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July 2021 Newsletter
Medicaid Managed Care Is Live!
NC Medicaid Managed Care is live! If you have questions or need support during this transition, please reach out to your SEAHEC Practice Support coach or email us at Practice.Support@seahec.net.
 

Timeline

  • July 1, 2021 (TODAY!) – NC Medicaid Managed Care launch 
  • August 1, 2021 – Beneficiaries have thirty (30) days from receipt of notification of their AMH assignment to change their AMH/PCP without cause (1st instance) and shall be allowed to change their AMH/PCP without cause up to one time per year thereafter (2nd instance). In addition, Members shall be allowed to change their AMH/PCP with cause at any time. 
  • August 30, 2021 – Last date by which the health plan will pay claims and authorize services for Medicaid-enrolled out-of-network providers equal to that of in-network providers (or until end of episode of care, whichever is less)
  • September 29, 2021 – Last date by which the health plan must honor existing and active prior authorizations on file with the North Carolina Medicaid or NC Health Choice program (or until the end of the authorization period, whichever occurs first)
  • September 30, 2021 – End of beneficiary choice period
MIPS Updates
MIPS Promoting Interoperability Performace Category Hardship Exception and Extreme and Uncontrollable Circumstances Exception

Applications are now open for the MIPS Promoting Interoperability Performance Category Hardship Exception and Extreme and Uncontrollable Circumstances Exception for the 2021 Performance Year: Those interested must submit their applications to CMS by December 31, 2021

Who is Eligible for a Promoting Interoperability Hardship Exception? 
  • MIPS eligible clinicians, groups, and virtual groups may submit a MIPS Promoting Interoperability Performance Category Hardship Exception Application whether they’re reporting traditional MIPS or the APM Performance Pathway.
  • Exceptions are granted if they:  Are a small practice; Have decertified EHR technology; Have insufficient Internet connectivity; Face extreme and uncontrollable circumstances such as disaster, practice closure, severe financial distress or vendor issues; Lack control over the availability of CEHRT. 
  • NOTE: If you’re already exempt from submitting Promoting Interoperability data, you don’t need to apply. 
CMS Reweighting 2020 MIPS Cost Performance Category

The Merit-based Incentive Payment System (MIPS) cost performance category weight is 15% of the final score for the 2020 performance period/2022 MIPS payment year. CMS would like to inform all MIPS eligible clinicians that CMS is reweighting the cost performance category from 15% to 0% for the 2020 performance period. 

Specifically, CMS does not believe it can reliably calculate scores for the cost measures based on the following reasons, as shown by our analysis of the cost performance category data for the 2020 performance year:
  • A significant decrease in service utilization in 2020 demonstrates cost measures may not accurately characterize patient risk due to the lack of diagnosis information in the lookback periods used for risk adjustment.
  • Episodes with COVID-19 diagnoses generally have higher observed and risk-adjusted costs, indicating COVID-19 impacted service utilization and wasn’t sufficiently accounted for through risk adjustment.
  • The overall number of clinicians who met 2020 cost measure case minimums substantially decreased from prior performance years. A substantial portion of clinicians had episodes with COVID-19.

Clinicians don’t need to take any action as a result of this decision because the cost performance category relies on administrative claims data.

MIPS Performance Category Weight Redistribution Policies Finalized for the 2020 Performance Period

The table below illustrates the 2020 performance category weights and reweighting policies that CMS will apply to clinicians under MIPS.  As a reminder, if a MIPS eligible clinician is scored on fewer than 2 performance categories (meaning 1 performance category is weighted at 100% or all performance categories are weighted at 0%), they will receive a final score equal to the performance threshold and a neutral MIPS payment adjustment for the 2022 MIPS payment year.
 

MIPS
Performance Category
Reweighting Scenario

Quality Category Weight

Cost Category Weight

Improve-
ment Activities
Category Weight

Promoting Interoperability Category Weight

No Additional Reweighting
Applies

55%

0%

15%

30%

Reweight 2 Performance Categories

 

 

 

 

No Promoting Interoperability,
No Cost

85%

0%

15%

0%

No Quality, No Cost

0%

0%

15%

85%

No Improvement Activities, No Cost

70%

0%

0%

30%

Anxiety Screening

Preventive visit codes 99381-99397 include “counseling/anticipatory guidance/risk factor reduction interventions,” according to CPT. However, when such counseling is provided as part of a separate problem-oriented encounter, it may be billed using preventive medicine codes 99401-99409.

Usually when you provide a preventive visit and a problem oriented visit on the same day you would use the modifier -25.  The important thing to note if it is significantly separate then it would usually require separate encounter notes (one for each).

Note: Modifier 25 is defined as a significant, separately identifiable Evaluation and Management (E/M) service by the same physician or other qualified health care professional on the same day of the procedure or other service.

To find what other codes are used for, find-a-code is a good place to search.

NC HealthConnex Statistics
  • 83.1% of patients eligible for Medicaid have clinical data in the HIE
  • 92.5% of State Health Plan members have clinical data in the HIE
  • 78.7% of physicians, certified nurse midwives, nurse practitioners, physician assistants, and dentists participating in the Meaningful Use/Promoting Interoperability program are onboarded to NC HealthConnex
  • 1.5 million notifications delivered in the month of April via NC*Notify, the HIE’s event notification service to support Medicaid managed care/value-based care and close gaps in care
  • 126 hospitals connected and submitting data; additional 19 in onboarding
  • 6,800+ ambulatory practices submitting patients’ medical records including primary care, county health departments, federally qualified health centers, free and charitable clinics, behavioral health, etc.
  • Additional 5,000+ in onboarding
  • 13 million unique patients in the HIE network.
Clinician-to-Clinician Advice "Warmline"

Did you know that there is a clinician-to-clinician advice “warmline” that takes calls to answer questions about substance use evaluation and management? 

The warmline is free, open to any provider/clinician or team member in the US. It operates Monday through Friday, 9am-8pm Eastern time - (855) 300-3595. Pre-pandemic, calls were answered live. At this time, the caller must leave a voicemail or send a message through the website and will get a same day response, usually within the hour. There is nothing to register for, nothing to download, just quick access to a physician, advance practice nurse or clinical pharmacist who can answer general questions or detailed clinical questions. 

The warmline is used by providers who see a low volume of patients using substances as well as specialty providers with a high volume of patients who use substances. It is open to all providers regardless of setting such as physician offices, ED departments, etc. 

Welcome Ashley Barton to the Practice Support Team!

The Practice Support Service Team is thrilled to welcome our newest Practice Support Consultant, Ashley Barton, MPH, RD, LDN, who joined the team last month.

Ashley brings some valuable experience, most recently in her role as a Community Diabetes Educator with New Hanover County. She is also an Adjunct Faculty at the UNC Gillings School of Global Public Health.

Visit Practice Support Services Website
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