Clinical Laboratory Improvement Amendments (CLIA) ID ... · - All laboratory services subject to...
Transcript of Clinical Laboratory Improvement Amendments (CLIA) ID ... · - All laboratory services subject to...
Clinical Laboratory Improvement Amendments (CLIA) ID Requirement Policy UpdateSpring 2018
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Agenda
• Overview
• Requirements
• Claims Submission Process
• Compliance
• Summary
• Reference and Contacts
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© 2018 United HealthCare Services, Inc.
Overview
What is CLIA?
A set of laboratory regulations introduced in 1988 by the Centers for
Disease Control and Prevention (CDC), Food and Drug Administration
(FDA) and The Centers for Medicare & Medicaid Services (CMS).
• Clinical laboratories performing a test for the purpose of diagnosis or
treatment are required to be certified.
• Certified laboratories receive a CLIA ID.
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Requirements
UnitedHealthcare’s CLIA policy:
• Applies to:
- All laboratory services subject to the CLIA submitted on either a CMS
1500 claim form or HIPAA 5010 837P claim file
• Requires that:
- All claims for laboratory services subject to the CLIA include the CLIA
ID number for the servicing care provider and the servicing care
provider’s physical laboratory address if that address is different than
the billing care provider’s address listed on the claim
- The billing or servicing care provider address submitted on the claim
must match the address associated with the CLIA ID number.
• Affects:
- All lines of business
• Contains:
- Specific guidance around the claims submission process and CLIA-
specific resource links.
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Claims Submission Process
•
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Claim
Format and
Elements
CLIA
Number
Location
Options
Ordering Provider
Name and
National Provider
Identifier (NPI)
Number Location
Options
Servicing Laboratory Physical
Location
CMS-1500
(formerly
HCFA 1500)
Must be
represented
in field 23
Submit the ordering
care provider name
and NPI number in
fields 17 and 17b.
Submit the servicing provider name, full
physical address and NPI number in
fields 32 and 32A. The servicing
provider address must match the
address associated with the CLIA ID
entered in field 23.
CMS-1500
(formerly
HCFA 1500)
– State of
Virginia
Requirement
Must be
represented
in field 19
Submit the ordering
care provider name
and NPI number in
fields 17 and 17b.
Submit the servicing provider name, full
physical address and NPI number in
fields 32 and 32A. The servicing
provider address must match the
address associated with the CLIA ID
entered in field 19.
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Claims Submission Process – Cont’d
•
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Claim
Format and
Elements
CLIA
Number
Location
Options
Ordering Provider
Name and NPI
Number Location
Options
Servicing Laboratory Physical
Location
HIPAA 5010
837
Professional
Must be
represented
in the 2300
loop, REF02
element
Submit the ordering
provider name and
NPI number in the
2310A loop, NM1
segment.
Physical address of servicing care
provider must be represented in the
2310C loop if it isn’t the same as the
billing address and must match the
address associated with the CLIA ID
submitted in the 2300 loop, REF02.
HIPAA 5010
837
Institutional
Not
applicable for
institutional
claims
Submit the ordering
provider name and
NPI number in 2310A
loop, NM1 segment.
Not applicable for institutional claims
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Compliance
• We may reject or deny any claim as incomplete if it:
- Doesn’t contain the CLIA ID
- Is submitted with an invalid CLIA ID
- Is submitted without the complete servicing care providers demographic
information
• Claim line edits may also be applied if the provider’s CLIA certification type
doesn’t support the billed service code.
• Laboratory service providers who don’t meet the reporting requirements
and/or don’t have the appropriate type of CLIA certificate for the services
reported may not be reimbursed.
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Summary
Applies to all laboratory services that are subject to the CLIA and
submitted using:
• CMS 1500 claim form; or
• HIPAA 5010 837P claim file
Include the CLIA ID number for:
• The servicing care provider
• The servicing care provider’s physical laboratory address if it’s
different than the billing care provider’s address listed on the
claim
Check to make sure:
• The billing or servicing care provider’s address you submit on
the claim matches the address associated with the CLIA ID
number.
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Reference and Contacts
Reference Materials
• UnitedHealthcare Commercial Policies: UHCprovider.com > Policies and
Protocols > Commercial Policies > Reimbursement Policies for
UnitedHealthcare Commercial Plans
• UnitedHealthcare Medicare Advantage Policies: UHCprovider.com >
Policies and Protocols > Medicare Advantage Policies > Reimbursement
Policies for Medicare Advantage Plans
• UnitedHealthcare Community Plan Policies: UHCprovider.com > Policies
and Protocols > Community Plan Policies > Reimbursement Policies for
Community Plans
Key Contacts
• Debra L. Locke, RN, MLT [ASCP], CPC, Process Consultant, UHC Payment
Integrity/ Laboratory SME
• Shelly Woelfel, CLIA Program Manager, UHC Payment Integrity
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Questions?
Thank you!
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The Enterprise Medical Records
(EMR) Program and EMR
Interoperability
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PCA-1-010085-03162018
Agenda
❑ Opening and Purpose
❑ EMR Point of Care, Access and Connectivity
Solutions Overview
• Direct EMR Access
• Structured Clinical Data Exchange
• UHC EMR Point of Care Solutions
❑ Resources and Contacts
❑ Call to Action
❑ Q&A
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Why We Request Medical Records
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UnitedHealthcare often needs clinical information to process claims correctly. We also
conduct a number of reviews for medical necessity, risk adjustment, fraud and payment
integrity, level of care, DRG, compliance regulations and other reasons. Many teams
request medical records, including:
• Clinical Services
• Complex Care
• Eligibility
• Medical Underwriting
• Payment Integrity
• Pharmacy
• Risk Adjustment
• And others
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PCA-1-010085-03162018
The High Cost of Record Requests
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Currently UnitedHealthcare and our vendors make 13 million
medical record requests a year – and that number is growing.
Our care providers often receive multiple requests for the
same information.
Requests from different teams and different lines of business can
be inconsistent, repetitive and confusing.
These requests drive up administrative costs for the care provider
and take time away from patient care.
Care providers are frustrated by delayed claims processing and
spend additional time filing appeals and reconsideration requests.
They frequently contact us about the volume and frequency of
these requests.
Now the UnitedHealthcare Enterprise Medical Record Program is making it easier for care providers to do business with us.
Our goal is to:
• Reduce care provider frustration
• Offer an easy and efficient provider experience
• Improve NPS scores
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PCA-1-010085-03162018
Care Provider Benefits
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The UnitedHealthcare Enterprise Medical
Record Program improves the care
provider experience in multiple ways,
including:
• Lowered administrative costs
• More time to focus on patient care
• Reduction in medical record requests
• Elimination of duplicate requests
• Faster timeframe for accounts receivables
• Drop in the number of pended or denied claims
requiring clinical information
• Reduced filing of appeals and reconsiderations
• Increased revenue for HEDIS and Star Ratings
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PCA-1-010085-03162018
EMR Point of Care, Access and Connectivity Solutions
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1. Direct EMR Access
Information delivery to the EMR by requesting and receiving medical records.
➢ Example:
▪ EMR All Access - Minimizes the need for medical record requests by allowing UHG staff to remotely
retrieve medical records directly from the care provider’s EMR – safely downloading clinical information
such as progress notes, operation reports, labs, radiology results and more.
2. Structured Clinical Data Exchange
Accessing specific sets of patient data from the EMR and receiving that data.
➢ Examples:
▪ Admit Discharge Transfer Documents (ADTs) - By automatically receiving these records, our staff can
address medication errors, Educate members on their prescriptions , and lower the risk for adverse
medication interactions – helping us potentially avoid unnecessary readmissions
▪ 278N for authorization - By automatically receiving these records, we reduce provider abrasion
eliminate inbound and outbound faxes for authorization thus providers see faster aster authorization
decisions with less administrative burden
▪ Health Information Exchanges (HIEs) - We are willing to explore using an HIE for the ADT records and
eligibility/authorization information if it feasible
3. UHC EMR Point of Care Solutions
Transaction-based solutions embedded in the physician work flow with the goal of delivering real-time accurate data to the provider at the point of care.
➢ Example:
▪ PreCheck MyScript (PCMS) - An innovative pharmacy solution providing real time accurate data at time
of prescribing
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Direct EMR Access
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PCA-1-010085-03162018
EMR All Access
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EMR All Access takes the
hassle out of medical record
collection for care providers.
Unlike other technology that only allows
viewing medical records, EMR All Access
allows UHG staff to remotely retrieve
medical records directly from the care
provider’s EMR – safely downloading
clinical information such as progress
notes, operation reports, labs, radiology
results and more.
This direct access to care provider
records is already established in our
Provider Agreements.
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PCA-1-010085-03162018
EMR All Access Benefits
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EMR All Access is secure and compliant – meeting all HIPAA and
other compliance regulations.
Because the care provider is not disrupted, they can:
• Reduce their collection and submission costs
• Lighten their staff’s administrative burden
• Focus on providing care to their patients
• Speed up their accounts receivables
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PCA-1-010085-03162018
EMR All Access Provider Benefits
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Since the EMR All Access pilot was launched, we’ve seen:
• Reduction (up to 55%) percent reduction in claim adjudication turnaround times
• Reduction (60% - 85%) in the number of requests for medical records
• Reduction (up to 82%) in the number of claims denials related to requests for
additional information
Our Community Transitions Program will use it to help with coordination of care post
discharge and medication reconciliation.
“Since the ERM All Access go live, where we have shifted theadministrative burden of clinical data collection toUnitedHealthcare, claims are paying faster and earlier in theirlifecycle and, as an example, the UnitedHealthcare ManagedMedicare product has seen an improvement of 7% in our 60+days-in-accounts receivable category and 7% in our 90+ days-in-accounts receivable category.” Centura Health, Colorado
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Structured Clinical Data
Exchange
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PCA-1-010085-03162018
Admit/Discharge Notification and Discharge Summary Data Exchange Program
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Our new automated data exchange process lets care providers send
over Admit, Discharge, Transfers (ADTs), Discharge Summaries and
prescribed medication lists.
By automatically receiving these records, our staff can:
• Address medication errors
• Educate members on their prescriptions
• Lower the risk for adverse medication interactions – helping us potentially avoid
unnecessary readmissions
Making the Switch
We support multiple industry standard exchange options for setting up an automated
process for sending ADT, Discharge Summaries with Medication list, including
• Standard HL7 format for ADT
• Master Document Management (MDM) process for Discharge Summary
• Medication List sent using Continuity of Care Document (CCD)
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PCA-1-010085-03162018
Other Clinical Structured Data Exchanges
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Health Information Exchanges (HIEs)
Benefit: Provider can, with a single access, provide information to multiple
providers.
Can we get the right data via the Health Information Exchange?
HL7 for Prior Authorization/ 278 NBy automatically receiving these records, we reduce provider abrasion,
eliminate inbound and outbound faxes for authorization.
Benefit: Faster authorization decisions with less administrative burden
Continuity of Care Documents (CCDs)
?
For Internal Use Only
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UHG Current State
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Talking Points
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PreCheck MyScript (PCMS) Facts
• PreCheck MyScript dashboard version is now available through the Link Marketplace.
• PreCheck MyScript Point of Care version is available through the following
EMR partners:
− DrFirst and partner EMRs – Current
− AthenaHealth and NewCrop – May 2018
− RxRevu (Cerner/Epic) and Center X (Epic) July 2018
− Allscripts September 2018
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PCA-1-010085-03162018
Talking Points
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• The functionality of PCMS can be embedded in EMR.
We are looking to use the influence of the provider group with their EMR to request it be
implemented. The following EMRs have or will have the functionality
− DrFirst and their partners – currently has functionality embedded
− Allscripts – currently working to add the functionality
− AthenaHealth – currently working to add the functionality
− NewCrop – currently working to add the functionality
• No cost for providers or staff using the solution
• No “all payer” real-time pharmacy benefits solution exists in the marketplace
• Functionality for UHG patients will only be available via PreCheck MyScript
connectivity
• Available to all providers seeing UHC M&R, C&S and E&I members
Collateral - External
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Externally approved provider materials are available at: https://www.uhcprovider.com/en/resource-library/uhc-enterprise-medical-records.html
Payment Integrity Iowa Administrative Advisory Committee
November 15, 2017
Payment Integrity (PI)
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Payment Integrity delivers solutions that improve healthcare affordability. Our mission is to ensure UnitedHealth Group pays what it owes and to comply with Centers for Medicare and Medicaid Services (CMS) and state program integrity guidelines.
By the responsible party for eligible members
According to terms of the contract
Free of fraudulent and abusive practices
Not in error, waste or duplicate
Payment Integrity ensures the medical claim is paid:
PI FOCUS THROUGHOUT THE CLAIM LIFECYCLE
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AUTOMATION
HIGH DOLLAR
CONTRACT AUDIT
PAYMENT POLICYCOORDINATION OF
BENEFITSFRAUD, WASTE, ABUSE
& ERROR
INJURY COVERAGE COORDINATION
FRAUD, WASTE, ABUSE & ERROR
COORDINATION OF BENEFITS
SUBROGATION
DATA MINING
CREDIT BALANCE RESOLUTION
RECOVERY
PREMIUM AUDIT SERVICES
PI FOCUS
PISERVICES
CLAIMCYCLE
ADVANCED ANALYTICS DRIVES PRECISION
CLAIMSEDITING
ELIGIBILITY VERIFICATION
CLAIM VALIDATION
CLAIM PROCESSING RECOVERY
PROSPECTIVE RETROSPECTIVE
POST-SUBMISSION;PRE-ADJUDICATION
POST-PAYADJUDICATION
POST-ADJUDICATIONPRE-PAY
Why Payment Integrity Requests Medical Records
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By the responsible party for eligible members
According to contractual terms
Free of fraudulent and abusive practices
Not in error, waste or duplicate
Data on the claim form alone is insufficient to validate billing
accuracyCauses of Erroneous Billing
Services Not Performed
Unbundling
Upcoding
Incorrect Coding
Modifier Not Supported
Fraud
Sanctions / Exclusions
• UnitedHealth Group has a fiduciary responsibility to protect our clients and members from the impact of erroneous billing.
• Medical records validate that the services provided are the services reflected on the claim and are properly billed.
• Medicare rules indicate that if it is not documented it is as if the service was not rendered.
Experts estimate 1/3rd of the $3.2 trillion spent on U.S. healthcare in 2015 was either fraudulent, waste and error, or abusive
– Institute of Medicine of the National Academies
Keying Errors
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Medical Record Request Process Overview
Review Approach:1. Pre Payment – Identify and stop high risk claims prior to payment2. Post Payment – Identify and stop high risk claims after payment.
Detect
• Provider- and claim-centric approaches
• Various analytic techniques employed
• Pattern recognition
• Outlier/peer comparison
• Risk scoring
• Predictive modeling
Evaluate
• Determine whether claim properly billed
• Majority of claims stopped require review of documentation (medical records)
Take Action
• Pay or deny claim based on results of documentation review
• Arrange for provider education if warranted
• Recover overpayment if claim already paid
Fraud, Abuse, Waste and Errors
Identify claims and claim patterns that indicate potential for fraud, waste, abuse or errors using sophisticated algorithms and predictive models.
Intentionally misrepresenting or concealing facts to obtain something of valueFraud
Unintentional practices that result in unnecessary costs; providing information on a health care claim in way that improperly uses resources for personal gain or benefit
Abuse
WasteInaccurate payments for services such as unintentional duplicate payments; may include inappropriate utilization and/or inefficient use of resources.
There are times when something that looks like potential fraud, waste, or abuse is really an error made by providers, members, vendors, employees, or contractors.
Error
Medical Record Request Volumes and Perspective
• Payment Integrity has thousands of analytics and algorithms working to detect
Fraud, Waste, Abuse, and Errors.
• From the medical record reviews that result in a denial:
o 94% are attributed to errors that may be subsequently paid as a result of the provider furnishing additional information or submitting a corrected claim.
o 6% are attributed to potential waste or abuse and are not resubmitted for payment.
• Less than 1% of all the claims submitted result in a request for medical records.
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Who is Requesting Medical Records to perform
Payment Integrity Reviews?
• Optum (A UnitedHealth Group company) performs the majority of our prepayment medical record reviews as well as some post
payment reviews.
• UnitedHealthcare also uses several vendors to perform post payment reviews for Hospitals.
• Each letter requesting a medical record and the Determination letter should provide the name of the entity performing the review and
their telephone numbers. The Determination or Findings letter will also have the contact information for any dispute requests.
• Reviews are conducted by Certified Coders
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Vendors
Product Phone Number
Employer & Individual/Commercial
(866) 230-5783
Medicare & Retirement (844) 464-8227
Community & State/Medicaid (800) 864-9084
Oxford (866) 230-8320
Texas ERS, Empire, NY Exchange, UHG Employees
(866) 235-5271
Optum
Vendor Name Phone Number Website
Omniclaim (781) 932-4600 Omniclaim.com
ChangeHealthcare/EquiClaim (630) 282-9300 Changehealthcare.com
Cotiviti/Connolly (800) 530-1013 Cotiviti.com
HMS/HDI (888) 700-3282 Hms.com
CERiS/Corvel (844) 868-0058 Ceris.com/provider-relations/customer-service
MedReview (212) 897-6006 Medreview.us
SCIO Home Health (866) 709-60533DME (866) 628-3488 ext.7411
Sciohealthanalytics.com
Medical Record Requests – Improvements Underway
• Reducing duplicative medical record requests across UnitedHealth Group
• Improving the precision of our medical record requests
• Improving education and collaboration with our providers to identify and
correct trended coding errors.
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LINK and UHC On-Air
• Updates
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Questions and Answers