There are proposed policy revisions in Medicare payment schedule by American Medical Association (AMA) in collaboration with Centers for Medicare and Medicaid Services (CMS). The aim is to streamline reporting requirements, reduce paperwork, improve workflow and contribute to a better environment for healthcare professionals as well as their Medicare patients.

The provision to alter how documenting & coding (E/M Services) stands out and will be implemented in 2021, worked on by both AMA & CMS with the help of the medical community. This showcases the complexity of the rendered services and the resources required. This is a big step in curbing the documentation burdens in medicine.

This proposal reveals the raised complexity of these services and the means needed to provide them, the significance of this represents an initiative towards reducing administrative burdens in medicine and make it easy for doctors to concentrate on providing quality services to patients. The AMA is fully prepared to help the entire healthcare community system through implementing the simplified method to E/M coding and documentation with an aim to encourage key principles of accessibility, quality, affordability and innovation.

CMS show its pledge in lining up patients over paperwork, collaboration with the medical community is a rigorous effort to further improve former policies and proposals. CMS and AMA is looking forward for further collaboration together with joint aim of providing high-value care to the patients.

As of the signing of Senate Bill 1264 on June 14th, Texas is now among a slew of states that have consumer protection laws in place for Surprise billing.

The bill will be effective as of September 2019 and will focus on getting rid of surprise billing for some specific health plans as well as the mandatory mediation requests and also by implementing limitations on surprise billing information being reported by reporting agencies.

Under the new bill, mediation will not require involvement from the patient at all but instead it will be between the health plan and the provider and it will be managed by an impartial mediator. All types of providers can request help with mediation from the state and the cost of that mediator will be then split between the respective parties. It is then the responsibility of the state to notify the affected parties that are so named in the mediation request. 

As per the legislation, mediation must be started within 180 days of the request being submitted. The new bill also requests health plans to pay any emergency care given by any out of network providers at an established rate that the organization considers reasonable. 

From 26th August 2019 onwards, Blue Cross and Blue Shield of Texas is updating its in-house review process for behavioral health claims that need benefit preauthorization. This should be taken into consideration that updates are for the claim review process only. There is no change in Benefit preauthorization required by particular services and the process for submitting benefit preauthorization requests.
How does these changes have an impact? It must be ensured that claims are billed properly. Remember, for all claims:

• Check eligibility and benefits via an electronic 270 transaction through the Availity's Provider Portal or any preferred vendor portal for each patient before rendering services. This will help in determining if benefit preauthorization is required.
• Before providing services get the benefit preauthorization if there is any required.
• In order to help expedite claim payments it is necessary to bill industry standard codes.

This claim review process is not applicable for claims submitted for HMO, Government Programs or Federal Employee Program members.

The Texas Health and Human Services Commission (HHSC) is preparing to roll out its new provider and enrollment system. With the help of associating and switching some processes and systems, the new Provider Management and Enrollment System (PMES) will reduce administrative burden for providers.

The following processes and systems will be consolidated into the PMES system:

• Manual enrollment processes
• Texas Medicaid Healthcare Partnership (TMHP) systems
• Long Term Care
• Vendor drug program
• HHSC long term services and supports
• Medical transportation program

PMES Rollout Timetable and Feedback Opportunity:
Throughout 2019, the HHSC will be preparing for a March 2020 implementation of the new system:

• May: Provider collaboration and feedback opportunities
• October: User testing
• November: User training
• By March 2020: Fully operational

Providers are encouraged to submit feedback about their needs through the implementation period at this link:  “CLICK HERE”

Benefits of New PMES System for Providers

• Single system to manage information even for providers with different lines of business. Easier to update information and renew enrollment.
• Online “smart” application – providers apply for multiple programs once. Only relevant fields that must be completed will be shown.
• Timeline reduced for enrollment and re-validation. Real-time workflows and electronic validations will reduce submission processing cycles. PMES will issue status alerts and automatic reminders.
  

Read more about the PMES system in this HHSC fact sheet