like us on facebook connect with us on linkedin follow us on twitter October 16, 2019

Welcome to the Reimbursement Bulletin

MSHO Confidentiality Statement

This Bulletin will be published semi-monthly.  As always, any comments, suggestions, stories or questions can be sent to billing@msho.org

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Important Oncology Related News

~ HHS Proposal to Reform of Stark Law and Anti-Kickback Statute is Good First Step, But More Changes Needed
~ ASCO in Action Brief: Co-pay Accumulators and Co-pay Maximizers
~ Including Financial Assistance in ASP a Dangerous Proposal for Patients With Cancer
~ Rule Buried in Proposed Medicare Fee Schedule Could Have 'Chilling Effect'

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A Message From Your E-bulletin Sponsor

Lilly

Verzenio® (abemaciclib) Significantly Extends Life

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Please Join Us for the Health Can't Wait Action Day

Your voice is the key to our success at the Capitol!

Wednesday, October 30th Radisson Hotel, 111 North Grand Ave., Lansing, MI

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MSHO 10th Annual Payer Update

Wednesday, October 23, 2019

Registration Ends October 16th!

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MSHO Legislative Update Webinar
Key Changes for 2020

Wednesday - December 4, 2019 12:00-1:00 PM

Save the Date!!!

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MSHO Featured Corporate Sponsor Assistance Program

Astellas

~ Oncology-related products: Tarceva® (erlotinib) tablets (co-marketed with Genentech, Inc.), Xospata® (gilteritinib) tablets, Xtandi® (enzalutamide) capsules

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WPS Oncology Related LCD Updates

October 2019

Including;
~ 2020 ICD-10 Code Updates
~ Billing and Coding: Biphosphonate Drug Therapy

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WPS Recent Oncology Related News

Part A, Part B and Part A/B News

Includes articles that may be of interest to oncology released in the past 2 weeks
~ Also, Medicare Hot Links to Fee Schedules and 2020 Proposed and 2019 Final CMS Rules

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Join WPS for a Teleconference, Webinar or Seminar!

Check out these upcoming training events....

Including....
~ In Person Events including; Medicare Day of Learning (MDL) 10/29/2019 - Traverse City, MI - 8:00 AM - 4:00 PM
~ Webinars: Medicare Secondary Payer (MSP) Webinar Series, Completing the CMS Form 855B
~ PLUS many more educational opportunities including E & M training opportunities!

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Michigan RAC Information

Region 1 - Performant Recovery, Inc.

Latest Issues Under Review That May be Significant to Oncology...
~ Complex Coding Validation and Subsequent Hospital and Discharge Day Posted in April, 2019 - no oncology related new issues posted since.

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Recent RAC Monitor Article

This edition includes an article on......

~ HHS Unveils Proposals to Tweak Key Regulations  

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CMS-Medicare

Recent Oncology Related Articles

~ Physician Self-Referral Regulations Proposed Rule
~ Quality Payment Program: MIPS Dates and Deadlines
~ Proper Use of the KX Modifier for Part B Immunosuppressive Drug Claims
~ Medicare Overpayments
~ PECOS for Physicians and NPPs
~ Quality Payment Program: New 2019 Resources
~ Recent LearnResource & MedLearn Matters Articles

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BCBSM/BCN

Recent Oncology Related News

~ Internet Claim Tool issues
~ Duplicate Medicare crossover claims received from August 17, 2019
~ We're reprocessing HCPCS code C9031 for a reimbursement rate correction
~ Links have been fixed for AIM oncology webinars
~ MDHHS Healthy Michigan Plan webinar Oct. 24, 2019
~ The oncology management program will include Medicare Advantage plans starting Jan. 1, 2020
~ Starting Jan. 1, 2020, Blue Cross' PPO and BCN HMOSM plans will cover hemophilia drugs under members' pharmacy benefits
~ Blue Cross adjusting Medicare Plus BlueSM claims for drugs, biologicals acquired through 340B Program
~ Starting in January, AllianceRx Walgreens Prime is BCN's specialty pharmacy provider
~ Effective November 1, Inflectra® is the preferred infliximab product for adult Blue Cross' PPO (commercial) members

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BCBSM/BCN

Publications

~ The Record
~ BCN Provider News
~ Blues Brief for Oncology Providers

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Medicare Plus Blue

October Monthly Status Report

Many updates/corrections. Listed below is a sampling of what you will find...
~ Providers are getting inaccurate eligibility information from eviCore
~ J0881 and J0885 claims are denying incorrectly (Issue Being Closed)
~ Providers are getting false eligibility information for processing eviCore claims
~ Claims are denying for exceeding units on professional claims when the facility bills with a 59 TC modifier for the same procedure code

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Payer Issue Tracking Page

Last Updated 10/16/19

Review the reported payer reimbursement issues MSHO is currently addressing including WPS & BCBSM. This update includes information on the resolution of the MDS Retacrit issue with WPS Medicare AND what to do if you have rejected claims/appeals.

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Medicaid

Recent Oncology Related Issues and News

Pending Medicaid Issues being Addressed by MSHO:
~ None at this time.

Additional Medicaid Updates:
~ Proposed Medicaid Policy 1936-Pharmacy
~ MDHHS Soliciting Comments on the Michigan Medicaid Health Plan Common Formulary
~ MSA Bulletin Updates
~ Biller "B" Aware Notices

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Newsletters of Interest

~ Aetna OfficeLink Updates
~ Cigna
~ HAP
~ Humana YourPractice
~ UHC Network Bulletin
~ UHC Medical Policy Update

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Managed Care Committee Reimbursement TIDBITS

Featuring this month: McLaren Health Plan

Tidbits regarding;
~ Service code list requiring Prior Authorization
~ Genetic testing requirements
~ Prescription medication request form online

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UnitedHealthcare Update

~ New Cancer Therapy Pathways Program
~ Outpatient Injectable Chemotherapy and Related Cancer Therapies Prior Authorization/Notification Updates

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Priority Health Update

~ We're making changes to our remittance advice (RA) and explanation of benefit (EOB) codes for commercial and Medicare APC claims effective Nov.  1, 2019
~ Changes to remittance advice (RA) and explanation of benefit (EOB) codes effective Oct. 7, 2019

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Recent Oncology Related Drug News

~ Product Specific J-code for ELZONRIS' (tagraxofusp-erzs) 
~ Product Specific J-code for LIBTAYO® (cemiplimab-rwlc)

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Recent Oncology Related News

~ Complimentary Webinar: CMS' Proposed Radiation Bundling: Disaster or Boon?
~ Coding for Hospital Observations
~ Unanticipated Out of Network Billing Debate to Unfold in Michigan — What You Should Know

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ASK MSHO

October 2019, Frequently Asked Questions

Topic:
~ Time documentation for prolonged code 99354
~ CBC with no differential code
~ Unlabeled drug coverage
~ Medically Unlikely Edits (MUE) list
~ Examples of medications not reasonable and necessary
~ Details on the RAC audit for prophylactic and diagnostic injections

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