Provider Workshops June 2011 Agenda Welcome and Introductions - PowerPoint PPT Presentation

Bureau for Medical Services & Molina Medicaid Solutions Provider Workshops June 2011

Agenda  Welcome and Introductions  Healthcare Reform  Provider Incentive Program  5010 Electronic Transactions  Provider Enrollment & Screening  Provider Re-Enrollment  Policy & Program Updates  Managed Care Updates  BMS Website  General Billing Information  Innovative Resource Group (APS) BMS/Molina 2011 Provider Workshops 2

Healthcare Reform  What is Healthcare Reform?  Key areas of Reform  Purpose of PPACA (Patient Protection and Affordable Care Act)  PPACA and the States  PPACA provisions for Medicaid  PPACA funding opportunities BMS/Molina 2011 Provider Workshops 3

What is Health Care Reform  This presentation provides a high-level overview of the purpose, provisions, and related funding of the Patient Protection and Affordable Care Act (PPACA, Act), as well as an overview of how the Act will affect the West Virginia Department of Health and Human Resources (DHHR) and Bureau for Medical Services (BMS).  The Act is also referred to as the Affordable Care Act (ACA).  The Obama Administration has stated that the intent of the Act is to “put individuals, families, and small business owners in control of their healthcare.” BMS/Molina 2011 Provider Workshops 4

Key Areas of Reform Much of the PPACA must be resolved through regulations. Many of the provisions became effective upon enactment, and requirements of the Act continue through 2019. Most of the reform activities will occur between 2010 and 2014. > Health Insurance Reform > Employers offering health insurance to employees > Public Programs including Medicaid, the Children’s Health Insurance Program (CHIP), Medicare, and Public Health > Healthcare workforce training > Elimination of fraud, waste, and abuse in healthcare > Improving the quality of healthcare BMS/Molina 2011 Provider Workshops 5

The Purpose of PPACA  PPACA starts to change the way healthcare is delivered. PPACA deals in great part with insurance reform. Among those reforms: > Holding insurance companies accountable to keep premiums affordable and prevent denials of care and coverage, including for preexisting conditions > Making health insurance affordable for middle class families and small businesses with tax credits for health care, and reducing premiums and out-of-pocket expenses.  PPACA creates powerful incentives so that more healthcare providers can begin to deliver the kind of coordinated, patient-centered care that has been shown to get best results. BMS/Molina 2011 Provider Workshops 6

PPACA and the States  The critical role of State government is in managing and financing the Medicaid and CHIP Programs. The PPACA creates new requirements for expanded coverage and accountability mandates for those programs.  States must also create, manage, and regulate new insurance exchanges for both individual residents and businesses.  The extensive new regulations for the health insurance plans must be enforced by the States as well. BMS/Molina 2011 Provider Workshops 7

PPACA Provisions for Medicaid  Continues Medicaid coverage to any individual who has been in foster care under the age of 26.  Develops a core set of health care quality measures for Medicaid-eligible adults.  Eliminates fraud, abuse and waste in the system which may require outside vendor procurement and outside contracting meeting the federal requirements.  Provides new options to States to provide Medicaid long-term care services and support. BMS/Molina 2011 Provider Workshops 8

PPACA Funding Opportunities  The Medical Home State Options offers states enhanced match of 90 percent FMAP (Federal Medical Assistance Program) for two years and small planning grants may be available to promote the use of medical homes for enrollees with chronic conditions. West Virginia has been a leader in developing the medical home concept.  WV has applied and received a planning grant for this opportunity. Health Homes for Members with Chronic Conditions.  WV has applied and received a Money Follows the Person grant. BMS/Molina 2011 Provider Workshops 9

Provider Incentive Program (PIP)  The Electronic Health Records (EHR) Provider Incentive Program (PIP) is a federal program offering financial support to assist eligible providers to adopt, implement, or upgrade certified EHR technology.  The Medicaid EHR Incentive Program will provide incentive payments to eligible professionals, eligible hospitals, and critical access hospitals (CAHs) as they adopt, implement, upgrade , or demonstrate meaningful use of certified EHR technology in their first year of participation and demonstrate meaningful use for up to five remaining participation years.  Incentives will be available through both Medicaid and Medicare. > Eligible healthcare professionals will be required to choose between Medicaid and Medicare. > Those in border counties should choose the state from which they will receive the incentive payments. Hospitals may be able to receive incentive funds from both programs. > The Bureau for Medical Services (BMS) will administer the Medicaid EHR Incentive Program for West Virginia. BMS/Molina 2011 Provider Workshops 10

Provider Incentive Program (PIP)  Providers eligible for payment are: > Physicians, Dentists, Pediatricians, Nurse Midwives, Nurse Practitioners, Physician Assistants who practice in a Federally Qualified Health Center (FQHC), Critical Access Hospitals, Acute Care Hospitals  Estimated Go-Live date is July 2011  Payments will be made through the claims processing system  Link for provider attestation will be available through Molina’s webportal > www.WVMMIS.com  Payment information will be reflected through provider’s remittance advice  Questions related to PIP will be handled through Provider Relations BMS/Molina 2011 Provider Workshops 11

Provider Incentive Program (PIP)  Key dates from Centers for Medicare and Medicaid Services (CMS): > January 2011 - Medicaid providers can register with the Federal National Level Repository (NLR). > July 2011 - Attestations from Medicaid providers can be submitted through state MMIS portal. > Late July 2011 - WV State payments to Medicaid providers are expected to start. > September 30, 2011- Last day of the federal fiscal year. Reporting year ends for eligible hospitals and CAHs. > October 1, 2011 - Last day for eligible professionals to begin their 90-day reporting period for calendar year 2011 for the Medicare and Medicaid EHR Incentive Program. BMS/Molina 2011 Provider Workshops 12

Provider Incentive Program (PIP)  Key Dates continued: > November 30, 2011-Last day for eligible hospitals and CAHs to register with NLR and attest to receive an incentive payment for federal fiscal year (FY) 2011. > December 31, 2011- Reporting year ends for eligible professionals. > February 29, 2012 -Last day for eligible professionals to register with the NLR and attest to receive an incentive payment for calendar year (CY) 2011. BMS/Molina 2011 Provider Workshops 13

5010 and D.0 Electronic Transactions  CMS is monitoring the States’ compliance with the regulatory requirement to convert from Health Insurance Portability and Accountability Act (HIPAA) Accredited Standards Committee (ASC) X12 version 4010A1 to ASC X12 version 5010 and National Council for Prescription Drug Programs (NCPDP) version 5.1 to NCPDP version D.0.  All covered entities are targeted to be fully compliant on January 1, 2012.  The new HIPAA 5010 electronic transaction standard will drive billing, reimbursement, and many administrative functions, as well as accommodate the larger ICD-10 code sets. Version 5010 has more than 2,500 generic and 1,000 unique changes ranging from field size increases to entire new segments of data, resulting in considerably more data than its predecessor 4010A. BMS/Molina 2011 Provider Workshops 14

5010 and D.0 Electronic Transactions  Readiness of provider community  Testing process > Providers will need to test with outside vendor (Edifecs) before testing with Molina > If the provider submits through clearinghouse, the individual provider is not required to test  Testing schedule > Once the provider/clearinghouse is certified from outside vendor, the provider /clearinghouse will be required to have three successful tests before submitting 5010 transactions  Companion guides and comparison XML will be posted on the web portal BMS/Molina 2011 Provider Workshops 15

5010 and D.0 Electronic Transactions  The following transactions will be affected by 5010: > 837 I/P/D Inbound > 276/277 > 270/271 > 835 Outbound  Direct Data Entry (DDE) into the web portal will not be affected by 5010. All screens will remain the same.  Batch uploads via the web portal will need to be submitted in the new 5010 standard.  All real-time pharmacy transactions will be impacted by the new D.0 standard. BMS/Molina 2011 Provider Workshops 16