Physical therapist site visits, Georgia Medicaid fair notes, and other updates

Hello everyone! It's been awhile since I've reported changes, however there are always several things going on in the billing world. The reprocessing of claims back in January kept a lot of us busy fixing old claims that Georgia Medicaid's processing system didn't catch all the way back to Oct 2010.

Recently Medicaid had their semi‐annual fair on May 4th in Gwinnett. I've been awaiting answers back from the state to some of my questions before sending out any news. See below some of the details covered this time that I thought were of importance to the majority of my clients and known providers.

Medicaid has a fair twice a year. One is held in Gwinnett during the month of May ﴾usually﴿, the other is usually somewhere during Nov/Dec and often held in Macon. Notifications are put under messages on the web portal when the next fair date is. This notification of the next fair can be anytime months in advance, so watch for notifications in these messages. Power points from the recent Medicaid fair can be found without logging into the web portal under provider information, provider notices

Check your Remittance Advices/EOBs on the web portal within 30 days

Medicaid reminded us several times at this recent fair to make sure RAs ﴾remittance advices/EOBs﴿ are checked every month for reviews/reprocesses. They are not responsible for issues that providers do not catch on an RA that are over 30 days, even if the provider does not enter billing every month. Recently with the issues of the reprocess at the end of January 2016, all sorts of providers were effected, including service coordinators. If you only do your billing once a month or once a quarter, please make sure you check your RA for any unknown issues no matter what.

Claim appeals

Appeals for claims = 30 days from date of denial ﴾dma 520﴿ online only.

Second appeal must be within 30 days of notification of denial of first appeal.

There is no time frame for administrative review to get back to providers for appeals.

Medical records

Documentation should be kept for 6 years ﴾previously we were told it was 5, now it has been changed to 6﴿

Authorizations

CMO PAs submitted via the portal generate a 12 digit GMCF tracking ID that starts with "7". This is not the PA ID used for CMO claims submission or adjudication. Use the tracking number to search for the PA via the portal.

When the CMO approves the PA, the CMO assigns an authorization number. The authorization number is used for claims submission and adjudication.

Member validation fails: This is a hard edit and the PA cannot be entered. If enrollment is verified, send issue to centralizedPA@gmcf.org.

Submit a reconsideration request: Denied PAs and less than 3 days since the denial.

Change of credentialing information

Part I Policy & Procedure Section 105.8 Should the information submitted during enrollment

﴾e.g., office location, change of an address, the payee, etc.﴿ change, the provider must report those changes within ten ﴾10﴿ days of the change

Change of Information "Reminder": A provider or provider group who has moved their practice from one location to another location and the Tax ID remains the same, may use the Change of Information form to update their service locations address. However, a copy of their IRS Form W‐9 must be submitted with the completed Change of Information form.

On site reviews for Physical Therapists

At the Medicaid Fair we were giving notice that physical therapists are seen as moderate risk and now require an onsite visit before a physical therapist can be credentialed as a provider for Medicaid. This became effective 5/1/16.

From the power points presented at the Medicaid fair:

A Physical Therapist or Physical Therapist group that is also enrolled in Medicare with the same practice locations and the Medicare assigned risk category is "moderate" or "high" ﴾i.e., the provider is also subject to a site visit by Medicare﴿, DCH PE is then not required to conduct a site visit. The site visit will be verified in the Provider Enrollment, Chain and Ownership System ﴾PECOS﴿ and the 12‐month rule does not apply.

If the private practice physical therapist's practice location is his or her home address and it exclusively performs services in patients' homes, nursing homes, etc., no site visit is necessary.

At the time when this information was giving at the fair, the state didn't know the details for this new regulation. I emailed the director of Provider enrollment at DCH to ask the following questions:

Does the policy effect only clinics owned by physical therapist or clinics that have therapists working in a clinic/individual? Any clinic that has a physical therapist working within the group

When will these evaluations be due by? Site visits will occur for new enrollment, revalidation/recredentailing and additional locations.

How do they sign up to have it performed? They do not need to sign up, they will be notified during the application process and our team will know due to the COS that a site visit is due.

50﴿ Moderate Categorical Risk means categories of service that pose a moderate risk of fraud, waste, and abuse to the Medicaid program. These include ambulance service providers, hospice organizations, independent care waiver program, independent clinical laboratories, physical therapists, revalidating home health agencies, and revalidating durable medical equipment providers.

A. Site visits‐ The Division and/or its agent shall conduct unscheduled, unannounced site visits at any or all of the provider's service locations prior to enrollment, post‐enrollment, re‐enrollment, revalidation, or during any period of time in which the provider is enrolled. Site visits will be conducted for providers who are designated as "moderate" or "high" categorical risk providers; however, the Division reserves the right to conduct site visits for any category of service. The purpose of the site visit is to verify that the information submitted to the Division is accurate and to determine compliance with Federal and State enrollment requirements. Based on the results of the site visit, providers may be denied enrollment, suspended or terminated from the Medicaid/PeachCare for Kids program for any of the following, but not limited to:

· Current provider or applicant's service location is not operational;

· Current provider or applicant's service location is not physically located at the address identified in the enrollment application;

If the service location is closed, inoperable, or at a different location other than the address provided in the application at the time of the initial site visit, the Division will conduct a second unannounced site visit. Enrollment will be denied, suspended, or terminated if the service location is closed, inoperable, or at a different location other than the address provided in the application at the time of the second unannounced site visit.

Thanks again for staying in touch, ignoring my spelling and grammar mistakes, passing this along, and sending me any information you guys might have so that I can share as well.