Medicaid / Provider Workgroup meets in Atlanta - October 28, 2009
A group of GAMES / GRTC providers met with representatives of DCH earlier this week to resolve some of the ongoing billing and procedural issues resulting from the recent changes to the Medicaid fee schedule & policies.
During the over 90 minute meeting, we simply were not able to address all of the issues raised by GAMES / GRTC members, however, we made some good progress. More detailed notes are being prepared by Chip Fiske, GRTC Chair. In the meantime, here are some important highlights.
PA’s are currently taking up to 30 days to be approved
While it is not their preferred standard, GMCF is in compliance. They have up to 30 business days to approve / deny. GMCF offered that the additional codes are requiring more detailed review and therefore extending the review time. They are aware of the concerns and are working through the learning curve.
Providers request consideration for pushing back the reprocessing (recoupment) date from November 1, 2009
Medicaid representatives agreed to present this request to Financial Services and to Jerry Dubberly, Medicaid Director for consideration. A decision is expected by COB Oct. 29. (Nothing yet at press time.)
Batteries – Denying for no PA
There is currently a conflict regarding requiring a PA or not requiring a PA. Medicaid and GMCF representatives will review and get back to us. These should not be denying.
E1340 U1 being denied for PA, when is under $200
While modifier U2 does not require a PA for repair services under $200; the U1 modifier used to bill for labor requires a PA always.
Repairs for deleted codes K0010, K0012 under $200 and over $200 –need clarification on the procedure for changing the WC code without impacting payments made prior to 07/01/09
When billing the wheel chair base codes (K0010 and K0012) with the repair/labor code E1340, provider must update the PA with the new CPT Code K0800-K0813, and K013-K0865.
K0108 approved list:
(1) The list is incomplete. What is the process for adding items not currently on the list?
For wheelchair assessor services not already on Appendix E, providers will identify directly on the PA request—advising of request for consideration for service to be added to Appendix E. GMCF will determine medical necessity of the item being requested and make recommendation for coverage to DCH. If medically necessary, DCH will then approve and add to Appendix E (K0108 approval list); and post at next manual update. Providers need to make sure they note on MSRP invoice submitted with PA that this item is a K0108, and whether or not it is on the approved K0108 List.
(2) Some approved products are manufacturer specific product names where the same product will be called a different name by another manufacturer.
For wheelchair accessory supply/services already on Appendix E under a specific name, the provider will advise (in the narrative section) of the standard name/crosswalk. (For example: a Foot Positioner, Shoe Holder, or Shoe Sandal – all are different manufacturer’s description for the same item, which is on page E-3 of Appendix E as Foot Positioners, Large 9-12.) GMCF will approve accordingly, if the item is found to be medically necessary/appropriate.
Nebulizers & Wellcare
CMO’s were given DCH rates on Sept. 29. They have 45 days to implement changes, so the new pricing should be in effect Nov. 2.
September 15, 2009 - New DME Policy Manual
The new policy manual and schedule of maximum allowables has been posted to the Georgia Health Partnership website. Get answers to questions about the new HCPCS codes, discontinued codes, reprocessing of claims and more.
CLICK HERE for the DME Policy Manual.
CLICK HERE for the new Schedule of Maximum Allowable Payments for DME.
Georgia Medicaid holds DME training workshops to review the new fee schedule and reprocessing of claims.
ACS, in conjunction with DCH and GMCF, will conduct a Provider Service training and workshop for Durable Medical Equipment (DME) Providers on Friday, September 18, 2009, from 10:00 a.m. until 12 noon at the Georgia Mountains Center in Gainesville, Georgia. CLICK HERE for the banner message.
ACS, in conjunction with DCH and GMCF, will conduct a Provider Service training and workshop for Durable Medical Equipment (DME) Providers on Wednesday, September 23, 2009, from 10:00 a.m. until 12 noon at Central Georgia Technical College in Macon, Georgia. CLICK HERE to read the banner message.
September 3, 2009 - Provider Training with DCH/GMCF/ACS
The first in a series of provider meetings was held today at the Atlanta office of ACS. Although the meeting was called with very short notice, over 40 providers were in  attendance seeking an opportunity to ask questions.
Some of the areas covered include:
What happened to the new codes scheduled to be open on September 1?
Of the 500 new codes to be opened, due to a system glitch, approximately 50 were not opened. DCH assures us they are testing the system and working to have the codes open on September 8, 2009.
When will/did the SMAP fee schedules go into effect?
The new fees / codes apply to all claims with a date of service of July 1, 2009 and after.
When will claims begin being paid at those rates?
After September 1, 2009
When will the reprocessing/payment corrections take place? All at one time, or will it take place over several weeks/months?
Reprocessing of all claims paid with date of service on or after July 1, 2009 will be reprocessed beginning November 1, 2009 and will happen at once, not over a period of time. Money owed back to the state will be deducted from remittance. (If this recoupment will be a hardship for providers, there is a process to appeal to the commissioner for a different repayment plan. No further details were given on this process.)
If a complex rehab provider is asked to provide a WC modification, they need to first find the correct HCPCS code (if one exists), and determine if the GA Medicaid allowable is adequate. The example used was a custom headrest, which may cost the provider $500, but the HCPCS code allowable is $125. If there is a code and allowable established, Medicaid will not pay more for that code, even if the product cost the provider more. Only if there is there is no HCPCS established can the K0108 code be used, which would then be paid By Review (Manufacturer quote). This means that there may be many items which providers can no longer provide (except at a loss). We need to document those items/HCPCS codes. If a code and allowable exist, Medicaid will not pay more than the rate set by 80% of the 2007 Medicare allowables.
The GHP web site has a code lookup feature that can be used to determine if a new code has been added. Go to the claims tab, and in the lower right corner is a Code Lookup box. We were assured that this code lookup contains real time, up to date code information, which tells you valid codes and valid modifiers, along with prior approval requirements, but does not contain allowables.
(Thank you to Weesie Walker, Ed Cockman, and David Petsch for this update.)
CLICK HERE to read the ongoing list of Questions & Answers between GAMES / GRTC and GA DCH.
August 30, 2009 - DCH to hold DME Training Workshops
CLICK HERE for details.
August 11, 2009 - Banner Message addresses reprocessing of claims filed between July 1 and September 1, 2009
CLICK HERE to read the banner message.
May 14, 2009 - NEW Medicaid maximum allowable reimbursement for DME services. Public comment invited.
CLICK HERE to read the public notice from the Georgia Department of Community Health.
CLICK HERE to read the ongoing list of Questions & Answers and get information on how to offer comments.
CLICK HERE to review a partial 2007 Medicare fee schedule and the 80% comparison.
CLICK HERE for sample comments offered by DME and Rehab providers.
CLICK HERE for sample letters from elected officials.
February 2009 - The deletion of K0108 has been suspended.
CLICK HERE to read the banner message.
February 11, 2009 - GRTC Meets with Medicaid
Members of the Georgia Rehab Technology Council (GRTC) met with representatives from Georgia Medicaid / DCH to discuss a variety of issues important to Rehab Providers. At the conclusion of the meeting the following topics below were presented to DCH for consideration:
- Allow codes 97001and 97542 (same date of service) to be approved on 1 PA request
- Minimum of 90 days to notify providers of any policy changes and/or updates
- Distinguish Custom Rehab services/supplies as a separate entity from other DME services
- Open modifiers associated with K0108 or other codes with no modifier assigned
- Open ALL codes approved by Medicare or ALL codes associated with Complex Rehab (Providers - please clarify request)
- Conduct quarterly meetings in an effort to solicit provider input and enhance provider communication
- A banner message is forthcoming regarding the denials of K0108
* *It is important to note that Medicaid is aware there are billing issues with the K0108 code. They will release a banner message shortly.
Jan 29, 2009 - Medicaid announces web-based educational sessions to communicate the intent of the policy changes, respond to provider's questions and concerns, and to solicit provider input/feedback.
CLICK HERE for details.
January 26, 2009 - A message from Georgia Medicaid dated January 22, 2009 suspending all proposed policy changes pending further review and prior notification.
CLICK HERE to read the message.
GRTC also received the following statement from Margie Preston, Director of the Medical Policy Unit:
"It is our intent to host a minimal of two calls over the next month or so. The objectives of the conference calls will be to communicate the intent of proposed policy change, respond to provider's questions and concerns regarding the proposed DME & O&P policy changes, and to solicit provider input/feedback."
As GAMES receives more information, it will be posted here.
How to contact Georgia Medicaid
Providers should making inquiries to the Georgia Health Partnership Member or Provider Inquiry lines. Provider inquiries are outlined in Appendix L and Section 803.2 of the manual. Member inquiries should be directed to the GHP Member Service line at 770-578-3378 or toll free at 866-211-0950.
For issues specifically related to policy clarifications contact Lindsay Ryan at 404-463-3412. Additionally, policy related questions or concerns, can be sent directly to the Medical Policy mail box at medicalpolicy@dch.ga.gov.
Important Updates to the Medicaid Policies and Procedures Manual for Durable Medical Equipment Products and Services
December 31, 2008 Medicaid Released its 2009 DME Policies and Procedures Manual
CLICK HERE to view the manual.
December 8, 2008 - Important change in the time window for submitting requests to
review DME supplies and services
Effective for dates of services on and after January 1, 2009, the time window for submitting requests to review DME supplies and services will change from ninety (90) to thirty (30) days.
CLICK HERE to read the Provider Communication from Georgia Medicaid.
Need Help with a Medicaid Claim?
GAMES has been informed that questions regarding Medicaid billing issues should not be directed to Medicaid directly, but should go through the appropriate ACS Field Representative.
Breaking News!!
SALES TAX BILL SIGNED BY GOVERNOR:
Governor Perdue signed into law HB 1078, a Sales and Use Tax bill. CLICK HERE to read the bill.
As of July 21st, 2008 the Georgia Sales tax law was changed by the passage of HR 1078. Although GAMES was very much involved in the passage of this bill, GAMES is not in a position to offer advice or counsel. GAMES is simply able to inform you that the change in law does offer relief from state sales tax, that was not previously available. The relief is on items of DME as defined by the Social Security Act and prescribed by a licensed physician, or such person that is licensed to prescribe in Georgia. Those items of DME are now exempt even for payments made by a third party such as private insurance plans.
GAMES suggest that anyone needing advise obtain such from their accounting or legal services.
Thank you to Representatives' Jeanette Jamieson and Butch Parrish and Senator Chip Rogers for their strong support! Thank you to David Petsch and Wallace Whiten for their tenacity and commitment to the patients and the businesses that serve them.
Clarification to the CPAP Language
This language is found on page 7 of the Georgia Medical Board April 2008 Newsletter:
"Individuals must be licensed in order to provide care planning, provide education to the patient or family or to size an interface device for a CPAP or BiPap device with or without oxygen."
GAMES Respiratory Committee has requested a face to face meeting with the Medical Board for further clarification. Check back for more details.
CLICK HERE to read the April 2008 Georgia Medical Board newsletter.
From the General Assembly
Click here for Senator Chip Rogers Session Wrap, April 2008.
Amerigroup Retracts Fee Reduction
Click here to see the November 2, 2007 fax from Amerigroup.
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