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Inside this Edition

Continued Presidents Mes-sage

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Bundled Payments 3

Tribute to Alex 6

New Members 9

Member Passes 11

Mid Atlantic 12

Understanding Changes 14

Directory 17

April 2012 Issue

Mountain Talk President's Message - Keith Morgan In an earlier newsletter, I included a quote from Charles Dickens where he said “It was the best of times, it was the worst of times”. As I look back on the 2011-2012 year, a number of ‘best times’ come to mind: We had our winter meeting at a new location, the Embassy Suites in Charleston, it got good marks by those in attendance. We continue to work in a exciting and quickly changing environment of healthcare reform, Stage 2 of Meaningful Use has just been released; providers continue to work toward a seamless delivery of healthcare services. We have transitioned to a new website with the able assistance of Lisa Simmons, it will give us the ability to better track our meetings and attendance. The new website will give us improvements in the development of mailing lists, special notices and newsletters. Some of us had the opportunity to see Bob Miller receive the Frederick Morgan Achievement award for career-long contributions to healthcare finan-cial management and HFMA at ANI in Orlando last year. I had a letter from Richard Clarke, the CEO of HFMA announcing the ap-pointment of Alex McFadden to the National Advisory Council. Linda Dugan has graciously volunteered to ‘scout out’ ANI this year by going to Vegas next month. Sponsorship, Membership and Program committees spent countless hours to provide education and assistance to our members, our Newsletters were ex-cellent, well done all!

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PRESIDENT’S MESSAGE

Continued: We made a conscious effort to involve our vendors and sponsors in the Chapter, we need your support and want you to share in our success. We have gained 31 new members this year! And then there were some ‘worst times’ we experienced: Richard Clarke is retiring as CEO after 26 years in HFMA’s top staff position. We lost Tom Cunningham, someone who many of us worked with at Blue Cross, Tom developed our first website and hosted it through his employers’ data center for many years. We lost Alex McFadden who was a real professional and a nationally recognized asset to HFMA.

It was heartening to have other HFMA chapters represented at Alex’s funeral and Eileen Crow from Na-tional was in attendance. It has been a privilege to be involved with HFMA over the years. In the past thirty years, I started with mainframe computers, transitioned to client server models then to distributed PC based systems. Now eve-ryone is moving to the ‘cloud’, I think there are mainframes hidden up there somewhere! WV HFMA will continue to grow and be recognized as one of the best chapters in HFMA, a leader from one of the Ohio chapters indicated he ‘came to WV to see how to run a good chapter’, I envision that con-tinuing. I am also hopeful that some of the 31 new members will become involved with HFMA, will ‘Step Up” and “Believe to Achieve”. Hope to see you at Stonewall or next fall at Snowshoe, our first meeting in the real mountains!

LTC Ft Lauderdale, Fl April 21-24, 2012 Mini LTC Flatwoods, WV July 12, 2012 Spring Meeting Stonewall Jackson May 16-18, 2012 ANI Las Vegas, NV June 25-28, 2012 Fall Meeting Snowshoe September 26-28, 2012

Calendar of Events

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WILL BUNDLED PAYMENTS ADD VALUE TO THE HEALTHCARE SYSTEM?

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By: Victoria Bergmans, MBA, CHFP

Finance team members in the healthcare sector do an excellent job developing budgets and forecasts, con-ducting detailed analysis of key cost drivers, and projecting medical trends through modeling of historical costs. Critical data is distributed to senior leaders through cost management reports, metrics and KPI dashboards; yet, nobody seems to have a handle on the actual cost of medical care in the U.S. While there is broad agreement that the current fee-for-service (FFS) methodology promotes spending, there seems to be a lack of consensus on what payment model best aligns incentives across the healthcare system to provide value-based care focused on health rather than just disease. Harvard Professor and co-author of Redefining Health Care: Creating Value-Based Competition on Results, Michael Porter, defines value in healthcare as patient results or health outcomes achieved per dollar spent on care. According to Professor Porter, patients, providers and payors all benefit when value improves while the economic sustainability of the healthcare system increases. Value should be the pre-eminent goal in the delivery of healthcare as it is what matters to the patient and unites the stakeholders.

The Accountable Care Act (ACA) created a pathway for the development of patient care and reimbursement models designed to increase value in the delivery of healthcare. The core principle of accountable care is aligning payments, benefits, and other healthcare policies with measurable, meaningful progress in improv-ing healthcare while reducing costs. Section 3021 of the ACA established the Center for Medicare and Medicaid Innovation (CMMI), within the Centers for Medicare and Medicaid Services (CMS). The purpose of CMMI is to collaborate with stakeholders on piloting innovative delivery systems and reimbursement models that improve quality and reduce cost. CMS established the Bundled Payments for Care Initiative (BPCI) as the first initiative in a series of activities focused on care episode redesign. The BPCI program of-fers four categories of models with various degrees of financial risk and gain sharing.

Model 1: Retrospective payment for acute inpatient services. Model 2: Retrospective payment for acute inpatient, physician and post-acute services. Model 3: Respective payment for post-acute services. Model 4: Prospective bundle for hospitals and physicians for acute inpatient services. A bundled payment, or episode-based payment, is defined as “a single negotiated episode payment of a pre-determined amount for all services (physician, hospital, and other provider services) furnished during an epi-sode of care.” The goal of bundled payments is similar to the Institute for Healthcare Improvement’s (IHI) Triple Aim objectives of improving the health of the population, enhancing the patient experience and reduc-ing the per capita cost of care. Using Model 2 and a knee arthroplasty surgical procedure as an example, the bundled price for an episode of care would include pre-admission services that are billed as part of the hospi-tal stay, hospitalization, surgery, post-acute rehabilitation and follow up care. The current FFS methodology reimburses each provider separately for their part in the episode of care, leading to fragmented care and minimal coordination among the providers. Bundling payments would align acute and post-acute service de-livery, reduce duplicated care and waste, and improve quality outcomes.

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WILL BUNDLED PAYMENTS ADD VALUE TO THE HEALTHCARE SYSTEM?

Continued:

Pricing the bundle of acute and post-acute services delivered during an episode of care requires a thorough un-derstanding of the key cost drivers and resource utilization for the full cycle of care. In order to gain consen-sus and increase trust among stakeholders, sharing historical cost and quality data provides a level of transpar-ency to the process. So what is the starting point in pricing a bundle of care? The first step is to convene the strategic partners to decide what services to include in the bundle and define the episode of care. The strategic partners for the Model 2 knee arthroplasty episode include the interdisciplinary providers from the continuum of care, as well as administrative and financial team members. In the world of project management, clearly defining the “project scope” is critical to getting all of the stakeholders on the same page to accept full ac-countability for outcomes and costs. A project scope outlines the parameters, boundaries and limitations of the project, clarifies assumptions, defines timeframes and identifies exclusions. In the knee arthroplasty episode, defining the episode of care can be viewed as defining the project scope.

Continuing with the Model 2 knee arthroplasty episode, the next steps, which can be completed simultane-ously, are assembling the historical Medicare FFS claims into distinct episodes of care and creating a process map of current care pathways. Organizing claims data from the Medicare limited data set (LDS) file into meaningful episodes of care requires significant database and/or business intelligence programming skills. Health plans utilize commercially available bundling tools, such as the Ingenix Episode Treatment Group, the Thomson Reuters Medical Episode Grouper, and the 3MTM Clinical Risk Grouping software packages to de-velop episode-based rates. Each of these grouper methodologies utilizes an anchoring event, such as an admis-sion into an acute care hospital for a specific Diagnosis Related Group (DRG) to begin the episode. The meth-odologies of grouping assignable acute and post-acute claims in some pre-determined prospective period differ somewhat, but all yield a specific group of billing codes assignable to the anchoring event.

CMS has defined the episode of care for Model 2 as beginning on the admission date, including preadmission testing, and extending to a minimum of 30 days post discharge. Identifying the episodes of care, based on each DRG from the Medicare LDS file is the starting point in analyzing the claims data. The Medicare LDS files for institutional (UB-04) or non-institutional claims (CMS-1500) contain utilization and payment infor-mation on inpatient hospital, outpatient services, skilled nursing facilities, home health agencies, durable medi-cal equipment and Part B claims. If your organization has an advanced analytics department and the expertise to complete the data analysis in-house, the Medicare LDS files are loaded into a database application (e.g., SAS, Oracle or Sybase), since database programs such as Microsoft Access do not have the capacity to handle these files. The other option is to outsource the data analysis to a consulting services partner, such as TRG Healthcare Solutions or Singletrack Analytics. According to Jonathan Pearce, the founder of Singletrack Ana-lytics, his organization has found that the LDS data for the BPCI application requires an enormous amount of programming, which would be difficult to complete in a short period of time. Mr. Pearce indicated the overall data sizes are huge (most of the data sets provided CMS expand to about 30 gigabytes) with calculation nu-ances, such as selection of the correct fields, date timing and others that need to be done correctly. The epi-sode files completed by Singletrack for the BPCI program, including all of the carrier claim level detail have been typically 5 to 12 million records in length. Once the episodes of care are created for each DRG in the

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WILL BUNDLED PAYMENTS ADD VALUE TO THE HEALTHCARE SYSTEM?

Continued:

Medicare LDS file, Singletrack works with the client using an enhanced Excel based analytical tool with drill down capabilities, to assist with pricing of the bundle of care and analysis of the historical episodes of care, in-cluding DRG specific analysis, such as variations in payment per DRG.

Another tool designed to assist with decision-making around an episode of care is the PROMETHEUS Payment model, which is based on evidence-informed case rates (ECR). The Healthcare Incentives Improvement Insti-tute (HCI3), which designed and is implementing the PROMETHEUS Payment model, offers a SAS-based freeware analysis package that is partially based on that model, to assist BPCI applicants with analysis of the Medicare FFS claims data. The analysis package is free of charge, however, the applicant requires a SAS li-cense, hardware, software and SAS programmers to implement the system. Using well-accepted clinical prac-tice guidelines and best practices, ECRs bundle all covered inpatient and outpatient services for a single episode of care. The bundle is risk adjusted to factor in the patient’s severity of illness and the software generates a price for the bundled episode of care. The foundation of the Prometheus model is that within an episode of care, risks inherent to the patient and risks imputed by the providers in management of the patient’s care can be identified allowing bifurcation of provider technical risk from probability risk. The negative consequences of technical risk are defined as potentially avoidable consequences (PACs) that lead to increased cost for the epi-sode of care. Analyzing technical risk and developing a strategy to avoid preventable complications and read-missions presents an opportunity to improve patient outcomes, enhance patient satisfaction and reduce the per capita cost of care. Examples of PACs in the Model 2 knee arthroplasty episode are readmissions for manual rupture of joint adhesions, debridement of wound infection and revision of knee arthroplasty.

According to the Executive Director of HCI3, Francois de Brantes, feedback received from BPCI applicants utilizing the freeware to complete the BPCI application suggested it was a starting point for organizing and ana-lyzing the CMS data. While applicants reported the freeware as easy to install and user friendly, the run time, which varied from 48 hours to several days due to the size of the CMS files, was the main technical point. The applicants are using the reporting capabilities of the analytic package to develop the episode bid price, identify PACs, and analyze the historical episodes of care.

The BPCI program brings healthcare entities one step closer to aligning reimbursement with value and to un-derstanding cost in relation to quality and outcomes. The Model 2 knee arthroplasty episode includes the total cost of care for the patient’s condition, which requires alignment among the stakeholders. Strategic opportuni-ties to attain the best clinical pathway for the defined episode of care are achieved by engaging the strategic partners in discussion of the data and review of the current state process maps. Developing and implementing bundled payments is extremely complex and not for the faint of heart. However, the applicants in the BPCI program are gaining experience in developing the capacity to implement bundled payments, which may be con-sidered a competition advantage in the near future.

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Tribute to Alex

Alex Jerrold McFadden December 17, 1962 – March 29, 2012

It is with a heavy heart that we the leadership of WV HFMA tell you that we have lost one of our members Alex McFadden. Alex died on Thursday morning at Ruby Memorial Hospital surrounded by his family and friends after a short but courageous fight with cancer. Alex’s passing is such a loss to HFMA and to all of us personally. For so many years his dedication to healthcare and his compassion for making healthcare better at every level was an inspira-tion to all who knew him. Alex was the Director of Patient Access and Patient Financial Services at WVU Healthcare. He was responsible for revenue cycle operations at WVU Hospitals, Scott Avenue and WVUH East in Martinsburg and Ranson. Alex was a past president of the WV HFMA Chapter. He went on to serve as a Regional Executive in Region IV, on the Chapter Advancement Team for National HFMA and just this month was appointed to a National Board position on the Na-tional Advisory Council. Each and every one of you have grand memories of Alex from your encounters with him be it as a speaker at our edu-cational meetings, a traveling companion to HFMA meetings or as a co-worker but most importantly as a friend as Alex never knew a stranger. He was the ultimate professional at all times and he exemplified “Believe to Achieve”. Alex you will be missed but most of all we can smile as we think of your infectious laughter that will never be forgotten. Shared by Bruce McClymonds, CEO WVU HealthSystems: Alex was a part of our hospital family for over 25 years; I worked closely with him nearly all of that time. He was a loyal leader and mentor of many people at the hospital. He held numerous leadership roles, the most recent being the Director of Revenue Cycle Operations. Alex began his career as an analyst in the decision support department. From the beginning, his influence within the organization, driven by his energy, work ethic and creativity, extended well beyond his specific responsibilities. Evi-dence of that is that many who are here today to recognize Alex never worked with him directly, but all were influ-enced by his leadership and presence. Alex’s leadership reached far beyond the hospital. He had a passion for reaching into the community. He was the Board President of the United Way of Monongalia and Preston Counties. He held leadership positions in the Health-care Financial Management Association and was both Speaker of the Year and the Chair of the Charter Advancement Team within HFMA. His selflessness led Alex to volunteer for US Project Literacy as well as to become a Member of Alpha Phi Omega Service Fraternity. Alex had several families and spheres of influence. Today we are celebrating with his family members. Every day Alex blessed his hospital family with his presence, smiles and stories. We will always remember his laughter – and his inability to give up the microphone. The day of his death was a very solemn day at the hospital for all us; you could feel the sadness throughout the facil-ity; it was clearly not the vibrant, fun atmosphere Alex fostered.

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Tribute to Alex

Continued: Probably best said are a few of the quotes you find on Facebook about Alex, such as: We need to all take a look at our lives and take a lesson from you – my friend. One of the best that made us better people because he crossed our path. I’ve never met anyone who embraced and loved life more – I’m a better person for knowing you. Thank you for sharing your huge heart, incredible laugh and intelligence with us. Alex was taken away from us too soon – will miss you terri-bly – but God wanted you with him. Your legacy and your laughter will live on. At a time like this, it’s almost cliché to say that people are irreplaceable and that their memory and legacy will live on. In this case, it’s true. The impact he had on WVU Hospitals and, more importantly, on all of us, was substantial. We are all better from having known and worked with him. Submitted by Jan Strope, Past President of WVHFMA Alex's generous spirit was evident in everything he did for HFMA at the chapter, region, or national level. I always ad-mired his ability to talk to any group, at any time, on any subject without any preparation. Alex was a great leader, a great teacher, and a great mentor. I got to take a lot of fun HFMA trips with him, and we got the chance to meet Lonnie. Alex, we have been blessed to have you in our lives. We love you and will miss you!!

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Want To See Your Name In Print?

Gas prices too high? Back to School Shopping got you down? We can help. How does $250.00 sound?

What do you need to do? Write an article for the WVHFMA Newsletter.

During 2012, we will be accepting articles from WVHFMA members.

Belinda Bennett: belinda_g_bennett@chs.net If you are winner of the best article you can win $250 first prize and $150

for second.

Certification Program

As a member of HFMA, we wanted to ensure that you are among the first to hear that HFMA’s newly improved CHFP certification program is live. The CHFP program is now available online, allowing candidates the ability to purchase study materials and access online resources like the complimen-tary practice exam. The single examination is no longer proctored but can be taken at one of the several hundred sites with Castle Worldwide, HFMA’s support partner. Effective January 2011, the certification requirements are as follows: Successful completion of one comprehensive certification examination designed for mid-level

healthcare finance professionals Minimum of 3-5 years of healthcare finance management experience Current and active HFMA membership Study/preparation materials available online Becoming CHFP certified is more important than ever—it distinguishes you as a leader and role model in the healthcare finance community. Donald P. Schott, FHFMA, AVP-Provider Reimburse-ment, Blue Cross Blue Shield of ND sees immense value in being certified, “HFMA certification has helped me gain the respect of my peers in the healthcare finance profession." We are certain that these changes will provide candidates fewer barriers and a more seamless proc-ess in their pathto certification. For more information on CHFP certification or program changes, please reference the FAQ document,visit us online, or contact the certification office at certifica-tion@hfma.org.

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Whitney R Patterson, Controller John R. Biros, Associate Professor Company: Fairmont General Hospital, Inc. Marshall University Graduate College Work Phone: (304) 367-7109 Work Phone: (304) 746-1941 Email: wpatterson@fghi.com Email: jbiros@marshall.edu Janena M. Davis, Accountant Chris L. Rawlings, CPA Senior Associate West Virginia United Health Systems, Inc. Arnett & Foster P.L.L.C. Work Phone: (304) 368-2714 Work Phone: (304) 346-0441 Email: davisjan@wvuhs.com Email: chris.rawlings@afnetwork.com Sam Heflin, Senior Accountant Eileen Mazzei, Senior Accountant II Fairmont General Hospital Fairmont General Hospital Work Phone: (304) 367-7106 Work Phone: (304) 367-7387 Email: sheflin@fghi.com Email: emazzei@fghi.com Kevin G Tennant, Supervisor of Budget/Reimbursement George G Couch, Vice President Monongalia General Hospital Wheeling Hospital Work Phone: (304) 598-1895 Work Phone: (304) 243-3892 Email: tennantkg@monhealthsys.org Email: gcouch@wheelinghospital.com

Susie M Heston, CPA, Senior Financial Analyst Jane Antulov, Manager Patient Access Fairmont General Hospital, Inc. WVU Healthcare Work Phone: (304) 367-7599 Work Phone: (304) 598-4000 Email: SHeston@fghi.com Email: antulovf@wvuhealthcare.com

Corey Slider, Senior Audit Associate Deborah A Kincell, Patient Account Manager Dixon Hughes Goodman LLP Summersville Regional Medical Center Work Phone: (304) 225-3152 Work Phone: (304) 872-8420 Email: corey.slider@dhgllp.com Email: dkincell@srmcwv.org

Brian Kelbaugh, Chief Finance Officer Melissa D Harper, Business Office Supervisor Summersville Regional Medical Center Grant Memorial Hospital Work Phone: (304) 872-2891 Work Phone: (304) 257-1026 Email: bkelbaugh@srmcwv.org Email: mharper@grantmemorial.com

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Robin Eckhart, Health Care Consultant Arnett & Foster P.L.L.C. Work Phone: (304) 346-0441 Email: robin.eckhart@afnetwork.com Chris G Patella, Vice President Wells Fargo Insurance Services Inc. Work Phone: (304) 636-1574 Email: chris.patella@wellsfargo.com Kimberly A Rogers, Manager Network Operations Coventry Work Phone: (304) 363-7516 Email: KimberlyRogers330@comcast.net

We would like to welcome all of our new members!!

Congratulations!!!

Ohio Valley Health Services & Education Corporation, parent company of Ohio Valley Medical Center and East Ohio Regional Hospital, has received national recognition as an award-winning healthcare system from Amerinet, a leading healthcare group purchasing organization, as part of the company’s fourth an-nual Healthcare Achievement Awards. Out of nearly 5000 healthcare facilities across the country, OVHS&E was one of three hospitals nationwide to receive this year’s Amerinet Healthcare Achievement Award in the category of Finan-cial and Operational Improvement.

OVMC has been recognized as a true leader and innovator in our industry. Con-gratulations and job well done!!!

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Former WV HFMA Member Passes THOMAS MICHAEL CUNNINGHAM Thomas Michael Cunningham, 60, of St. Albans passed away on Friday, March 16, 2012, at his home.

He was preceded in death by his mother, Opal Cunningham.

Thomas is survived by his father, Robert Cunningham; brother, Mark Cun-ningham (Dawn); sister, Diana Cunningham; nieces, Christa and Crystal Cunningham; and his great-nephew, Elijah Cunningham.

Thomas graduated from West Virginia State University with a degree in accounting. He also attended West Virginia Technical Institute and West Virginia University.

Thomas was a director of claims processing for Blue Cross Blue Shield. More recently, he was employed at Gander Mountain.

With an adventurous spirit, Tom set out on many trips and truly lived life to its fullest. In addition to mountain biking, Tom was an avid hiker. He started the "Thru Hike" of the Appalachian Trail in April 2004. Beginning at Springer Mountain in Georgia, he backpacked 2,174 miles, ending his trip six months later when he summated Mount Katahdin in Maine. Tom was also a motorcycle enthusiast. In 2005 he rode the Old Route 66 to California, where he also spent time backpacking.

Tom had a farm he loved; it was his little piece of paradise.

He was a wonderful brother, uncle and great-uncle, and will be sadly missed by all who knew him.

A service honoring Thomas's life will be held 2 p.m. Tuesday, March 20, at Bartlett-Burdette-Cox Funeral Home with the Rev. Johnna Wheaton officiating. Burial will follow the service at Spring Hill Cemetery.

WVHFMA Store Now Open

WV HFMA members can now purchase clothing and other merchandise with the organization’s logo!!

Below are the URLs for you to start shopping.

You can set up an individual account and purchase whatever you like.

There are two logos available—a white logo and a blue/gold logo.

If there is something you would like but don’t see it on the website please contact Lisa Simmons.

Lands’ End - http://ocs.landsend.com/cd/frontdoor?store_name=WV_HFMA&store_type=3 From the Members Area on the WV HFMA site - http://www.wvhfma.org/site/epage/125032_455.htm

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. Kentucky HFMA Welcomes You to the 2012 Region IV Mid-Atlantic Meeting

Join us in August 1 – 3, 2012 at the

Hyatt Regency, downtown Louisville, KY Reservations can be made directly on-line @ https://resweb.passkey.com/go/kyhfma or by calling 1-888-421-1442. Room rate $130 a night Reservation Code: HFMA

Information on the Louisville visit: http://www.louisvilleky.gov/visitors/

Planned Educational Sessions Include:

Day 1: Professional Ethics Day 2: Keynote General Session: “Communication Bleeps and Blunders in Business”

Todd Hunt speaks to organizations that want to add fun to their events and send Members back to work smiling, with tips to improve communication and success.

Reimbursement/Medicare rules effective 10/1/2012 Behavioral health beds in a hospital or not? Healthcare from Cuba MAP Indicators of revenue cycle excellence 12 Labors of Hercules

A different approach to analyzing and solving seemingly overwhelming problems, understand how to manage through difficulty times

CFO Panel representing Virginia, Maryland, and Kentucky Day 3: Keynote General Session from Ralph Lawson, HFMA National Chair Elect

Mr. Lawson will be the HFMA National Chair at the time of the Mid-Atlantic event ICD-10 Part II More To Come………….

Attendees will enjoy our a cruise on the Belle of Louisville down the Ohio River

For information regarding the conference: Contact: Tony Sudduth @ tsudduth@tjsamson.org or Scott Reed @ sreed@blueandco.com

Numerous Sponsorship and /or Exhibitor Opportunities Are Available! For Information Contact Richard Schneider: rschneider@tjsamson.org

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West Virginia Chapter – HFMA 2011-2012 Corporate Sponsors

EMERALD LEVEL HealthCare Financial Services

RUBY LEVEL Arnett & Foster PLLC

West Virginia University Hospitals Helvey & Associates

PNC Bank

SAPPHIRE LEVEL Advanced Patient Advocacy

Highmark Blue Cross & Blue Shield ParrishShaw + Co

Quadax, Inc Wells Fargo Insurance Services

The MASH Program Martin & Seibert, L.C.

The Wellington Group, LLC United Collection Bureau,Inc National Hospital Collections

ParenteBeard Data Image, Inc

McKinley Carter Wealth Services PCB Medical Collections Specialists

PEARL LEVEL NCO Financial Systems

Booth & McCarthy

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Understanding Changes to Medicare Provider Enrollment and CMS-855 Application

By: Leslie Dykman Introduction In order to conform to the more stringent fraud and abuse mandates included in the Patient Protection and Affordable Care Act (PPACA), CMS has updated the 855 Enrollment Application to require more specificity regarding ownership and control; incorporated new screening guidelines into the enrollment process; and has undertaken the revalidation of enrollment information for all providers and suppliers who enrolled in Medicare prior to March 25, 2011. These changes are likely to add complexity for providers in managing the enrollment process. It is important to note that the review and approval of the 855 is no longer considered a clerical function but is now part of CMS’ fraud and abuse pro-gram. Failure to complete the enrollment forms correctly or within the required timeframes can result in the suspension or loss of Medicare billing privileges. Institutional changes which require an 855 include change in ownership, change in practice location, acquisitions/mergers, consolidations, and any change of information, additions or deletions under your current tax identification number. Schedule for Revalidation Revalidation requires providers to certify to the accuracy of existing Medicare 855 Enrollment Application. The revali-dation process is not a new one -- current regulations require all enrolled providers & suppliers to revalidate enrollment information every five years or when necessitated by a change in ownership and/or other reasons (reference 42 CFR § 424.57(e)). CMS is undertaking a phased approach to the revalidation process. During the first phase 89,000 letters were sent to providers who are billing Medicare, but are not currently enrolled in the internet-based Provider Enrollment, Chain and Ownership System (PECOS). Upon receipt of the request to revalidate its enrollment, the provider/supplier has 60 days from the date of the letter to submit complete enrollment information. Institutional providers (including all providers except physicians, non-physicians practitioners, physician group practices and non-physician practitioner group practices) must submit the application fee with the revalidation. The next phase, which is just beginning, will start with a smaller group of providers. Efforts will increase as the Medi-care Administrative Contractors (MACs) ramp up staffing and processes to handle the volume. CMS expects that revali-dation notices will be sent through March 2015. Failure to submit the requested enrollment form within 60-days of re-ceiving a Revalidation Request may result in the deactivation of the provider/supplier’s Medicare billing privileges. New Screening Guidelines Section 6401 (a) of the Patient Protection and Affordable Care Act (PPACA) requires that all new and existing provid-ers be reevaluated under the new screening guidelines in Section 6028. Entities that are either revalidating or newly en-rolling are placed in one of three screening categories – limited, moderate or high—depending on the degree of risk posed to Medicare. The assigned level will determine the degree of screening done by the MAC during the enrollment/revalidation process. The degree of scrutiny increases with the level of risk, with the “high risk” category subject to the current screening pro-tocols as well as a site visit and a fingerprint-based criminal background check (to be implemented at a future date). The “moderate risk” category will be subject to site visits, while “limited risk” screening category procedures remain largely the same. Newly enrolling home health agencies and DMEPOS are the only entities considered at “high risk”; all hos-pices, and existing home health agencies and DMEPOS are considered at “moderate” risk, and hospitals, physicians, medical groups, and ambulatory surgical centers are among those providers classified as “limited” risk.

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Understanding Changes to Medicare Provider Enrollment and CMS-855 Application

Continued: Revisions to Enrollment Application (Form 855) Revisions to the CMS-855 enrollment forms are also a key component in implementing the program integrity require-ments included in the Affordable Care Act. The revamped versions of the Medicare enrollment application, 855A, 855B, 855R, and 855I, new form 855O which was developed for referring physicians, were published in July 2010. The most substantial revisions were made to the 855A, which applies to institutional providers. The new 855A requires the submission of additional information regarding ownership and management control by all enrolling providers. For example:

Providers must now report any deed of trust, or other security interest in the provider equal to five percent (5%) or more of the total property and assets of the provider. This includes investment funds, holding companies, banks and financial institutions, and charitable and religious organizations. Providers must report the entity’s name, address, tax identification number, type of organization, and percentage of interest in the provider. Dates of birth and social security numbers are additionally required for individuals who hold security interests.

Section 5 and 6 covering organizations and individuals with an ownership interest or managing control have been completely revamped, and now require reporting of the “exact” percentage of ownership or control, as well as dates of birth and social security numbers for individuals with controlling interest.

Providers must detail multiple levels of direct and indirect ownership interest and management control, and are

required to submit an organizational diagram identifying all entities listed and their relationships with the pro-vider and each other.

Organizations with an ownership interest or managing control must indicate whether they were “solely created

to acquire/buy the provider and/or the provider’s assets.” All organizations and individuals listed must complete a certification regarding adverse legal actions and convic-

tions. This may impose your facility to implement or enhance existing employee, vendor and clinician screening processes.

Preparing for Revalidation Given the specificity of the information that must now be reported, providers should expect the process to be more com-plex and time consuming than in the past. Providers should prepare for the process by identifying which of the six 855 enrollment forms they must complete, gathering the required information relative to ownership and control, reviewing currently filed 855 enrollment forms for changes that may have or are expected to occur, developing the resources to track and coordinate data for multiple 855 forms, if needed, and to respond to requests for information in a timely man-ner. BESLER is prepared to assist you in preparing for and completing the 855A as your organization confronts changes in ownership or control, a revalidation request, or any other issue relative to obtaining or maintaining Medicare billing privileges. For more information please contact Leslie Dykman at 732-392-8316, or ldykman@besler.com or visit us at www.besler.com.

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SAVE THE DATE - September 26-28, 2012

Please join us for the

“CHANGING SEASONS OF HEALTHCARE MEETING” Snowshoe Mountain Resort

Sponsored by:

West Virginia Healthcare Financial Management Association (WVHFMA)

West Virginia Health Information Management and Systems Society (WVHIMSS)

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Page 17 President Keith Morgan 304-346-0441 Vice President Lisa Ann Simmons 304-598-6247 Secretary Belinda Bennett 304-469-8620 Treasurer Steve Meadows 681-342-3135 Board Members John Yeager 304-368-2760 Rebecca Hammer 304-637-3156 Linda Dugan 304-285-2690 Okey Silman II 304-473-2127 Please feel free to contact us at any time.

Committee Name Chairs Members Advisory Jan Strope Susan Cunningham Linda Dugan John Byrne Mary Ann Brown Jim Holden Awards Jill Epstein Board Officer and Directors Past Presidents Danielle Heston-Raddish Amy Kirk Belinda Bennett Sponsorship Joan Namey l Brenda Glaspell Financial Review Outgoing President Incoming President Angela Coburn Outgoing/Incoming Treasurer Technology Steve Meadows Member Services Linda Dugan Joan Namey Ryan Lindsay Brenda Glaspell Mid Atlantic Julie Shaw Newsletter Belinda Bennett Program and Entertainment Sonja Raddish Diana Cesa Steve Meadows Dan Honebrink Jill Newberry Becky Hammer Susan Cunningham Belinda Bennett Lisa Simmons Carol Haugen Okey Silman John Yeager Linda Dugan Alex McFadden Revenue Cycle Okey Silman Belinda Bennett Jill Epstein Candace Powers Diana Cesa Susan Cunningham Jeanette Steadus Adrienne Crutch