Medical Fee Schedule: Is Change Always a Challenge?

1. Located at the Greater Richmond Convention Center October24 -25 2017

2. Medical Fee Schedule, Is change always a challenge? Presented By: Tammy Tomczyk, Lesley Wagner, and Drema Thompson Medical Fee Services Department

3. Agenda • The making of the VWC Medical Fee Schedule • Key Considerations for Statutory and Regulatory Provisions • Development of Ground Rules • Data used to develop the fee schedule • Design and Methodology for the fee schedule • Medical Billing and Reimbursement Guidelines • ABCs of Coding for the fee schedule • Medical record documentation • Provider medical claim submission • Prompt payment • Provider and Payor Relations • Medical Fee Services Department • Dispute resolution process • Post Fee Schedule statute limitations • Required forms and documentation

4. Framework of the Medical Fee Schedule Tammy Tomczyk • Key Statutory and Regulatory Provisions • Development of Ground Rules • Design and Methodology • Results

5. Key Statutory and Regulatory Provisions

6. Key Statutory and Regulatory Provisions 7 provider groups are defined for each of the 6 medical communities

7. Key Statutory and Regulatory Provisions

8. Development of Ground Rules

9. Design and Methodology

10. Design and Methodology

11. Results

12. Results

13. Billing and Reimbursement Lesley Wagner • ABCs of Coding for the fee schedule • Medical record documentation • Provider medical claim submission • Prompt payment

14. What’s Changing? Standardized Coding Principles Medical Fee Schedule (MFS) Defined Reimbursement No Change Contracts (PPO, provider agreement) Prima Facie (bill is reasonable and necessary) Prevailing Community Rate (PCR) Uncertain Reimbursement

15. ABCs of Coding for the fee schedule • Standardized coding • CPT • HCPCs • DRG • Modifiers • NCCI

16. Medical record documentation Documentation Guidelines • Legal record and is required • Appropriate Support for diagnostic coding • Determines accuracy in procedure coding • Key element for appropriate reimbursement

17. Provider Medical Claim Submission A Clean Claim is a complete and accurate claim form that includes all provider and member information, as well as records, additional information, or documents needed from the member or provider to facilitate prompt payment.

18. § 65.2-605.1. Payment and Denials • Payment for health care services that the employer does not contest, deny, or consider incomplete shall be made to the health care provider within 60 days after receipt of each separate itemization of the health care services provided. • If the itemization or a portion thereof is contested, denied, or considered incomplete, the employer or the employer's workers' compensation insurance carrier shall notify the health care provider within 45 days after receipt of the itemization that the itemization is contested, denied, or considered incomplete. • The notification shall include the following information: • 1. The reasons for contesting or denying the itemization, or the reasons the • itemization is considered incomplete; • 2. If the itemization is considered incomplete, all additional information • required to make a decision; and • 3. The remedies available to the health care provider if the health care • provider disagrees. • Payment or denial shall be made within 60 days after receipt from the health care provider of the information requested by the employer or employer's workers' compensation carrier for an incomplete claim under this subsection.

19. Provider and Payor Relations Drema Thompson • Medical Fee Services Department • Medical dispute resolution • Required forms and documentation • Administrative Decision Process

20. Medical Fee Services Department • Team – Rachel McIlyar, Hope Hill, Chris Branham, Drema Thompson • Goals • Ensure medical fee schedules are properly executed, monitored, and audited in accordance with the statute. • Establish billing procedures and support reimbursement levels for health care providers treating injured workers. • Provide direction for medical fee schedule disputes as needed. • Provide information and training to the public and trading partners on the medical fee schedule requirements.

21. Medical Fee Dispute resolution • Providers or payers may not dispute a payment because of dissatisfaction with an MFS scheduled reimbursement amount. • Any dispute between a provider and payer over application of the medical fee schedule can be submitted to the Virginia Workers’ Compensation Commission for determination. • Include the appropriate supporting documentation • Explanation of Review • Medical bill with applicable code • Documentation • A request for determination of such disputes should be forwarded to: • Virginia Workers’ Compensation Commission • Attn: Medical Fee Services Department • 1000 DMV Drive • Richmond, VA 23220 • Fax (804) 823-6932 • medicalfeeservices@workcomp.virginia.gov

22. Forms and Notices MFS Dispute Request •  copies of the original and resubmitted bills; •  copies of the explanation of • reimbursement/benefit; •  copies of supporting documentation; and

23. Forms and Notices cont.… MFS Dispute Response Form •  Copies of the bills; •  Copies of the explanation of • reimbursement/benefit; •  Copies of supporting documentation Notice issued for Response • Requestor • Date of Dispute Request • Date of Service • Disputed Amount • Response required in 30 days

24. Administrative Decision The Medical Fee Services Department will make an administrative decision, and provide written notification of its decision to both the provider and the payer within 30 days of receipt of all requested information. This Dispute Resolution process shall be subject to the prompt payment or limitation of claims provisions of Va. Code Section 65.2-605.1.

25. Questions and Discussions