New Client Training - Quest Diagnostics · 2017-10-10 · New Client Training Medicare Limited Coverage Policies (MLCPs) and eTrailer Introduction Billing Processes . October, 2017
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New Client Training Medicare Limited Coverage Policies (MLCPs) and eTrailer Introduction Billing Processes October, 2017
New Client Training Medicare Limited Coverage Policies (MLCPs) and eTrailer Introduction Billing Processes
October, 2017
Presenter
Presentation Notes
Hello and welcome to today’s webinar for Quest Diagnostic’s clients. I’m Corrie Alvarez, West Regional Mgr., Revenue Operations for Optum 360, supporting Quest Diagnostics. Today we will be reviewing Medicare Ltd Coverage policies and how our new product, e-trailers, can help you resolve missing information requests in a more efficient manner. We will also discuss how you can use the e-trailers to identify orders that do not meet Medicare coverage rules and the resources Quest provides to help guide your next steps. So, let’s get started! Lastly, I will provide you with the steps to sign up for e-trailers, as well as demonstrate how easy it is to complete an order with missing information, electronically.
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Medicare Limited Coverage Policies (MLCPs)
Navigating the complexities of MLCPs
1. Requests for missing billing information
2. Patients may be billed for testing
Customers struggle with understanding MLCP policies and submit orders that are not supported by Medicare medical necessity policy
Presenter
Presentation Notes
It’s complicated! An understatement, right? The complexities of navigating through Medicare’s website and understanding their policies is difficult and time consuming. You have a lot of competing priorities and I know the top two are servicing your patients and assisting your providers. When your providers order testing on a Mcare patient, Mcare expects that the reason for ordering specific tests will meet their guidelines for medical necessity, or the patient will be informed of their financial responsibility to pay for the testing. If a test is ordered w/o a supportive diagnosis, the order must include an advanced beneficiary notice, known as an ABN. If an ABN is not obtained, Quest Diagnostics will send a missing information request, known as a trailer, to your office. The information requested on this trailer is required in order for Quest to be paid for performing the testing ordered. Frequently, I’m asked why we call this missing information request a trailer. We call it a trailer because these requests follow the results. Quest Diagnostics’ priority is to get you your results, asap. We do not hold up any results due to missing information. We trust that we will work together to resolve any missing or additional information requests on your laboratory orders. Medicare may add, delete or revise their medical coverage policies on a quarterly basis. Medicare publishes a MLCP Coding Policy Manual (copy of the cover on this slide), and you can download it from their website, but it is approx. 2,000 pages long and you would need to keep track of the updates and reprint this manual at least quarterly.
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Coverage variations can create challenges for providers, patients and laboratories - Challenges in determining coverage
1 ICD-10 conversion introduced many new diagnosis codes
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EHRs may not be programmed with all payer policies to alert ordering providers to specific limitations 3
It is difficult to know all coverage policies and coding guidelines for all orderable tests
Quest provides education and tools to help providers to navigate these complexities Quest utilizes an e-Trailer process requesting verification that the most specific, documented reason(s) for ordering testing was provided at the time of order. If additional documented reasons were not provided at the time of order, the client is given an opportunity to update the order before the claim is submitted for payment.
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Patients may not understand why they are being asked to pay for certain tests
Laboratories may be denied payment for testing performed
Presenter
Presentation Notes
There are many challenges with trying to determine proper coverage, obtaining the proper and complete information for billing, meeting medical necessity edits and completing an ABN. On Oct. of 2015, a major change happened with the implementation of ICD-10. When this went into effect, our coding choices went from 14k to over 70k. So, our MLCP edits for laboratory testing went from just a few code choices for each test, to in some cases, hundreds of choices. This makes using paper lists nearly impossible. Electronic health records were to make our workflow easier and more efficient. Although it has helped modernize our world, it has come with added complexities. There are many EHRs to choose from. Some have MLCP edits that can prompt a provider to review the supportive diagnoses for laboratory testing, while others do not. So, Quest Diagnostics has created tools to help streamline your workflow and navigate through these complexities.
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Diagnosis codes on the claim tell the payer why the services are ordered.
Only the provider ordering the services can assign diagnosis codes. (or authorized representative of the ordering provider) All diagnosis codes provided must be documented in the patient medical record
Cooperation among ordering providers and laboratories is critical to reducing errors and denials • Medicare publishes coverage policies for commonly
ordered tests (both nationally & locally)
• Medicaid publishes coverage criteria in handbooks & bulletins
• 3rd Party insurers publish policies
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Diagnosis Resource Information
Medicare NCD
Medicare LCD Preventive Services
Third Party Policy Medicaid Policy
Presenter
Presentation Notes
Medicare expects that services provided, including orders for laboratory testing, meet medical necessity guidelines. A provider must document the intent for ordering laboratory testing in the patient’s medical record, along with the diagnoses supporting the order, and also provide those supportive codes on the laboratory order. Any additional diagnoses given to Quest after the initial order, must also be documented within the patient’s medical order. Look, we are in this together! When there is a Medicare CERTS audit on laboratory testing, CMS requires a copy of the provider’s order, the laboratory results, AND the provider’s medical record for the date the laboratory test was ordered. So, proper documentation is important for us all.
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Coverage varies by test and by payer
Preventive Services (tests ordered to screen for disease) may be covered when specific screening diagnosis codes are supplied
Example: a screening PSA will be covered as a preventive service benefit once every 12 months with dx code Z12.5 (Medicare)
Coverage policies determine when services are considered reasonable and necessary and may be covered when diagnosis codes that support their medical necessity are supplied
Example: PSA is covered when a diagnosis of (BPH) N40.0 is supplied (Medicare)
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Diagnosis Resource Information
Medically Necessary
Non-covered Preventive Services
Other Waiver ABN
Presenter
Presentation Notes
Here is an example of a test having both a coverage policy for diagnostic testing and preventive service coverage when ordered as a screening test. Prostate Specific Antigen Test, aka a PSA, has two polices to consider-medical necessity & frequency. If ordered for screening purposes, it can only be performed once yearly, per patient. If ordered for diagnostic purposes, a specific supportive test is needed to support testing. So, same test, with different policies to consider, based on the reason for testing.
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Coverage varies by test and by payer Services that are not medically reasonable and
necessary to the overall diagnosis and treatment of a condition may not be covered. Examples of non-covered services include:
• Services that exceed published frequency limits • Services ordered for reasons that are not deemed
medically necessary by coverage policy • Services that are not proven effective (investigational) • Services considered bundled or included in payment
of another service* (no patient liability; these are considered NCCI edits)
Patients should be informed of their financial liability when testing will be considered non-covered. Medicare patients are informed via the ABN; other patients are informed via payer specific waivers.
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Diagnosis Resource Information and the role of ABN’s
Medically Necessary
Non-covered Preventive Services
Other Waiver ABN
Presenter
Presentation Notes
Since it is complex, and there are various reasons why a test may not be covered, we believe that patients should be informed of the possibility of any financial liability when it comes to testing, prior to performing the tests, when feasible.
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Vitamin D
Medicare patient visits a Quest PSC
When patients receive a bill!
Ordered for a reason that is not supported by Medicare policy
Ordered for a reason that is supported by Medicare policy
Patient signs ABN and pays list price
Full Medicare reimbursement
Patient pays
Medicare pays
Presenter
Presentation Notes
At our patient service centers, we call PSCs, we are required to obtain an ABN from the patient when we do not have a supportive diagnosis on the laboratory order. When this happens, Medicare is billed and the patient receives a bill for any tests Medicare did not pay for. Very often, these patients will call your office, causing you re-work or extra time to explain to the patient why they received a bill for testing ordered by their provider. If all testing is ordered for reasons Medicare pays for, patients will generally not receive any bill from Quest other than co-pays on certain pathology testing.
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Medicare Coverage Jurisdictions
National & Local Coverage Determinations (NCDs & LCDs)
National Policies (NCDs)
27 National MLCPs Covers all 50 states, Puerto Rico and the
U.S. Virgin Islands Maintained by CMS
Local Policies (LCDs)
12 local Medicare jurisdictions Maintained by individual MACs 7-15 local MLCPs per region
Medicare jurisdictions are determined by the state where the laboratory testing is performed—not where the patient was drawn
Presenter
Presentation Notes
In addition to national Medicare coverage policies, we also have local coverage policies for additional lab tests. Here is how CMS divides their territories. There are 12 jurisdictions, managed by 8 different Medicare contractors, known as MACs. CMS has created National Medicare Necessity Policies that all MACs must follow. CMS then allows each MAC to create local policies based on the ordering practice experience within their specific territory. There are 27 National tests and 7-15 local tests, per region. Our region is covered by Noridian. Adding to the complexity for laboratories, is that Medicare jurisdictions are determined not by where the patient lives or where the laboratory testing is drawn, but, rather where the laboratory testing is performed. Let’s look at some of the tools available to assist you with determining medical necessity on your laboratory orders.
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Use these online resources to help determine coverage before ordering Determining Medicare Coverage in 3 clicks
Quest Sales Aid Quest MLCP Website Regional Policy List MLCP Reference Guides
QuestDiagnostics.com/MLCP
Presenter
Presentation Notes
Our clients may order on-line, these guides to help you with supporting medical necessity. With 3 easy clicks, you are able to obtain help with navigating through our website and review several on-line resources that will assist you with this process. Starting on the left you see a Quest Sales Guide with instructions on the use of these tools, a Medicare coverage and coding guide, a regional policy list and then a series of 1-2 page MLCP reference guides. These guides are available for the most frequently ordered tests. All of these tools are available on our website: QuestDiagnostics.com/MLCP. Let’s take a peek at one of the MLCP reference guides.
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MLCP Reference Guides
• Concise documents that include everything you need to know about the policy
• Includes coverage indications, limitations, frequency and utilization guidelines
• Highlights top 20 most common medically supportive ICD-10 codes that Quest receives from ordering providers
• Available to download on the Quest website for all Medicare Limited Coverage Policies (MLCPs)
Presenter
Presentation Notes
This reference guide is for Vitamin D, one of the most recent tests added to our local Medicare coverage policies. Listening to the voice of our customer, our clients wanted a 1-2 page sheet for the most commonly ordered tests on CMS’s MLCP list. This tool helps you zero in on the most common diagnoses a provider would use for these tests. For example, on the Vitamin D test, there are over 300 diagnoses that would support medical necessity. However, there are only 20 that are used over 80% of the time. So, our customers wanted an easy short reference guide with the most common tests, with the most common diagnoses that would support medical necessity. The tool also provides you with test ordering limitations and utilization guidelines. These are available for downloading on your desktop for fast and easy reference. It is important to remember the Quest Reference Guides are just that – guides that address some commonly ordered scenarios. It may be necessary to go to the CMS website and review policies in their entirety if the reason provided for ordering the test is not listed amongst the most common reasons.
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Accurate claim information improves patient care
Ensure your laboratory orders accurately reflect the reasons why testing is ordered!
Avoid trailers and follow-up calls to verify diagnosis codes Administrative
Work Follow-up phone calls Trailers
Orders with specific and accurate diagnosis information reduces the need for office staff follow-up and holds patients financially responsible only when testing is ordered for non-covered reasons.
Streamline workflow and reduce administrative burden
Avoid delays or cancellations to your test order
Prevent patients from being billed when the test is medically necessary
Presenter
Presentation Notes
So, you can see how providing a complete order with the necessary supportive diagnoses and benefits both the patient and your practice! You can avoid unnecessary rework by preventing trailers and follow-up calls from our office, which may delay the completion of your order. So, the goal is to prevent rework or unnecessary billings to your patient. So you, your patients and Quest Diagnostics are happy! Everyone has a great experience. That’s our goal!
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A new online solution that makes handling billing requests from Quest a lot easier
Introducing eTrailer
Overview eTrailer enables Quest customers to
update missing billing information electronically
Reduces paper missing information requests
Benefits
• Reduce missing information requests, follow-up phone calls and visits
• Resolve billing requests in real-time so you can close out the request immediately
• View all outstanding billing information on one screen by selected category
• Enhance the ability to sort by various categories to work trailers more efficiently
• Alert clients when there are Trailers to be worked
Presenter
Presentation Notes
The most exciting tool available to our clients is our Care360 e-trailer module. This is an on-line, interactive, real time application to help our clients resolve missing information requests, more efficiently. The application allows clients to control their workflow via the multiple sort options that are available. Many of our larger clients appreciate the ability to sort the orders by the ordering providers, or to sort between diagnosis requests and insurance or demographic requests. This allows for different departments or work groups to complete the orders by error type. For example, you could have your coders work the diagnosis requests and your billers work the orders with missing insurance information. Let’s see how easy it really is to complete a request for missing information, electronically.
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Quanum eLabs - eTrailer Launch Page
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Accessing eTrailer from within Quanum eLabs
Presenter
Presentation Notes
For your reference, the instructions for the initial registration and our contact information can be found at the end of the presentation. You will find that the initial registration is quick and easy! After your initial registration, you will be able to directly sign on to the screen here: the e-trailer application page. When you have incomplete orders, you will see a YELLOW stripe across the screen. On this slide, you see it underneath the red arrow. You would follow the instructions and click where it states “launch application”. The application will then take you to the following screen…….
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eTrailer Summary Page
Presenter
Presentation Notes
This is a mock-up page for demonstration purposes. In about the middle of the page on the left hand side, you will see your client name and number. Each client has a unique 8 digit client number. Some clients have more than one client #, so you if you have more than one client #, keep in mind that each client # needs to be separately registered to enjoy the benefits of etrailers for all your orders. This page also indicates that there are 10 entries shown on this page and near the bottom of the patient ls name column , you see there are a total of 33 incomplete orders. You would click on the individual order that you want to complete and on the next page you will see that individual order.
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eTrailer Detail
Presenter
Presentation Notes
On this slide you see the one order that was chosen to complete. Underneath the client number you see the patient name along with the information necessary for you to identify the patient and the specific order in question. The middle box is in red and indicates the information that is needed to complete the order. On this order, there were two pieces of missing information. The physician’s NPI # and a request to review the order to see if the need for any additional diagnosis codes are documented that support the need for the ordered test(s). Let’s now review the screen where you would enter the diagnoses.
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eTrailer Additional Diagnosis Capture
Presenter
Presentation Notes
At the top, there are 10 different boxes where you can enter a diagnosis code. Down below, under Service Summary, are the laboratory tests associated with this order for this patient. Notice the “LCP” flag column on the right? Do you see that red box with a “Y”? This is the specific test that requires the additional supportive diagnosis code. After you add the additional diagnosis code in the first box above where it indicates “diagnosis code”, the next step is to press the Validate MLCP button on the right next to the top large green arrow. This button enables the application to bump against all the hundreds of diagnoses on the CMS website, in real time. This immediately validates that whether medical necessity is established. After you have determined that the diagnosis supports medical necessity, you hit the submit button, located on the bottom of the page. If medical necessity is not established, the order Is not complete and it will not release. This isn’t acceptable. How can they release the order if there are no additional codes?
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Process Update, Select Submit or Enter to Complete Your Update
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Presenter
Presentation Notes
Here on this screen, you will see, where the first green arrow is on the left, that the order was successfully updated. Let’s now look at how you would update the ordering provider’s NPI #
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eTrailer Additional Missing Information
Presenter
Presentation Notes
On the top left box, you will see the ordering provider information received. In the red box to the right, you would simply type in the ordering provider’s NPI#. Do you notice purple boxes? Any of these boxes an be edited, if you find the need to change the original information submitted. For example, you could find that this patient’s dob should not be 12/24. That it should be 11/24. You will be able to enter the corrected information and submit.
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Insurance Drop Down
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Presenter
Presentation Notes
When you need to add, update or change the insurance carrier information on a record, we have this convenient drop down menu that is alphabetized by payer name. You can enter as many letters as you need in the drop down menu to find the correct carrier name.
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How to get a Quanum eLabs account and login credentials
Accessing Quanum eLabs
1. If you do not have a Quanum eLabs account, visit GetCare360.com and follow the account setup
instructions. Please make sure to have your Quest Diagnostics Account Number(s) available to complete the account setup process
2. If you need to add users to an existing Quanum eLabs account, call the Quest Connectivity Help Desk 1-800-697-9302 or contact your Quest Sales Representative
3. If you need to retrieve your user ID or reset your password, use the Forgot User ID and Reset Password link:
4. You can contact your Quest Sales Representative to set up an account
Presenter
Presentation Notes
Here is the information you will need to set up your e-trailer account. You DO NOT have to order laboratory testing via Care360 to use the e-trailer process. You would log on to GETCARE360.com to get started. Following the prompts will be easy
This is what you will see on the initial set-up screen
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Initial Registration Step
Presenter
Presentation Notes
Next, you will see the registration steps listed
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Registration
Presenter
Presentation Notes
Here you will fill in the necessary information to set up your account. On the left side is your practice information Do you see the box marked “I am the physician”? Do not check off that box unless you’d like your physician to complete the missing information requests! You will use the drop down menu under “requestor role”. Press that and you will see a variety of job titles to choose from. Choose the one closest to your title if you do not find an exact match. Enter your name and your email address. And, that’s it! You see. Very easy and user friendly.
Contact your Physician Account Executive (PAE) or your Physician Account Manager
Presenter
Presentation Notes
Here is our contact number and fax number in case you have additional questions about MLCP or the e-trailer process. After today’s presentation, a packet of information will be emailed to you using the email address you used to sign up for this webinar. You will also receive a copy of the slide presentation. I hope you enjoyed today’s presentation and that you found it useful and informative. For any additional support or questions, please feel free to reach out to your sales executive or your billing service specialist. They will be glad to schedule a visit with you. I truly appreciate the time you’ve spent with me today. Thank you.
