and provisions are also rearranged for readability, however no content / language has changed unless outlined within this summary document.

2018 Summary of Changes Page 6: Updated language to better clarify the intent of this provision. 1.6 Wholly Owned Subsidiaries Any entity which provides and/or bills members and/or BCBSKS for health care services, which advertises or represents itself to the general public as being owned/ owning , controlled/ controlling , managed/ managing , affiliated with, or operated by a Contracting Provider, must also be contracting with BCBSKS, unless otherwise permitted by BCBSKS. Failure of such providers to contract with BCBSKS shall be considered cause for termination of the Agreement in accordance with Section V, paragraph 2 of the Agreement. This provision is applicable to entities serving members in the same general locale as those served by the Contracting Provider.

2018 Summary of Changes DEFINITIONS Page 7: Added the definition "For Cause." 2.6 For Cause Includes, but is not limited to any of the following (1) breach of contract; (2) a civil case ruling, settlement in a civil or criminal matter, a verdict or plea of nolo contendre and/or any other instance determined by BCBSKS as moral turpitude; and/or (3) any act of defamation, slander, and libel toward BCBSKS and it's subsidiaries (as determined by BCBSKS).

2018 Summary of Changes CLAIMS Page 9: Added verbiage as notification that employee groups may impose alternate timely filing requirements. 3.4 Timely Filing Initial billings must be submitted to BCBSKS within one year, three months (15 months) from the date of discharge or the date of outpatient services. In the event initial billings for covered services are not submitted timely, deductibles, coinsurance and shared payments may be recovered from the member [ when approved by BCBSKS ]. T he [ all other balances as it relates to these initial billings will be a write-off to the ] Contracting Provider must write off all other balances. When BCBSKS becomes aware, BCBSKS will notify Contracting Providers when employee groups impose alternate timely filing requirements. [ Notification will be provided when employee groups impose alternate timely filing and claim assessment requirements. Failure to meet those requirements will result in claim denial .]

2018 Summary of Changes Page 10: Clarified existing language specific to remittance advice. 3.8 Remittance Advice BCBSKS sends to the Contracting Provider notification regarding claim payment and claim denials via the remittance advice. The remittance advice will indicate whether the charges for denied services may be billed to the Member or if the Contracting Provider must write off the charges. Charges for services excluded from coverage by the Member's contract may be billed to the Member. Charges for services that are deemed to be not medically necessary or experimental / investigational by BCBSKS may not be billed to the Member unless the patient was given advance notice and signed a Limited Patient Waiver prior to the service. More information regarding coverage of services can be found in the BCBSKS Medical Policies, BCBSKS newsletters and in the Institutional Provider Manual. [ The Contracting Provider will be informed through the remittance advice of services not included as covered benefits under the various member contracts. BCBSKS will also identify the amounts for these services which can be billed directly to the member. All such charges shall be included in the total charges billable to BCBSKS. Services that are not covered benefits and either billable or non- billable to the member and claim submission procedures for those services are identified in the BCBSKS Institutional Provider Manual or BCBSKS newsletters .]

2018 Summary of Changes GENERAL CONDITIONS Page 13: Updated language for clarity. 5.1 Audit Requirements Post-Pay Audits: BCBSKS conducts periodic post-payment audits of patient records and adjudicated claims to verify congruence with BCBSKS medical and payment policies, including medical necessity and established standards of care. Post-payment audits are performed after the service(s) is billed to BCBSKS and payment(s) has been received by the provider. Post-payment audits can range from a basic audit to determine if the level of care is accurately billed, to a complete audit which thoroughly examines all aspects of the medical record. [BCBSKS cannot go back further than 15 months following the date of claim adjudication to initiate an audit .] BCBSKS will not initiate audits more than 15 months following the date of claim adjudication. Post-payment audits being performed to resolve an allegation of fraud or abuse are not subject to the 15 month limitation.

2018 Summary of Changes MEDICAL AND UTILIZATION REVIEW Page 16: Added language regarding the use of alternative waivers. 6.2 Medical Necessity …The Contracting Provider shall not bill members for services which have been determined medically unnecessary, experimental/investigational, have been denied due to Utilization Review, and/or are patient demanded services unless the member has been given written notification in advance of services being provided, that specific services will be the member's responsibility. Contracting Providers are strongly encouraged to use the Limited Patient Waiver (LPW). However, if the Contracting Provider wishes to use an alternate waiver, the Contracting Provider must obtain prior approval from BCBSKS. Generic or all- encompassing notifications without advanced written authorization by BCBSKS shall not be deemed to meet the specific notification requirement mentioned above. In instances where medical necessity is questionable, the Contracting Provider may contact BCBSKS medical review department for a predetermination of coverage. This provision applies to inpatient, outpatient and partial-day services.

2018 Summary of Changes Page 16: Added language regarding the use of alternative waivers. Continued: [ All claims for services for which the member has been given a LPW shall be submitted on a paper claim form with the LPW form attached. Charges shall be billed as non-covered. ] If a [ the ] member does not want a [ the ] claim to be filed, obtain this instruction in writing from the member and keep it on file with the LPW. For additional information and a copy of the LPW form, refer to the BCBSKS Institutional Provider Manual.

2018 Summary of Changes Page 19-20: Removed redundant language from this provision. 6.9 Inpatient Claim Reviews Reviews may be conducted to determine medical necessity, which may include but not be limited to the following: 1. Patterns of practice within the hospital's medical staff that deviate from the norms as seen in other Kansas hospitals 2. Re-admission frequencies 3. Assignment and reporting of principal diagnosis, procedures and other criteria used in assigning the MS-DRG for payment 4. [Mental and substance use disorder MS-DRG MAPs are limited to the inlier MAP where the number of covered days is less than the high trim point, regardless of the patient's actual length of stay. In the event that the number of covered days exceeds the high trim point, the outlier MAP will be limited to the number of covered days, even though the patient may have stayed longer. Charges for services provided on days where no coverage exists may be billed to the Member.]

2018 Summary of Changes REQUESTS FOR INFORMATION Page 20: Added language describing claim adjudication when requested medical records are not received. 7.2 Medical Records The Contracting Provider must provide or make available complete medical records at no charge in a format which can be utilized by BCBSKS or an entity acting on behalf of BCBSKS. When medical records are requested to substantiate a claim for services, each patient record must contain adequate documentation to justify the course of treatment provided and reflect the patient's status and progress during the course of treatment. Medical records shall include all versions, whether handwritten or Electronic Medical Record (EMR) generated. Any applicable audit log documentation must be provided if requested by BCBSKS. In most instances, BCBSKS will allow 30 calendar days for the production of the requested records. Failure to send the requested documentation or providing insufficient documentation to determine medical necessity may result in a claim denial and accordingly a provider write off.