The Maine Lung Cancer Coalition Working Together to Reduce Lung Cancer in Maine
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Maine Lung Cancer Coalition (MLCC) Webinar Insurance Coverage For Low Dose CT Lung Screenings with Barbara Wiggin, MBA, CNMT, CBDT and Angela Criswell, MA July 18, 2018 12-1pm
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Today s Presenters: Barbara Wiggin, MBA, CNMT, CBDT Manager of Imaging Patient Access, Cardiology, Radiation Oncology, Cancer Registry, Nuclear Medicine Services. Barbara has worked in health care for over 16 years managing multiple departments and developing programs with a focus on ensuring we improve patient access, quality care and reimbursement for our services. Angela Criswell, MA Angela Criswell, LCA Senior Manager of Medical Outreach, provides technical assistance to advance lung cancer screening best practices, manages the Screening Centers of Excellence network, and coordinates LCA s partnership in the Kentucky LEADS Collaborative. She serves on the International Association for the Study of Lung Cancer (IASLC) Smoking Cessation and Tobacco Control Committee and previously managed the Kentucky Department for Public Health s Tobacco Prevention and Cessation Program. She taught political science at the college level for 8 years, has an MA from UVA, and is a Certified Prevention Specialist.
INSURANCE COVERAGE FOR LOW-DOSE CT LUNG CANCER SCREENINGS Maine Lung Cancer Coalition Angela Criswell, MA Senior Manager of Medical Outreach
NAVIGATING THE COVERAGE LABYRINTH Sometimes feels like: 10
WHICH PATHS LEAD TO COVERAGE AND WHICH ARE DEAD ENDS? Commercial Insurance ACA-compliant plans Grandfathered plans Medicare Original Medicare Medicare Advantage Medicaid And now, Association Health Plans 11
TWO BIG COVERAGE UMBRELLAS ACA & Medicare 12
PATIENT PROTECTION AND AFFORDABLE CARE ACT Mandates preventive services coverage: Individual and small group plans sold on state or federal exchange Self-Funded Plans (with exceptions) Medicaid Expansion Plans 13
COMMERCIAL PAYERS Mandated under the ACA to cover all USPSTF Grade A & B preventive services without co-pays or cost sharing. Plan holder must stay in network If out of network, cost-sharing applies But 14
GRANDFATHERED PLANS There are some individual and employersponsored plans that are grandfathered (not subject to all ACA requirements such as Essential Health Benefit) The number of grandfathered plans has steadily declined but includes a substantial share of employer-sponsored plans. 15
GRANDFATHERED PLANS Commercial payer must clearly disclose a plan s grandfathered status to plan holders in their Summary of Benefits and Coverage (SBC). The US Department of Labor has suggested template language: Being a grandfathered health plan means that your policy may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing 16
MEDICARE Covered without co-pays or cost-sharing for beneficiaries meeting CMS eligibility criteria. 17
MEDICARE Written order for G0297 must state the following: Beneficiary date of birth Actual pack-year smoking history (number) Current smoking status; for former smokers, # of years since quitting Statement that beneficiary is asymptomatic Ordering physician NPI For G0297, 11 full months must elapse from the date of the last screening. (G0296 has no such timing limitation.) Both G0296 & G0297 will be denied if beneficiary is not between ages 55-77. 18
MEDICARE ADVANTAGE CMS gives Medicare Advantage plans wide latitude to establish own administrative rules and processes. They must cover all Medicare preventive services without co-pays or cost-sharing, just as original Medicare does. As long as in network! If beneficiary goes out of network, cost-sharing may apply. 19
MEDICAID Medicaid Expansion plans must cover all USPSTF Grade A & B Preventive Services without co-pays or cost-sharing. Original Medicaid is not required to cover preventive services States currently receive a 1% Federal Medical Assistance Percentage (FMAP) as an incentive if they elect to cover USPSTF A & B services without copays/cost-sharing. 20
WHAT IT CAN FEEL LIKE: Who covers what, and which codes do I use for which plans? CMS codes are clearly outlined, but commercial plans can set their own coding requirements to establish medical necessity. For example: Z12.2 (Encounter for screening for malignant neoplasm of respiratory organs) 21
WHO CAN HELP? For Medicare Fee-For-Service issues, you can contact your Medicare Administrative Contractor (MAC), Part B Contractor. For Maine, it is: National Government Services, Inc. 888-379-3807, http://www.ngsmedicare.com/ For Medicare Advantage, CMS issued a Memorandum in February 2017 to identify best practice recommendations for MAOs in requesting and obtaining information necessary to make timely and accurate coverage decisions Programs are directed to contact Part_C_Appeals@cms.hhs.gov for more information on this guidance for Medicare Advantage plans. For Commercial Plans, consider reaching out to the Maine Bureau of Insurance at (207) 624-7475 or (800) 300-5000 Coveragerights.org has great, state-specific guidance on the appeals process in Maine. 22
acriswell@lungcanceralliance.org 202-774-5389
LDCT-Lung Screening Billing and Coding
Getting Started Who should be at the table 1. Billing Compliance 2. Coding 3. Revenue Cycle
Start with the CMS Requirements Make sure you can meet the CMS requirements 1 st. Many patients may retire and still participate in the screenings. You may want to keep the process and order the same for both private and CMS patients so if they transition to Medicare there are no concerns. This makes it easier for providers and ensures you are collecting LDCT data in the registry for everyone.
Standardize your Process Standardize the ordering process. Standardize the workflow Create checks and balances
Order for providers to complete outside of our system
Electronic Order
CPT CODES Different Payers are looking for different CPT Codes. Most private payers have switched to G0297 and are no longer using S8032.
Billing codes and Authorizations Insurance Payer LDCT- Lung Screening Code Does the insurance cover? Y/N FG Medicare B G0297 Y Blue Cross G0297 Y Mainecare 71250 Y Aetna G0297 Y FG Aetna G0297 Y FG United Healthcare G0297 Y EBPA G0297 Y Harvard Pilgrim 71250 y Cigna G0297 y United Healthcare GO297 y
CPT CODES Work with your revenue cycle team. They should be able to switch codes per payer so you don t have to worry about it. VERY IMPORTANT Have the rev. cycle team check with each payer on your contract. The pre-authorization requirements will be different depending on the contract you have.
Coding Please note that the following ICD-10 codes are the only codes that meet Medical Necessity for a Lung screening. Z87.891 Personal history of Nicotine Dependence F17.210 Nicotine dependence, cigarettes uncomplicated F17.211 Nicotine dependence, cigarettes F17.213 Nicotine dependence, cigarettes, withdrawal F17.218 Nicotine dependence, cigarettes nicotine-induced disorders F17.219 Nicotine dependence, cigarettes, with unspecified nicotine-induced disorders
Compliance Check All CT orders are checked for compliance, orders and authorization requirements prior to the scan. Denials on claims are reviewed weekly to identify any problems.
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Questions
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