Facilities reported incorrect UPMC CHC payments for Q1 of 2023. UPMC updated the Q1 2023 CHC rate in June 2023 and began reprocessing claims. Facilities should start to see claims being adjusted if they have yet to start receiving them. No action is required by facilities as long as their claims are on file; however, facilities should monitor claims identified as impacted.
Pennsylvania Proposed July 2023 Medicaid and Community HealthChoices (CHC) Nursing Facility Rates
The PA Department of Health and Human Services (Department) issued a communication on June 22, 2023, regarding the proposed July 2023 fee-for-service rates calculated in accordance with 55 Pa. Code Chapter 1187 regulations and the Centers for Medicare & Medicaid Services (CMS) approved State Plan. The fee-for-service rates also impact the corresponding Community HealthChoices (CHC) minimum fee schedule for nursing facilities. In reviewing the July 1, 2023, rates, the Department noted that the variances between the April 1, 2023, rate, and the July 1, 2023, rates appear to be greater than variances in prior years. No changes have been made in the rate setting process requirements. Therefore, the Department is providing additional background prior to the publication of the public notice of proposed rates to help providers understand the requirements, highlight the public comment process, inform providers of rates to be paid until all final approvals are received and reinforce the Department’s goal to ensure continued access to quality nursing facility services for Medicaid residents.
CMS must approve a State Plan Amendment after working through the payment methodology of the previous quarters. In the period beginning July 1 until the approval is received, the Department will continue to pay the April 2023 rates in both fee-for-service and as part of the HCC minimum fee schedule for nonpublic nursing facilities. The full Department issued communication is viewable here. Any provider with questions may contact Medical Billing Managers Lindsay Esterline or Gina Alifano.
Medicare Target Probe and Educate (TPE)
Target Probe and Educate is one process that a Medicare Administrative Contractor (MAC) can utilize when providers are selected by Medical Review. The review process may include up to three rounds of prepayment or post-payment probe review with education that may result in penalties. The first review round sets the tone. Facilities have 45 days from the date of the Additional Documentation Request (ADR) letter to submit the requested documentation. The Targeted Probe and Educate flowchart can be found here. An overview of the Targeted Probe and Educate process can be found here. Providers needing RKL’s assistance with gathering or analyzing documentation prior to submitting to their MAC may contact Stephanie Kessler.
Novitas — Electronic Billing EDI Smart Edits
Novitas has announced they will be introducing Smart Edits into their electronic billing systems. The enhancement will alert providers of any claims that can be repaired and resubmitted prior to a denial. Messages will be displayed on the 277CA electronic claims acknowledgment response report and may require resubmission of the claim. The introduction of Smart Edits is being done in two phases:
Phase 1 (Effective now): Education mode — Providers should review the Smart Edits list for Part A and Part B to make any necessary changes to your billing practice now to avoid claims being rejected once the edits are turned on in Phase 2.
Phase 2 (Effective date to be determined): Claims Processing mode — Smart Edits will be implemented. Claims may be rejected before entering the claim processing system when errors are identified and may require resubmission of the claim.
Providers should be receiving their 277CA reports after the submission of electronic files. The information included on the report is necessary to understanding and tracking the electronic claim billing process. Novitas’ website has made available the training module for Understanding the 277CA Claims Acknowledgement. It is recommended to check the Smart Edits web page for updates and more information on Phase 2 Implementation.
Aetna Skilled Nursing Facility Concurrent Review Process Change Effective August 1, 2023
Beginning August 1, 2023, the skilled nursing facility concurrent review process is changing for Aetna Medicare Advantage and Dual-Eligible Special Needs Plan in the following states: Connecticut, Delaware, Florida, Georgia, Indiana, Kentucky, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Vermont and West Virginia. Skilled Nursing Facilities that admit Aetna Medicare Advantage and Dual members who reside and receive care in the above mentioned states will return to using the Availity portal for uploading documents directly to Aetna for the following:
Admission Verification — Notification to Aetna of a member’s arrival in the facility, sending a face sheet
Conducting concurrent review process, including providing clinical documentation to Aetna
Join RKL for MDS 3.0 Training
Effective October 1, 2023, the MDS will undergo the first significant change since October 1, 2019. Due to these changes, RKL is offering two unique educational options! Both educational offerings are hybrid, allowing in-person training in our York, PA office and virtual training through the Zoom platform. Option I — August 29 & 30, 2023. RKL will offer a two-day training covering MDS, including the changes coming in October, the importance of MDS accuracy and the overall Resident Assessment Instrument (RAI) process. Attendees can earn 12 nursing CEs. Option II — September 6, 2023. RKL will offer a one-day training that will highlight the MDS 3.0 changes that will be effective October 1, 2023. Attendees can earn six nursing CEs. If you would like additional information on this training and how to register, please contact Stephanie Kessler or Tracy Montag.
PCC Corner — Collections Module
Did you know that there is a collection module in PCC that can be used for tracking collection activity, Medicaid Pending progress, ADRs and sending collection letters?
Security
Security access is needed for access to the Collections Module.
Group access can be provided when new users are added to the database.
Configuration
Group/Template setup allows for filtering accounts in the collection module and for limiting access to users as needed.
Payers are associated with applicable templates so that balances generate to the collection module.
Activities can be added and/or modified to meet organizational standards.
Collection letters can be customized per your organizational collection policy for usage in the database.
Functionality
The Collection module is available in the Management Console as well as within each facility for multi-facility databases.
The Collection module allows for activity notes to be added to the resident’s record for organizational visibility to what is happening with outstanding balances.
Collection follow up activity can be created and monitored on the Upcoming Activity Collections dashboard.
Collection activity notes can be printed on aging reports. Notes can be reviewed prior to or during AR reviews.
Collection letters can be generated within the Collection Module, which provides consistency in when and the type of letters that are being sent.
If your organization is not using the Collection module or not using it fully, RKL would be happy to review the configuration and provide training to staff to allow your organization to take full advantage of this Module within PCC.
Any provider with PCC questions may contact Paula Hynum.
Questions about these updates? Need support to meet requirements?
Contact Stefanie Knaub, RKL Senior Living Services Partner, at 717.590.8648.
RKL LLP, 1800 Fruitville Pike, Lancaster, PA 17601
