Medicare Contracting Reform Update:  Pending Changes Affecting Home Health and Hospice Providers Ben Hyman  Minneapolis, M...
Discussion Topics <ul><li>Medicare FFS environment (past, present and future) </li></ul><ul><li>What Medicare Contracting ...
VisionShare ®  overview <ul><li>High-speed Internet solutions for linking providers, Medicare contractors and other payers...
How Medicare Began <ul><li>Medicare started in 1965 </li></ul><ul><li>52 Fee For Service (FFS) contractors  </li></ul><ul>...
Medicare Contracting Reform <ul><li>Official name - Medicare Prescription Drug, Improvement  and Modernization Act of 2003...
Role of FFS Medicare contractors then and now <ul><li>Claims processing </li></ul><ul><li>Provider enrollment </li></ul><u...
Goals of the Medicare Modernization Act <ul><li>Implement contractor reform </li></ul><ul><li>Offer competition for all Me...
Past operational environment <ul><li>26 Fiscal Intermediaries </li></ul><ul><ul><li>Medicare contractors for Medicare Part...
 
 
Once MAC Reform is Completed Before 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 <ul><li>MAC for Jurisdiction 14 will be the payer for Medicare RHHI Jurisd...
Here is how Medicare will be handled in Home Health Region D RHHI Region D will be handled by the MAC for Jurisdiction 6 N...
MAC transitions - startup cycle Noridian took over J 3 in 2006 A/B MAC Jurisdictions - 2006 3
MAC Transitions - cycle one Cycle one, phase II = J1, J2, J7, J13 A/B MAC Jurisdictions – 2007-8 Cycle one, phase I = J4, ...
MAC transitions - cycle two A/B MAC Jurisdictions – 2008-9 11 15 8 6 14 10 9
MAC Transitions – Current Status of all Jurisdictions
Procurement process for payers <ul><li>CMS creates Request for Proposal (RFP) for each Jurisdiction </li></ul><ul><li>Paye...
Some of the MAC awards have been protested <ul><li>Bidders can protest award to Government Accounting Office (GAO) </li></...
FISS data center changes <ul><li>Used to be 15 mainframe data centers </li></ul><ul><li>CMS consolidated workload to 3 Ent...
15 primary Medicare data centers – “pre MAC” Regence BCBS OR EDS Chico EDS (2) Mutual of Omaha Arkansas BCBS NGS BCBS Alab...
Post MAC migration – 3 enterprise data centers CDS – Columbia SC EDS – Tulsa OK IBM – Southbury CT
In addition to the pending MAC transition <ul><li>New Medicare Data Network </li></ul><ul><li>Migration called The WAN Mod...
Official CMS notification – 2/20/09 “ In order to provide a more scalable and secure Wide Area Network (WAN) to support cu...
Medicare connectivity today Medicare Products MAC (Claims & Remits) EDC (FISS) AT&T Frame Relay Network (AGNS/MDNS) HETS E...
WAN Modernization changes CMSnet AT&T MPLS Network EXTRAnet  AT&T MPLS Network (EVPN)  More reliable Greater Security More...
What may change after this is completed Provider Medicare Products HETS Eligibility AT&T Passport 3270 Emulator MAC (Claim...
What if You needed new emulation software for each workstation? $ You had to replace your modem or other connection suppor...
What MAC reform means for all Medicare providers <ul><li>RFPs went out through September 2008 </li></ul><ul><li>Bidders fo...
VisionShare ®  approach to Medicare access today Leverage your existing Internet connection Supports all interactive and b...
Secure Data  Facility VisionShare ®  approach after WAN Modernization CMSnet AT&T MPLS Network EXTRAnet  AT&T MPLS Network...
Questions to ask your IT Department <ul><li>How do we access FISS today? (Modem? Frame Relay Circuit?) </li></ul><ul><li>W...
Questions to ask a potential vendor <ul><li>What do you know about the pending MAC transition that will effect me? </li></...
What we have learned <ul><li>Discussed current and pending changes of Medicare </li></ul><ul><li>Examined how these change...
Thank you!  <ul><li>Questions?  </li></ul>Ben Hyman [email_address] VisionShare , Inc.  612-460-4328
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09 Mar 07 Nj Hca Mac Corrected 4 10 09 Final

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MAC Reform Presentation for Home Care Providers in NJ

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  • 09 Mar 07 Nj Hca Mac Corrected 4 10 09 Final

    1. 1. Medicare Contracting Reform Update: Pending Changes Affecting Home Health and Hospice Providers Ben Hyman Minneapolis, MN VisionShare ® Inc.
    2. 2. Discussion Topics <ul><li>Medicare FFS environment (past, present and future) </li></ul><ul><li>What Medicare Contracting Reform means </li></ul><ul><li>Pending changes within Medicare landscape </li></ul><ul><li>How these changes could affect your Medicare reimbursement process </li></ul><ul><li>What connectivity vendors do and what questions to ask </li></ul>
    3. 3. VisionShare ® overview <ul><li>High-speed Internet solutions for linking providers, Medicare contractors and other payers </li></ul><ul><li>Provides opportunity to speed up the processing of administrative transactions </li></ul><ul><li>Assures the privacy and security of healthcare information </li></ul><ul><ul><li>HIPAA-compliant </li></ul></ul><ul><ul><li>CMS-approved </li></ul></ul>
    4. 4. How Medicare Began <ul><li>Medicare started in 1965 </li></ul><ul><li>52 Fee For Service (FFS) contractors </li></ul><ul><li>Contracts were automatically renewed each year by CMS </li></ul>
    5. 5. Medicare Contracting Reform <ul><li>Official name - Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) </li></ul><ul><li>Biggest Medicare change in 40 years </li></ul><ul><li>Replaces current claim payment contractors with new Medicare Administrative Contractors (MACs) </li></ul><ul><li>The Medicare Administrative Contractor will be the payer for Medicare A, B and RHHI in specific MAC Jurisdictions </li></ul><ul><li>Reduces entities allowed to administrate Medicare </li></ul><ul><li>Reviewed every 5 years (this could mean future transitions) </li></ul>
    6. 6. Role of FFS Medicare contractors then and now <ul><li>Claims processing </li></ul><ul><li>Provider enrollment </li></ul><ul><li>Reimbursement </li></ul><ul><li>Beneficiary and provider customer service </li></ul><ul><li>Appeals </li></ul><ul><li>Provider education </li></ul><ul><li>Payment safeguards </li></ul><ul><li>Financial management </li></ul><ul><li>Information systems security </li></ul>
    7. 7. Goals of the Medicare Modernization Act <ul><li>Implement contractor reform </li></ul><ul><li>Offer competition for all Medicare FFS contracts and regions </li></ul><ul><li>Eliminate duplication in Medicare system </li></ul><ul><li>Simplify processing of Medicare claims and FISS access </li></ul>
    8. 8. Past operational environment <ul><li>26 Fiscal Intermediaries </li></ul><ul><ul><li>Medicare contractors for Medicare Part A </li></ul></ul><ul><li>18 Carriers </li></ul><ul><ul><li>Medicare contractors for Medicare Part B </li></ul></ul><ul><li>4 Regional Home Health Intermediaries </li></ul><ul><ul><li>Medicare contractors for Medicare RHHI </li></ul></ul><ul><li>4 Durable Medical Equipment carriers </li></ul><ul><ul><li>Medicare contractors for Medicare DME </li></ul></ul>
    9. 11. Once MAC Reform is Completed Before After
    10. 12. Specialty Medicare Jurisdictions for DME Noridian NHIC Noridian
    11. 13. Specialty Medicare RHHI Jurisdictions Jurisdiction D Includes New Jersey
    12. 14. For RHHI Providers – new payer workload changes <ul><li>MAC for Jurisdiction 14 will be the payer for Medicare RHHI Jurisdiction A - NHIC will be the new payer </li></ul><ul><li>MAC for Jurisdiction 15 will be the payer for Medicare RHHI Jurisdiction B – Highmark will be new payer </li></ul><ul><li>MAC for Jurisdiction 11 will be the payer for Medicare RHHI Jurisdiction C - under protest </li></ul><ul><li>MAC for Jurisdiction 6 will be payer for Medicare RHHI Jurisdiction D – Noridian won Jurisdiction 6 and is under protest </li></ul>
    13. 15. 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 6 Will handle the workload of Region D
    14. 16. MAC transitions - startup cycle Noridian took over J 3 in 2006 A/B MAC Jurisdictions - 2006 3
    15. 17. 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 7 1 2 2 13 Cycle one, phase II = J1, J2, J7, J13 4 5 12 Cycle one, phase I = J4, J5, J12 1
    16. 18. MAC transitions - cycle two A/B MAC Jurisdictions – 2008-9 11 15 8 6 14 10 9
    17. 19. MAC Transitions – Current Status of all Jurisdictions
    18. 20. Procurement process for payers <ul><li>CMS creates Request for Proposal (RFP) for each Jurisdiction </li></ul><ul><li>Payers submit their response to the RFP, if they choose to bid on the Jurisdiction </li></ul><ul><li>If accepted, will be awarded MAC Jurisdiction; if not, they will be eliminated </li></ul><ul><li>If the current Fiscal Intermediary opts out of the bidding process, they may leave early (examples: BCBS of AZ, CareFirst, Premera, others) </li></ul>
    19. 21. Some of the MAC awards have been protested <ul><li>Bidders can protest award to Government Accounting Office (GAO) </li></ul><ul><li>GAO will review protest over 100 day period </li></ul><ul><li>GAO makes final decision </li></ul><ul><li>Most awards are not overturned </li></ul><ul><li>Review process has pushed out dates of final MAC migrations </li></ul><ul><li>These delays WILL affect Home Health and Hospice providers in Jurisdiction D </li></ul>
    20. 22. FISS data center changes <ul><li>Used to be 15 mainframe data centers </li></ul><ul><li>CMS consolidated workload to 3 Enterprise Data Centers (EDC’s) </li></ul><ul><ul><li>EDS in Tulsa, OK </li></ul></ul><ul><ul><li>IBM in Southbury, CT </li></ul></ul><ul><ul><li>Companion Data Services in Columbia, SC </li></ul></ul><ul><li>Most providers already using assigned EDC </li></ul>
    21. 23. 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
    22. 24. Post MAC migration – 3 enterprise data centers CDS – Columbia SC EDS – Tulsa OK IBM – Southbury CT
    23. 25. In addition to the pending MAC transition <ul><li>New Medicare Data Network </li></ul><ul><li>Migration called The WAN Modernization Act </li></ul>
    24. 26. 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, 2009 Implementation Date: July 31, 2009
    25. 27. Medicare connectivity today Medicare Products MAC (Claims & Remits) EDC (FISS) AT&T Frame Relay Network (AGNS/MDNS) HETS Eligibility Med A Provider Med B Provider Billing Services Clearing House Connectivity Vendor
    26. 28. WAN Modernization changes CMSnet AT&T MPLS Network EXTRAnet AT&T MPLS Network (EVPN) More reliable Greater Security More security requirements for providers and vendors EDCs FISS/DDE MACs Claims/Remits HETS Medicare eligibility “ POTS” for bulletin board claims/remits Provider Connectivity vendor or telephony provider Clearinghouse Bridge built by CMS between the CMSnet and EXTRAnet Region D providers will be asked to select a vendor to send and receive claims and remits
    27. 29. What may change after this is completed Provider Medicare Products HETS Eligibility AT&T Passport 3270 Emulator MAC (Claims & Remits) EDC (FISS) AT&T Frame Relay Network (AGNS/MDNS) Some legacy connectivity components not supported as part of WAN Modernization
    28. 30. 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? $$$$ All of the above? $$$$$
    29. 31. What MAC reform means for all Medicare providers <ul><li>RFPs went out through September 2008 </li></ul><ul><li>Bidders for the new MAC contracts are currently under review for Jurisdiction 6 </li></ul><ul><li>MAC award announcement is imminent for RHHI providers in Jurisdiction D </li></ul><ul><li>Notice will be sent out to all providers within 60-90 days after announcement is made </li></ul><ul><li>You will change where you send your claims and remits </li></ul><ul><li>An approved connectivity vendor will be required </li></ul><ul><li>WAN Changes later this year could also cause disruptions </li></ul>
    30. 32. VisionShare ® approach to Medicare access today Leverage your existing Internet connection Supports all interactive and batch submissions to Medicare Less expensive than standard lease line Provider Internet Secure Data Facility AT&T Frame Relay Network (AGNS/MDNS) EDC MAC HETS
    31. 33. Secure Data Facility VisionShare ® approach after WAN Modernization CMSnet AT&T MPLS Network 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 Provider Internet EDCs FISS/DDE MACs Claims/Remits HETS Medicare eligibility
    32. 34. Questions to ask your IT Department <ul><li>How do we access FISS today? (Modem? Frame Relay Circuit?) </li></ul><ul><li>What are the current costs to access FISS? </li></ul><ul><li>How do we send our claims and get our remits? (Direct via a bulletin board? Clearinghouse? Other vendor?) </li></ul><ul><li>How efficient has the connection been for billing staff? </li></ul><ul><li>Are there plans to add users? Medicare services? </li></ul>
    33. 35. Questions to ask a potential vendor <ul><li>What do you know about the pending MAC transition that will effect me? </li></ul><ul><li>Are you prepared for the pending CMS network upgrade? </li></ul><ul><li>Will I need to make any changes if I stay with you? </li></ul><ul><li>What other delivery methods do you offer? </li></ul><ul><li>How is it priced (per minute? per workstation?) </li></ul><ul><li>How do you enable expansion in either users or services? </li></ul><ul><li>Can you provide a live demonstration of your current access methods? </li></ul>
    34. 36. What we have learned <ul><li>Discussed current and pending changes of Medicare </li></ul><ul><li>Examined how these changes affect your facilities </li></ul><ul><li>Identified the steps you must take to prepare for the transition when it occurs in New Jersey </li></ul><ul><li>Developed questions to ask your IT Department and/or potential vendor </li></ul>
    35. 37. Thank you! <ul><li>Questions? </li></ul>Ben Hyman [email_address] VisionShare , Inc. 612-460-4328

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