Current & Timely Notifications

All healthcare practitioners/providers or staff who render healthcare services to Medicare Advantage enrollees or who administer the Medicare Part D Prescription Drug benefit, should complete Fraud, Waste and Abuse (FWA) annually.

The training should be documented by the healthcare providers and captured by The Health Plan as well as other health plans with Medicare Advantage plans.

The training should be completed once per year by December 31. The training will be accepted if taken on the CMS MedLearn website, or FWS training provided through your organization. If you or your staff have completed Fraud, Waste and Abuse Training through another healthcare provider or entity, this will suffice. All healthcare practitioners/providers and employees that have taken the training should attest to the completion of the training by completing The Health Plan Attestation Form.

Once you and your staff have completed your training, complete The Health Plan - Fraud, Waste and Abuse Training Attestation Form

• Fraud, Waste and Abuse Tool provided online by CMS 
  Please visit CMS; locate "Related Links Inside CMS" within the CMS website and select "Web Based Training (WBT) Modules". You will then need to select "Medicare Fraud and Abuse (February 2010)" and being the CMS online training course.
•  The Health Plan Attestation Form - Participating Provider Only

We have also included a Slide Presentation on FWA, a testing tool and answer key if you choose to measure the training by you and your staff. This is NOT a requirement and does not need to be returned to The Health Plan. Please access the Additional Educational Tools to see these additional tools.

Each year during January, CMS releases updated Physician Medicare Fee Schedules. For 2011, CMS made significant changes in values or weights creating a significant impact to the overall Medicare fee structure. The Health Plan bases physician practitioner reimbursement terms on the Medicare fee schedules, accordingly:

1. Effective January 1, 2011, contract terms that pay as a percentage of Medicare have been adjusted and implemented. This result causes individual fee amounts increasing or decreasing based upon CMS determinations.
2. For contract terms that pay based on pre-determined conversion factor, it will be necessary to perform an evaluation of the updated Relative Value Units (RVU's) in order to determine the revised conversion factor for 2011. This evaluation is taking place now and during this evaluation period, The Health Plan will maintain those fees paid on a conversion at 2010 levels. Physicians will be notified at the completion of the analysis. 

If you have specific questions regarding your fees and payment, please contact The Health Plan Provider Relations staff at 740.695.7901.

Effective January 1, 2012, The Health Plan will implement the Centers for Medicare/Medicaid Services (CMS) requirements regarding Advanced Diagnostic Imaging Accreditation. Advanced Diagnostic Imaging includes Diagnostic Magnetic Resonance Imaging (MRI), Computed Tomography (CT), and nuclear medicine imaging such as Positron Emission Tomography (PET).

All services billed for the total procedures or the technical component of the above mentioned procedures are required to have an accreditation from one of the following:

• American College of Radiology (ACR)
• Intersocietal Accreditation Commission
• Joint Commission Accreditation of Healthcare Organizations (JCAHO)

The Health Plan will require a copy of one of the above accreditations to be on file in order to receive reimbursement of the above services. Without the accreditation on file, the services will be denied as not allowed and the member cannot be billed for these services.

For additional information including a list of CPT codes which are in the Advanced Diagnostic Imaging policy, please go to Credentialing & Participation Guidelines, Procedural Manual, or view this Coding Article.

Clinical Laboratory Improvement Amendments (CLIA) is used to regulate all laboratory testing that is performed outside the hospital setting. The objective of the CLIA program is to ensure quality laboratory testing by setting up specific guidelines in performing each lab test based on equipment and tested proficiency of each lab service performed. The reimbursement is determined for each test by verifying the CLIA Certificate assigned to the provider of service by CMS. If the service billed does not match to the CLIA Certificate assigned to that specific healthcare provider, the service will be disallowed and you cannot bill the member for these services. If you receive a denial for lab services, please contact Provider Relations or fax a copy of your current CLIA to 740.699.6169. We will be sending out reminder letters to obtain the current CLIA for each of our healthcare providers. CLIA Certificates are updated every two years.