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September 2021 Newsletter
Common MIPS FAQ's

Q: I’m a MIPS eligible clinician who billed under multiple TINs during the 2020 MIPS performance year. Could I have multiple payment adjustments in 2022?

A: Yes. If you were MIPS eligible under multiple TIN/NPI combinations, you may receive a distinct MIPS payment adjustment for covered professional services furnished in 2022 and billed under each of those TIN/NPI combinations.

Q: Is the 2022 MIPS payment adjustment applied before or after sequestration?

A: Before sequestration. Sequestration is the automatic reduction in Medicare fee-for-service (FFS) payments to plans and providers, resulting from the Budget Control Act of 2011. The MIPS payment adjustment percentage is applied to the Medicare paid amount for covered professional services furnished by a MIPS eligible clinician after calculating deductible and coinsurance amounts but before sequestration.

Q: Is the 2022 MIPS payment adjustment applied to the Medicare paid amount or Medicare allowed amount?

A: The MIPS payment adjustment is applied to the Medicare paid amount for covered professional services (services for which payment is made under, or is based on, the Medicare Physician Fee Schedule) furnished by a MIPS eligible clinician.

Q: Do 2022 MIPS payment adjustments impact Medicare Advantage payments to in-network/contracted providers? If so, how?

A: Section 1854(a)(6)(B)(iii) of the Social Security Act prohibits CMS from interfering in payment arrangements between MAOs and contracted clinicians by requiring specific price structures for payment. Thus, whether and how the MIPS payment adjustments might affect an MAO’s payments to its contracted clinicians are governed by the terms of the contract between the MAO and the clinician. Additional guidance is contained in April 27, 2018 HPMS Memo entitled “Application of the Merit-based Incentive Payment System (MIPS) Payment Adjustment to Medicare Advantage Out-of-Network Payments.” 

Q: How will 2022 MIPS payment adjustments be reflected on remittance advice (RA) documents?

A: If a 2022 MIPS payment adjustment is applied to a payment made to a MIPS eligible clinician, the following codes will be displayed on the RA6:

Q: Will patients be notified if a claims payment made to one of their clinicians was adjusted due to that clinician’s participation in MIPS?

A: Yes. Every 3 months, Original Medicare10 patients receive a Medicare Summary Notice (MSN) in the mail for their Medicare Part A and Part B-covered services. MSNs show a patient all of his/her services or supplies that providers and suppliers billed to Medicare during the 3-month period, what Medicare paid, and the maximum amount the patient may owe the provider or supplier. For all the patient’s claims for which the clinician who furnished the service received a positive or negative MIPS payment adjustment, the following MSN message will be displayed: “This claim shows a quality reporting program adjustment.”

A Note About Medicaid Billing

After many practices shared issues with Medicaid/PHP Billing, the feedback we received was that this aligns with what the health plan CMOs shared on the webinar last week about the taxonomy codes being the top contributor to denied claims for each of the health plans. You can find the slides to this presentation here.

The most important point is getting the EHRs, claims clearinghouses, and NC Tracks in alignment and verifying all have the same Taxonomy codes. Practices have to work directly with their vendors and health plans to resolve. You can also find guidance of those experiencing payment issues Here.

  • The Medicaid Provider Ombudsman should be contacted if everything is done correctly on the vendor end and NCTracks but not getting what they need directly from the health plan.  The Provider Ombudsman will however need specifics in order to facilitate timely and quality resolution from the health plan. We have heard good success stories of folks who received resolutions to problems when using them.
You can contact the Medicaid Ombudsman at 866-304-7062 or email Medicaid.ProviderOmbudsman@dhhs.nc.gov
  • Amerihealth- Practices do not have to pay the EFT fee if they complete enrollment for the single payor option.  It is the multi-payor option that results in the charging of the fee. To enroll please visit, https://enrollments.echohealthinc.com/efteradirect/enroll.
    NOTE: For the CMS 1500 form, the rendering taxonomy code has to be in Box 33. 
  • In response to the potential for delayed payments and increased denials, Medicaid has established Hardship Advances for those at risk of not meeting financial obligations this month. To request a hardship advance, send an email to the Provider Ombudsman at Medicaid.ProviderOmbudsman@dhhs.nc.gov. In the body of the email, include: 
    • Financial obligations the provider is unable to meet 
    • Estimated total monetary impact to the provider of unpaid managed care claims 
    • The NPI number of the provider who will receive the advance 
    • A list of the unpaid managed care claims, the associated PHP and the reason the claim has not paid (i.e. denial reason) 
    • Name, telephone number and email address of the provider’s contact person 

DHHS and PHPs will respond to the completed request by contacting the provider to resolve any claim payment issues and sending a hardship agreement, if necessary. Upon resolution of the managed care claim transition issues, DHHS and PHPs will notify providers of the need to submit claims and if advances have been issued, they will be recouped from future payments.  

For more information, please see the Medicaid bulletin Expedited Hardship Advances for Managed Care Providers [medicaid.ncdhhs.gov]

Your Connection to NC HealthConnex
From NC Medicaid: You may be aware that the HIE Act deadline was extended until January 2023 as a result of a collaborative effort to bring additional relief to health care providers who have been on the front lines of the COVID-19 pandemic. We advocated on your behalf so that your organization would be allowed additional time to complete the technical onboarding process without being out of compliance with the HIE Act. 
 
However, there is a need to accelerate the progress on this critical initiative to make NC HealthConnex as impactful as possible for the Medicaid health care community. 

Please Note: With this extension of time, the need for hardship extensions is absolved, as the extension granted through the hardship process is now matched by the extension granted through new legislation. Therefore, effective Aug. 1, 2021, NC Medicaid will no longer accept submissions of the NC DHHS HIE Hardship Extension Request Form. For more details see the NC HIEA June 2021 Update, or to review changes in their entirety, see NC Session Law 2021-26
 
Why You Should Connect Now
  • With North Carolina’s move to managed care, all Medicaid providers will benefit from more complete health information aggregated within NC HealthConnex on Medicaid patients across the care continuum as providers are now focused on managing the health of a patient vs. the fee for service model.
  • There are more than 5,000 facilities in onboarding at this time. There are no guarantees of additional extensions; in fact, the General Assembly is requiring compliance reports from the NC HIEA by March 1, 2022.
  • There are additional resources available through September 30, 2021, to support independent providers in the technical connection process. In addition, various electronic health record (EHR) vendors are able to offset integration fees through September 2021. Unfortunately, due to the sunsetting of federal funds, there will be no additional surge resources available for those that postpone connections. 
  • It is incumbent upon the participant to reach out prior to the deadline to get connected. Currently, on-premises connections take 3-4 months and cloud roll-ons take 2-4 weeks.
Please note that the NC HIEA will report on efforts, progress, mandated Medicaid and State Health Plan providers not yet connected to the legislature in March 2022 as required by state law. All connection statuses and levels of engagement will be evaluated and reported to the NCGA Health and Human Services Joint Legislative Oversight Committee. 
 
For questions about resources or connecting to NC HealthConnex, contact the NC HIEA team at hiea@nc.gov or 919-754-6912.
 
Why Aren’t You Connected?
Click here to take our short survey.
Protecting Access to Medicare Act (PAMA)

CMS has delayed the penalty phase of PAMA to January 1, 2023 or January 1 that follows the declared end of the PHE for COVID-19. Nhrmc.org/pama will be updated to include the delay.

New Hanover will not be moving forward with requirements for external providers, until penalty phase is implemented.

CMS is proposing to begin the payment penalty phase of the AUC program on the later of January 1, 2023, or the January 1 that follows the declared end of the PHE for COVID-19. This flexible effective date is intended to take into account the impact that the PHE for COVID-19 has had and may continue to have on practitioners, providers and beneficiaries.

Source: https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2022-medicare-physician-fee-schedule-proposed-rule

Educational Opportunities
Cyber Risks for Medical Practices
Lunch & Learn, Webinar
September 22, 2021 12-12:30 PM


The healthcare industry is currently the #1 target for cyber breaches. If a breach occurs, your practice is responsible for all associated costs, including potential ransom or extortion fees and patient lawsuits. Learn how your practice can minimize your risk!

Register Here
Pediatric Sepsis and Dehydration
Livestream Event
September 29, 2021 9 AM- 12:15 PM


Sepsis is a leading cause of morbidity and mortality in the pediatric setting.  This program has been developed to assist attendees in understanding and identifying the signs and symptoms associated with pediatric sepsis and dehydration. 

Register Here
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