provide the supporting documentation. That time and effort, she felt, was not reciprocated when she called dozens of times to follow up and received little re- sponse as to why the claims were denied. Until TMA’s Payment Advocacy Depart- ment stepped in, that is.
“These appeals took so much time, and I expect a trained medical billing professional to answer my questions when I call,” Ms. Brown said, adding that each claim was successfully ap- pealed. “Yes, we got our money back, but where’s our interest for not timely refunding us?”
Having to jump through hoops even on smaller claims can be a big hit to practices that may perceive the burdens to outweigh the benefits, Dr. Malone added. “We do our best to provide ser- vices to patients when they need them. But every time these bureaucracies are inserted, physicians are less likely and less able to do this for patients.” Meanwhile, some physicians have ex-
pressed concern about heavy auditing of high-level evaluation and management (E&M) procedures for Medicare exams, an issue TMA’s Payment Advocacy staff is tracking.
When it comes to appeals, Mr.
Vaughan said Novitas’ contract requires the carrier to process old TrailBlazer claims using the same policies in effect when the original claim was processed. That means “the work is more cumber- some for us to adjudicate at the appeal level given our lack of familiarity with those policies and the extra effort to locate pertinent records needed for the review.”
Novitas also added staff and training
in this area early on, an indication that the carrier’s monitoring efforts and con- tingency planning worked, he says. “We did not copy TrailBlazer’s policies. But we still have a foot in both worlds for a little while longer.”
As for E&M codes, at present, physi- cians can expect higher level codes to get some scrutiny.
That’s because Novitas is required to pay claims accurately, and JH exceeds the national average for error rates when it comes to E&M codes. In other words, if doctors aren’t billing properly,
the carrier is penalized for incorrectly processing the claim. That doesn’t mean Novitas audits those codes across the board, rather it is sampling doctors’ bills for evaluation, Mr. Vaughan says. “We have to look at what’s driving that utilization, and often times there is very good reason behind it. Because Texas has a lot of teaching hospitals and spe- cialty hospitals, we know we have that in the mix, as well,” he said. “We don’t have a preconceived notion that [these codes] need to fit a certain distribution. But we are looking for assurances that doctors are coding properly, and once we get that, we’ll move on.” Mr. Vaughan recommends doc- tors familiarize themselves with the E&M documentation guidelines avail- able on the Novitas website at www
.novitas-solutions.com/em/index.html. TMA’s website also has information on E&M specialty exam score sheets avail- able online at
www.texmed.org/Tem plate.aspx?id=25572.
Making progress Other parts of the transition have re- vealed improvements.
Ms. Brown says some of Novitas’ newly instituted procedures now save the practice time and money, including the ability to fax versus mail the appeals, correct claims over the phone, and check doctors’ eligibility status online. Despite some shortfalls, CMS regional
office officials say Novitas’ performance to date is relatively consistent with past transitions and confirmed that the car- rier did rise to the occasion in what CMS called the “critical area of claims- processing timeliness.” Meanwhile, the erroneous recoupments have not been an ongoing issue. CMS expects Medicare carriers to pro- cess 95 percent of clean claims — claims that contain all the necessary informa- tion — within 30 days of receipt. From Sept. 1, 2012, through Jan. 31, 2013, which included the transition timeframe, Novitas processed more than 30 million Part B claims, with 99 percent of clean claims processed within 30 days, accord- ing to CMS data. However, Novitas’ performance re-
garding its Provider Contact Center — a top functional area of concern for CMS and the most persistent complaint re- ported to CMS — reached its nadir last
Recoupment audits to resume
When Novitas took over from TrailBlazer as the new Medicare carrier for Texas, the Centers for Medicare & Medicaid Services imposed a moratorium on pursuing recoupments for overpay- ments, known as recovery audit activities. The blackout period is generally instituted 90 days before and after the cutover date — in this case, Nov. 19, 2012. The post-transition 90-day window recently expired at the end of February, which means physicians should expect Novitas to resume actively pursuing overpayments. Novitas representatives said its process to handle overpay-
ment recovery and appeals follows the same requirements that applied to TrailBlazer, so physicians should not experience any changes in that process.
April 2013 TEXAS MEDICINE 47
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