09 mar 07 nj hca mac corrected 4 10 09 final
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Ben Hyman Minneapolis, MNVisionShare® Inc.
Medicare Contracting Reform Update: Pending Changes Affecting Home Health and Hospice Providers
Discussion Topics
• Medicare FFS environment (past, present and future)
• What Medicare Contracting Reform means
• Pending changes within Medicare landscape
• How these changes could affect your Medicare reimbursement process
• What connectivity vendors do and what questions to ask
VisionShare® overview
• High-speed Internet solutions for linking providers, Medicare contractors and other payers
• Provides opportunity to speed up the processing of administrative transactions
• Assures the privacy and security of healthcare information
– HIPAA-compliant
– CMS-approved
How Medicare Began
• Medicare started in 1965• 52 Fee For Service (FFS) contractors • Contracts were automatically renewed each year by CMS
Medicare Contracting Reform
• Official name - Medicare Prescription Drug, Improvement
and Modernization Act of 2003 (MMA)
• Biggest Medicare change in 40 years
• Replaces current claim payment contractors with new
Medicare Administrative Contractors (MACs)
• The Medicare Administrative Contractor will be the payer for
Medicare A, B and RHHI in specific MAC Jurisdictions
• Reduces entities allowed to administrate Medicare
• Reviewed every 5 years (this could mean future transitions)
Goals of the Medicare Modernization Act
• Implement contractor reform
• Offer competition for all Medicare FFS contracts and regions
• Eliminate duplication in Medicare system
• Simplify processing of Medicare claims and FISS access
Past operational environment
• 26 Fiscal Intermediaries– Medicare contractors for Medicare Part A
• 18 Carriers– Medicare contractors for Medicare Part B
• 4 Regional Home Health Intermediaries– Medicare contractors for Medicare RHHI
• 4 Durable Medical Equipment carriers– Medicare contractors for Medicare DME
Once MAC Reform is CompletedBefore After
Specialty Medicare Jurisdictions for DME
Noridian NHIC
Noridian
Specialty Medicare RHHI Jurisdictions
Jurisdiction D Includes New
Jersey
For RHHI Providers – new payer workload changes
• MAC for Jurisdiction 14 will be the payer for Medicare RHHI Jurisdiction A - NHIC will be the new payer
• MAC for Jurisdiction 15 will be the payer for Medicare RHHI Jurisdiction B – Highmark will be new payer
• MAC for Jurisdiction 11 will be the payer for Medicare RHHI Jurisdiction C - under protest
• MAC for Jurisdiction 6 will be payer for Medicare RHHI Jurisdiction D – Noridian won Jurisdiction 6 and is under protest
Here is how Medicare will be handled in Home Health Region D
RHHI Region D will be handled by the MAC for Jurisdiction 6
Note: awarded to Noridian and still under protest
Jurisdiction 6Will handle the workload of
Region D
MAC transitions - startup cycle
A/B MAC Jurisdictions - 2006
3
Noridian took over J 3 in 2006
MAC Transitions - cycle one
Cycle one, phase II = J1, J2, J7, J13
A/B MAC Jurisdictions – 2007-8
Cycle one, phase I = J4, J5, J12
4
5
12
Cycle one, phase I = J4, J5, J12
7
1
1
2
2
13
Cycle one, phase II = J1, J2, J7, J13
MAC transitions - cycle two
11
15
8
6
14
10
9
A/B MAC Jurisdictions – 2008-9
MAC Transitions – Current Status of all Jurisdictions
Procurement process for payers
• CMS creates Request for Proposal (RFP) for each Jurisdiction
• Payers submit their response to the RFP, if they choose to bid on
the Jurisdiction
• If accepted, will be awarded MAC Jurisdiction; if not, they will be
eliminated
• If the current Fiscal Intermediary opts out of the bidding process,
they may leave early (examples: BCBS of AZ, CareFirst, Premera,
others)
Some of the MAC awards have been protested
• Bidders can protest award to Government Accounting Office (GAO)
• GAO will review protest over 100 day period
• GAO makes final decision
• Most awards are not overturned
• Review process has pushed out dates of final MAC migrations
• These delays WILL affect Home Health and Hospice providers in Jurisdiction D
FISS data center changes
• Used to be 15 mainframe data centers
• CMS consolidated workload to 3 Enterprise Data Centers (EDC’s)– EDS in Tulsa, OK– IBM in Southbury, CT– Companion Data Services in Columbia, SC
• Most providers already using assigned EDC
15 primary Medicare data centers – “pre MAC”
Regence BCBS OR
EDS Chico
EDS (2)
Mutual of Omaha
Arkansas BCBS
NGS
BCBS Alabama
BCBS Florida
Verizon
PalmettoGBA
Highmark
IBM
Empire
CIGNA
Post MAC migration – 3 enterprise data centers
CDS – Columbia SC
EDS – Tulsa OK
IBM – Southbury CT
In addition to the pending MAC transition
• New Medicare Data Network
• Migration called The WAN Modernization Act
Official CMS notification – 2/20/09
“In order to provide a more scalable and secure Wide Area Network (WAN) to support current and future CMS business needs, CMS is phasing out the current Medicare Data Communications Network (MDCN). The MDCN is a legacy Frame Relay network that does not scale easily and does not meet current security requirements.”
Effective Date: July 31, 2009Implementation Date: July 31, 2009
Medicare connectivity today Medicare Products
MAC (Claims & Remits)
EDC (FISS)
AT&T Frame Relay Network
(AGNS/MDNS)
HETSEligibility
Med A Provider
Med B Provider
Billing Services
Clearing House
Connectivity Vendor
WAN Modernization changes
CMSnetAT&T MPLS
Network
CMSnetAT&T MPLS
Network
EDCs FISS/DDEMACs
Claims/Remits
HETS Medicare eligibility
EXTRAnet AT&T MPLS
Network(EVPN)
EXTRAnet AT&T MPLS
Network(EVPN)
“POTS” for bulletin board claims/remits
Provider
Connectivity vendor or telephony provider
Clearinghouse
Bridge built by CMS between the CMSnet and
EXTRAnet
More reliable Greater Security
More security requirements for providers and vendors
Region D providers will be asked to select a vendor to send and receive claims and remits
What may change after this is completed
Provider
Medicare Products
MAC (Claims & Remits)
EDC (FISS)
AT&T Frame Relay Network
(AGNS/MDNS)
HETSEligibility
AT&T Passport
3270 Emulator
Some legacy connectivity components not supported as part of WAN Modernization
What if
You needed new emulation software for each workstation?
$
You had to replace your modem or other connection support hardware to access the new Medicare Network?
$$
Maintain two connections as you transition from the old to the new network?
$$$
These changes caused delays in your Medicare reimbursements?
$$$$
All of the above? $$$$$
What MAC reform means for all Medicare providers
• RFPs went out through September 2008
• Bidders for the new MAC contracts are currently under review for Jurisdiction 6
• MAC award announcement is imminent for RHHI providers in Jurisdiction D
• Notice will be sent out to all providers within 60-90 days after announcement is made
• You will change where you send your claims and remits
• An approved connectivity vendor will be required
• WAN Changes later this year could also cause disruptions
Provider
InternetSecureData
Facility
VisionShare® approach to Medicare access today
AT&T Frame Relay Network
(AGNS/MDNS)
Leverage your existing Internet connection
Supports all interactive and batch submissions to Medicare
Less expensive than standard lease line
EDC
MAC
HETS
Provider
InternetSecureData
Facility
VisionShare® approach after WAN Modernization
CMSnetAT&T MPLS
Network
CMSnetAT&T MPLS
Network
EDCs FISS/DDE
MACs Claims/Remits
HETS Medicare eligibility
EXTRAnet AT&T MPLS
Network(EVPN)
EXTRAnet AT&T MPLS
Network(EVPN)
VisionShare® already connected to new EXTRANet
Required encryption provided by VisionShare® connection
VisionShare® will migrate providers to EXTRANet when required
Questions to ask your IT Department
• How do we access FISS today? (Modem? Frame Relay Circuit?)
• What are the current costs to access FISS?
• How do we send our claims and get our remits? (Direct via a bulletin board? Clearinghouse? Other vendor?)
• How efficient has the connection been for billing staff?
• Are there plans to add users? Medicare services?
Questions to ask a potential vendor
• What do you know about the pending MAC transition that will effect me?
• Are you prepared for the pending CMS network upgrade?
• Will I need to make any changes if I stay with you?
• What other delivery methods do you offer?
• How is it priced (per minute? per workstation?)
• How do you enable expansion in either users or services?
• Can you provide a live demonstration of your current access methods?
What we have learned
• Discussed current and pending changes of Medicare
• Examined how these changes affect your facilities
• Identified the steps you must take to prepare for the transition when it occurs in New Jersey
• Developed questions to ask your IT Department and/or potential vendor
Thank you!
• Questions?
Ben Hymanben.hyman@visionshareinc.comVisionShare, Inc. 612-460-4328
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