10/9/07

92507 Rate Increase Finally In Effect! 

GSHA representatives Donna Davidson and Jennifer McCullough along with our lobbyists Stan Jones and Helen Sloat succeeded in getting the full rate increase for the speech and language code 92507 from $47.82 to $62.53. This rate increase will be in effect retroactively from 7/1/07 for Medicaid Fee For Service children. The Department of Community Health (DCH) issued a banner message on September 25, 2007 stating this final rate increase. Click here to see this official banner message. This rate increase currently affects Medicaid Fee For Service children only. However, one of the CMO companies, Wellcare, has just notified GSHA that they are in the process of completing the configuration of their computer system to change the 92507 rate to the current Fee For Service Rate of $62.53. Wellcare was unable to estimate when this configuration process will be complete; however, they stated the effective date for reimbursement of this rate will be 10/01/07. Please check with each CMO company to determine if they will honor this rate change.

The rate increase for the 92507 comes after many years of lobbying efforts from GSHA and its representatives. In April, 2004 DCH announced that SLPs were no longer able to bill 2 units of the 92507 code. Prior to this change SLPs were paid $81.98 for a 45-60 minute session when billing CPT code 92507. Starting in April, 2004 the rate decreased to $40.99 for each session. GSHA representatives Donna Davidson and Jennifer McCullough initiated a forceful grass roots effort to restore the SLPs reimbursement rate. After spending countless hours with representatives from DCH and sympathetic legislators, GSHA representatives were able to get money allocated to the 2006 Georgia Budget. Unfortunately the initial money allocation did not cover the expenses for the full rate increase of $62.53. Therefore, effective January 1, 2007 DCH raised the rate for the 92507 code to $46.75. GSHA representatives continued to lobby, and as a result, legislators agreed to allocate additional money to fund the full increase to $62.53.

If you are an SLP who has positively been affected by this rate increase, please consider participating on GSHA's Executive Council or the Association's various committees. Our Association is run by volunteers, and changes such as these would not have occurred without people like Donna and Jennifer donating their time.

Way to go GSHA!! 

9/11/07
GSHA continues to work on issues related to CMO implementation. GSHA representative Donna Davidson is participating in a CMO Coalition made up of interested advocacy and provider groups established to work on the issues related to Georgia Medicaid’s Care Management Organizations. The Governor’s Council on Disabilities is working with the Survey Research Center at the University of Georgia to interview health care providers in Georgia regarding the implementation of the CMO initiative. If you or your administrative staff receives a call from the Research Center please take the time to participate in the short phone survey. In addition, Voices for Children is gathering stories from providers and families. If you know of a family that has had a difficult time obtaining services through the CMOs please encourage them to complete the CMO Story Bank Form by clicking this link http://www.gsha.org/slphealthcare/addlfiles/CMOstorybankformfinal.doc and emailing it to Danielle Hermann at dhermann@georgiavoices.org.

The Department of Community Health does not yet have CMS approval for the rate increase to speech code 92507. The hold up does not apparently relate to the rate increase per se, but to other questions CMS has raised about the school based program and some changes it wants to make to reimbursement for that. However, please remember that when the increase is approved it will be retroactive to July 1, 2007.
 

05/23/07
BCW has been in the process of making changes to their model for several years. In the past few months BCW has held two "stakeholder" meetings, both two day long meetings. Unfortunately members of GSHA were not invited to attend these meetings. When we requested BCW informed us that there was not space for a member of GSHA and assured us that there were SLPs present at these meetings.

On April 25th Jennifer McCullough, Chair of Healthcare for GSHA, was invited to attend a small meeting as part of the Trialliance to discuss these upcoming changes.

Along with other members of the Trialliance we met with Paula Forney and Martha Okafor to discuss issues related to therapy in the program. We were asked for evaluation information such as specific standardized tests that SLPs should be able to use to evaluate BCW children.  We were also asked about ideas for making the IFSP a more functional document that would reflect medical necessity of services. There was discussion about how the team approach might be implemented using a primary service provider to lead the services for a child and how the
IFSP can be a flowing, usable document to meet the needs of BCW documentation, billing to third parties and identifying goals and services for a child. We discussed with them that if therapists are to take on additional roles that these must be well delineated to make clear what services are "direct therapy" and therefore billable to third parties as SLP and what are "coordination and documentation" and therefore not billable to third parties as therapy. We also discussed that any
additional role, such as coordinating service, providers were asked to take on must be compensated fairly. We also made it clear that SLP providers would only be able to participate in a model that would reimburse them as close to the Market value as possible. BCW listened to our concerns and promised to keep us informed as these details were being discussed and implemented.

I realize this doesn't give you a lot of specifics, but right now we are waiting to hear more from BCW on the specifics. There are a lot of rumors, I would suggest waiting for specific information from the state BCW office before taking any action or making any decisions. GSHA will continue to monitor this and advocate for SLPs and the children and families we serve.

GSHA appreciates any feedback from members. Feel free to email Jennifer McCullough at jmccullough@pediaspeech.com with questions or feedback that you would like to share with BCW. Please understand that GSHA is attempting to work with BCW to benefit our members and the children we serve. However, this program is being implemented quickly and any feedback we provide to BCW needs to be done soon.

01/18/07
SLPs Concerned that 92507 Rate Increased Proposed for January 1, 2007 Has Not Yet Occured: 

GSHA has contacted The Department of Community Health asking why the rate increase proposed for January 1, 2007 has not taken effect. Mark Trail, director of Medicaid Services for Georgia, responded that his department is awaiting approval from the the federal government, Center for Medicaid Sercices (CMS). CMS has 90 days to respond to the state and if CMS has questions the "clock starts over". GSHA expressed the associations concern over this additional time delay given they have had the information to submit to CMS for months and Mr. Trail responded that the process had to "progress in sequence". GSHA representatives continue to work with our lobbyists and legislators on a weekly baisis to get this increase approved as well as the proposed increase of $62.53 for future fiscal year budgets. GSHA representative have also contacted representatives at CMS to obtain futher information and are awaiting a response.

New!  01/08/07
UPDATE OF CPT CODE 92507
The Department of Community Health released an Amended Public Notice on November 21, 2006, stating that “Effective for services provided on and after January 1, 2007 and subject to payment at fee for service rates, the Department is proposing to increase the payment rate for the “Treatment of Speech, Language, Voice, Communication and/or Auditory Processing Disorder, Individual” identified as CPT code 92507 from $39.55 to $47.82.” This notice invited Public Comment on this change on December 5, 2006. http://dch.georgia.gov/vgn/images/portal/cit_1210/22/50/69394469Public_Notice_CIS_and_CISS_
Speech_Therapy.pdf

As you will remember, GSHA legislative efforts resulted in legislative approval through the Appropriations process of increasing the rate of CPT code 92507 from $39.55 to $62.53. GSHA Legislative Chair Donna Davidson and GSHA Healthcare Chair, provided public comment to the DCH Board on December 5, 2006.  Click here to see their comments to the DCH Board.  Despite their efforts, the DCH Board approved the recommended increase of CPT code but only to $47.82 on December 14, 2006. GSHA will continue to meet with key legislators to implement legislative intent as written in the state budget.

Georgia Speech/Language, Occupational and Physical therapists continue to have difficulties with the Medicaid CMOs as well as feel for service Medicaid as it relates to both Prior Approvals and payment. The Trialliance is working with Representative Burkholter on drafting legislation that would ensure Medicaid services for children with disabilities. The purpose of this legislation is to establish requirements for basic therapy services for children with disabilities: to provide for definitions, to provide certain Requirements relating to administrative prior approval for services and appeals; to provide for sufficient reimbursement rates for providers of medical assistance services; to provide for related matters; to provide for an effective date; to repeal conflicting laws; and for other purposes. DCH Board members and Legislators are asking for data specifically related to therapy denials and non payment. GSHA will be sending out a mailing requesting specific data related to Medicaid payment and denials. The collection of statewide data on the problems SLPs are experiencing in providing services to children who are Medicaid recipients is critical to GSHA’s legislative effectiveness. Please ensure that you complete these surveys and send them in as soon as possible.

In addition, GSHA has been working with DCH on issues specific to the prior approval process for fee for service Medicaid. Therapists need to check for banner messages. Click here to review information related to PA approval documents.

10/19/06
GSHA CONTINUES WORK TO IMPROVE SOLUTIONS FOR PATIENTS RECEIVING MEDICAID
GSHA representatives Donna Davidson and Jennifer McCullough are continuing lobbying efforts to improve the therapy situation for the children receiving Medicaid in Georgia.  Check out the October 17 issue of the ASHA Leader which reports the trouble Georgia therapists are having with Medicaid.  In an effort to understand the magnitude of denials and barriers to services for the children receiving Medicaid, please help GSHA by clicking here to answer a questionnaire.  The results will be used in lobbying efforts with Georgia Medicaid and the Centers for Medicaid Services (CMS) to explain how the CMO implementation and the Prior Approval process are causing barriers getting the necessary services to the children who need them.  They also may be violating federal Early Periodic Screening and Detection (EPSDT) mandates.

The 92507 code increase from 40.99 to 62.93 is still tentatively scheduled to occur in January 2007.  Georgia Medicaid is required to post a public announcement at the Department of Community Health (DCH) board meeting and submit a State Plan amendment to CMS for approval.  Mark Trail, Director of Medicaid Services, state that this was to be done in September then October.  Unfortunately, the DCH was unable to complete this in time for the October meeting, and is scheduled to present it at the November meeting.  Mr. Trail state that this should still be in time for the implementation in January 2007 if it is approved by CMS.  GSHA representatives will continue to monitor the process.

10/05/06
GSHA LEGISLATIVE AND HEALTHCARE UPDATE
Members of the Trialliance met with Medicaid Staff as well as key staff from each of the Care Management Organizations (CMO) on September 20, 2006 to discuss ongoing issues since the transition to Medicaid Managed Care on June 1, 2006.  

Each of the CMOs indicated that they were not prepared for the number of therapy claims that were received. They stated that they were continually trying to improve their processes and providing training to their Customer Service Representatives.  Wellcare has asked the Trialliance to meet with them monthly to discuss any concerns that we may have. We will be providing input to Amerigroup regarding medical necessity and EPSDT guidelines.

We did learn that although the CMOs must provide the same services that were covered under Medicaid, the code logic may be different. As an example; Medicaid has a code for speech/language therapy, (92507) and a separate code for Augmentative Communication. (92609). As a provider, you may work on both of these during a session with a child and bill both of these codes. The CMO must cover both of these services, but some of the CMO companies’ “code auditing” software may indicate these services may be all covered under 92507, hence you could only bill for that one code during your session. We have asked the CMOs to provide us with a list of codes that they use.

Also, the CMOs will reimburse two evaluations per year. It is important to report results of standardized assessments. Goals must be measurable, specific and written to be addressed during the prior authorization period. If you are writing general long term goals on your plan of care, you may not be showing progress which may trigger questions related to “medical necessity”.

We have obtained contact numbers for you to use if you are not able to get your questions answered through Customer Service Representatives. They are as follows:

A continuing concern for the Trialliance is the CMO interpretation of “medical necessity” as well as interpretation of the federal Early, Periodic, Screening, Diagnosis and Treatment guidelines. We will continue to address these concerns with DCH staff, the CMOS and as necessary Center for Medicaid and Medicare Services.

The Trialliance also spoke to DCH staff about issues and concerns related to Fee for Service Medicaid for children in Aged, Blind and Disabled. Our concerns were related to delays in processing prior authorizations for children as well as denials due to what appears to be “technical” denials. DCH hopes to implement the ability to apply for PA’s through the website within the next 2-3 weeks. We are hoping to be able to attach documents in an electronic format to Georgia Medical Care Foundation (GMCF). They will save time in faxing and hopefully eliminate some of the technical denials therapists are receiving because faxed pages are now not all going through. There have been many format changes that are explained in the October changes of Part II Policies And Procedures For Children’s Intervention Services manual. To view that manual click here.

Please read this manual BEFORE contacting GSHA’s the DCH staff with questions about the process.

GSHA’s Healthcare Chair spoke in length with Doug Colburn, Georgia’s Inspector General who heads up the auditing department for the DCH. This meeting was scheduled by GSHA due to questions posed by our members concerning the possibility of increased auditing to our therapists.

Mr. Colburn reported that every category of service within the Medicaid system is subject to audits. He discussed that the procedure that his department uses to determine what provider to audit is based on a combination of reporting and random audits. Their department runs reports cross referencing areas that could indicate a provider was billing for a service inappropriately. For example he may run a report for billable services and hospital admissions. If they find providers billed for a home or “out patient” service on the same date of service as the Medicaid recipient was in the hospital that his department would audit that provider. He discussed that 90% of the time his department will contact the provider in advance of beginning an audit with their files. He recommends providers not be concerned that their being auditing because they did something incorrectly. There are many “random audits”. Mr. Colburn said it usually takes his department 1 – 1 1/2 days to complete the audit. They will come into the place where the files are located and use hand scanners to scan each of the files. The auditors then give the provider an “exit interview”. Mr. Colburn discussed that they are unable to give the provider detailed information at that exit interview as they have not reviewed the scanned files by that time. After the audit department reviews the files if they find reasons why a specific date of service should not have been billed (i.e. not an update care plan, no note, inappropriate code being billed for the service) than a bill will be issued to the affected provider to reimburse the DCH for the service.

Mr. Colburn discussed that hospital based services for both in-patient and outpatient were to be billed only for acute care. He discussed that he had recommended that Children’s Healthcare of Atlanta have their therapists apply to the Children’s Intervention Services department to allow them to see more chronic illnesses.

Mr. Colburn reported that he had no order from any government official to audit any specific provider. He also discussed that he is waiting a “couple of months” for the Prior Approval (PA) process to develop before he and his department use the paperwork GMCF is receiving by the therapy providers as “reasons to conduct an audit with a specific provider”. For further information on Medicaid audits please email Doug Colburn at dcolburn@dch.ga.gov.

The Trialliance will continue to meet with DCH staff and the CMOs however, we encourage you to bring your concerns to your state legislators as well as the DCH Board.

There has been much support from parent advocates about all of these changes affecting the Medicaid children.  Parent advocates along with concerned providers have spearheaded a “Healthcare Rally” scheduled for Saturday, November 4, at the capital. If these Medicaid changes are negatively affecting the children you treat please contact your legislators and invite them to attend this rally so they may be informed of the issues. For more information contact Heidi J. Moore (heidijmoore@comcast.net) or Marty Smith (brokersdad@hotmail.com).

9/18/06
The Department of Community Health (DCH) has provided tips for therapists attempting to get Prior Approvals on their Medicaid children. Click on "Tips for Submitting Requests for Prior Approval Above Policy Limits" to download the tips.  Remember, this process is for the children in the Fee For Service part of Medicaid, not the CMO children. The DCH staff recommends therapists follow these tips to decrease the number of technical denials that are occurring with this process.

The Trialliance is continuing to lobby with the DCH staff in attempts to streamline the paperwork and correct errors in their systems that are occurring as we submit the paperwork for the PAs. In addition, we are meeting with Medicaid and all of the CMOs on September 20 to discuss issues with contracting, prior authorizations and claims payment. We will post minutes from this meeting on GSHA's healthcare page. Please continue to educate your legislators on the issues surrounding providing therapy services to Medicaid children.

09/05/06
GSHA Continues Advocacy Efforts
GSHA representatives Jennifer McCullough and Donna Davidson continue advocacy efforts with the Trialliance. Working with the CMOs has been a slow but steady process. GSHA is hoping to have a meeting scheduled with each of the CMOs, Medicaid and the Trialliance representatives the week of September 20. The goal of this meeting is to address the mounting concerns regarding the contracting, claims payment and authorization issues surrounding the CMOs. GSHA representatives also joined other therapists and parent advocates and met with Governor Sonny Purdue's staff on September 5th in attempts to continue to inform the governor of the issues surrounding GSHA's members and Medicaid.

The Trialliance met with Mark Trail, Chief of Medical Plans at DCH along with other members on his staff on August 30 to discuss concerns that therapy providers were having with the September 1 changes in the Children’s Intervention Program (CIS) involving implementation of a stricter prior approval process. Representing GSHA was Jennifer McCullough, Chair of Healthcare.  The outcome of the meeting was both positive and promising.  Below is a summary of the proposed changes and or modifications.  Please keep in mind that these are proposed changes and any and all official changes will come from DCH in the form of banner messages or in the revised October 1, 2006 CIS manual.  Banner pages are authoritative chronologically. 

In response to concerns surrounding excessive paperwork, unreasonable and unexplainable denials surrounding medical necessity and potential reimbursement delays due to changes in systems requirements, DCH proposed to make the following changes:

1.       Stream line paper work requirements for prior approval requests to allow for one document which will combine the requirements of the Physician Plan of Care and the Letter of Medical Necessity.  This combined revised document will require one physician signature 

2.       Prescriptions will still be required which are good for six months

3.       Stream line ACS Web Portal application for prior approval to allow for therapist/s to type in see care plan and see progress notes in the “Description of Services Requested” and or in the “Outcomes” text box if the requested information is already stated on the hard copy care plan or therapists evaluation and or progress notes

4.       Medical Necessity is determined by the EPSDT CMS guidelines which provides for therapy services that correct (fix) and or ameliorate (make better)

5.       Georgia Medical Care Foundation (GMCF) will conduct peer reviews provided by discipline specific experienced therapists.  GMCF should give reasons for denials when refusing to grant total request.  They may not offer reasons for only granting partial requests.  Questions surrounding denials should be directed to GMCF who should provide an e-mail address for contacting them with questions. 

6.       IEPs and IFSP are now being requested for peer reviewers to determine if there is duplication in services.  To avoid denials based on presumption of duplicative services and or duplicative billing, therapists will be allowed to explain any justification for services in the “Description of Services Requested” box on the ACS Web Portal Application.

7.       Technical/ Systems concerns which will allow therapists to bill for units for services rendered on the same date of service for procedures that do not need prior approval along with procedures that exceed the threshold and will require prior approvals is still being worked on. 

8.       DCH does not anticipate any delays in reimbursement due to major erroneous system denials.  In the event of such, they are prepared to make mass adjustments. 

9.       Should Therapists experience erroneous denials their ACS Provider Rep and or the liaison should be the first point of contact.  Should there be unresolved issues, they should then be excelled to Sherrie Collins at DCH. (scollins@dch.ga.gov)

10.   For additional questions or concerns always feel free to contact Sherrie Collins or Mark Trail at Medicaid. 

We realize that there still exists concerns surrounding changes in the CIS program.  We are working along with the Tri Alliance to address many of these concerns.  As we make progress we intend to keep you informed on the work that we do.  In the meantime, we hope this is helpful and promising.  Remember that any and all official changes will be communicated by the Department of Community Health.  This update is for informational purposes only.  These are only proposed changes that we hope are helpful in answering some of the questions that you may have.

07/17/06 - CMO Denials
Currently, there are many changes affecting Georgia Medicaid relating to the Managed Care Organizations (CMO) and the Aged, Blind and Disabled (ABD) children. The ABD children are composed of Deeming Waiver and SSI as well as foster children. GSHA has been feverishly working with members of the Trialliance (GOTA, PTAG) in attempts to help minimize the effects of these changes on SLP providers and the clients we treat. It is imperative that every provider is informed about these changes and contacts their legislators. Jennifer McCullough, Chair of GSHA’s Healthcare Committee and Donna Davidson, Chair of GSHA’s Government and Legislative Committee, along with GSHA lobbyists have met many times with representatives from the Department of Community Health (DCH), including Mark Trail, and members of our legislature.

On Thursday, July 13, 20006, Donna Davidson represented the Trialliance at the DCH board meeting and made a public comment discussing the major problems our providers have experienced with the CMO transition and the concern for the proposed “gatekeeper” changes DCH plans to implement in September. The board members, as well as the DCH’s Commissioner, Dr. Medows, were interested in hearing about our issues and the Trialliance members felt the meeting was a good step toward our efforts to minimize the effects of the CMO transition and the “gatekeeper” changes proposed by the DCH.  GSHA members are strongly encouraged to continue discussing these issues with your legislators but it is very important that the information presented to your legislators is accurate. Please make sure that the families you treat also have accurate information related to the issues. For more detailed information about these issues, including talking points, click here.

The next step will be to gather information the board members requested and present it to Dr. Medows. What can you do to help? If you are a provider who has had CMO clients denied for services please fill out GSHA’s denial form so we can gather information about how the CMOs may be in violation of the EPSDT federal guidelines protecting Medicaid services to children. In addition, if you are a provider who submitted a contract in the fall/winter and are still waiting for a returned contract please click here.

The topics we are currently addressing include: CMO contract delays, CMO authorization delays, CMO denial of services, CMO’s policies regarding school-aged children, CMO claims reimbursement, ABD threshold visit decrease, ABD authorization for service and Medical Necessity guidelines, and the 92507 increase effective date.

CMO Contract Delays
Many providers have reported that the CMOs have not returned contracts in a timely manner. This delay has caused difficulty with timely authorizations, claims payment and many other difficulties in the transition to the CMOs. Medicaid representatives are working with Wellcare and PeachState to determine the cause of this delay and determine if providers can get reimbursed for services before they become active in the CMOs system.  If you are a provider who submitted contracts to the CMOs in the fall/winter, please fill out the contract form by clicking here.

CMO Denial of Services
The CMOs have been denying children due to Medical Necessity guidelines. The Trialliance have had many discussions with Medicaid representatives and the CMOs demanding both parties follow the Early Periodic Screening Detection and Treatment (EPSDT) Guidelines (click here for more information on EPSDT). Medical Necessity is not defined in the federal guidelines and therefore must be determined by the state organization. The Trialliance and our lobbyists have argued with Medicaid using rulings from court cases in other states stating that medical necessity is determined by a licensed provider’s recommendations. We continue to have discussions and meeting with Medicaid regarding this point.

CMO’s Policies Regarding School-Aged Children
The CMOs have attempted to limit all children aged 3 years and older from receiving therapies. They stated these children should be eligible to receive services in the school. The Trialliance met with Medicaid and argued this is against EPSDT guidelines. Medicaid agreed that this was true if the child did not have an IEP from the school. Medicaid stated that the services provided by the schools could not be duplicative of the services provided outside the school. Therefore, the CMOs were required to cover “medically necessary” services that were not provided by the schools. Wellcare then issued a “policy” stating providers were required to get letters from the school stating the services were not available at the schools. The Trialliance contacted Medicaid stating that it was not appropriate to request this information for children who were not in school. Wellcare has created a new “policy” that is currently being reviewed by the DCH. The Trialliance has requested a copy of this policy when it is released.

CMO Claims Reimbursment
As providers were beginning to be reimbursed by the CMOs questions arose as to the reimbursement rate. Providers were reimbursed below the known “Medicaid Rate” which is written into the contracts for all three CMOs. The Trialliance researched this issue and discovered that Children’s Intervention Service (CIS) fee for service has been reimbursing providers at the incorrect rate for years. The Medicaid rate is determined by calculating 84.5% of the RBRVS or national Medicare rate for the year 2000. Apparently, CIS calculated the rate incorrectly and thus, the rate in the CIS manual is not 84.645% of the 2000 RBRVS. Consequently, the CMOs are reimbursing providers slightly below the rate listed in the CIS manual. To determine the correct rate of reimbursement for each code used by SLPs click on the following link.

https://www.ghp.georgia.gov/wps/
output/en_US/public/Provider/MedicaidManuals/Sched_Max_Allow_for_Phys_et_al_07-06.pdf


Please note: If a code is not posted in this list of codes but is for CIS (such as 92526) we were told by Medicaid that the CMOs would still be required to reimburse at 84.5% of the 2000 RBRVs rates.

For information regarding the ABD issues please see the Trialliance Talking Points Paper or click here.

06/09/06 - CMO Denials
Georgia Managed Care went into effect on June 1, 2006. We have heard from many colleagues that they are receiving denial for services beyond the month of June. If you have received a Speech Therapy denial please click here to complete the CMO Denial Form.  [You must be a GSHA member to access this form.  You will be prompted for your User Name (first initial and last name) and Password (member number)]. 

GSHA is collecting this information to determine patterns of denial that are inconsistent with the federal EPSDT Guidelines. Each therapist is responsible for working with his/her clients to submit any appeals for the denial decision.

This information is critical.  Also, we suggest that you work with the children’s family to appeal the denial decisions. We have been working with the Department of Community Health to ensure that children receive appropriate services.

If you have further questions about any of GSHA’s speech-language pathology healthcare related issues or would like to participate in this committee e-mail Jennifer McCullough at jmccullough@pediaspeech.com