Provider Update
Volume 23, Issue 2
March/April
2006
Payment for Uncompensated Care to Hurricane Victims
Since the disasters caused by Hurricanes Katrina and Rita, many Louisiana providers have incurred significant costs providing health care services to hurricane evacuees and affected individuals who do not have health care coverage through insurance or any other financing mechanism. Federal funds are now available through the Uncompensated Care Costs (UCC) Pool Plan to pay for these services if the provider and the evacuee or affected individual meet the plan criteria.
Eligible Populations
The UCC plan offers reimbursement for services provided to affected individuals (an individual who resides in designated hurricane affected parish) and evacuees (an affected individual who has been displaced to another state) who received health care for which there is no other source of payment. The affected individual or evacuee must be a U.S. citizen or a legal alien.
Eligible Providers
In order to receive reimbursement for covered services, the providers must have been enrolled as a Louisiana Medicaid provider on or before August 24, 2005, and they must have been enrolled on the date(s) of service.
Covered Services
Payment is only available for the following covered services when provided within the state of Louisiana to the eligible population.
� Inpatient and outpatient hospital including ancillary services
� Physician services, outpatient and inpatient
� Mental health clinic services
� Inpatient psychiatric services
� Emergency ambulance services
� Home health services
� Nursing facility services
� Pharmacy
� Laboratory services
� X-ray services
� Hemodialysis services
� Hospice services
� Rural Health Clinic Services
� Federally Qualified Health Clinic Services
� Durable medical equipment (restricted to emergency equipment or supplies only).
Dates of Service
Requests for payment from providers will be accepted for dates of service of August 24, 2005, for Hurricane Katrina, and dates of service of September 23, 2005, for Hurricane Rita, through January 31, 2006. Hurricane Rita claims will be pended until federal funds become available. The last possible date of service for which providers may submit requests for payment was January 31, 2006.
Invoice Submission
An invoice must be "person specific" for each hurricane evacuee and affected individual. Specific instructions for claim submission are provided in the Provider Companion Guide for Disaster UCC Project (Batch and Paper Invoice Submissions) and the UCC Web Applications User Guide located on the
www.lamedicaid.com website.
The two guides and the provider attestation can be downloaded from the following URL:
http://www.lamedicaid.com/provweb1/hurricanereliefpoolplan.htm. The website will also feature any new information about the plan as it becomes available.
A notarized attestation will be required from providers to confirm that:
� The provided services were medically necessary,
� Payment has not been received from any other source,
� No other source will be subsequently billed for the service,
� That they are unaware of any other source of payment, and
� Payment will be accepted as payment in full for the claim.
Katrina invoices will be paid an interim payment of 70% of the Medicaid fee-for-service rate currently on file for the respective service. Additional payments shall be contingent on the availability of funds in the UCC Pool. Providers may submit claims hardcopy, batch or web.
Hardcopy and CD/DVD invoice submissions must be received no later than close of business June 30, 2006. Invoices that are submitted electronically can be accepted until midnight June 30, 2006.
All invoices received after the deadline will be returned to the provider as not timely filed.
All invoice submissions (except electronically), as well as all attestations must be received at the
following address:
Louisiana DHH
HIPAA Section,
8545 United Plaza, Suite 250,
Baton Rouge, LA 70809
Louisiana Medicaid Coverage Ending For Out Of State Recipients
Displaced recipients now eligible to enroll in other states' Medicaid programs
People with health coverage through Louisiana Medicaid or the Louisiana Children's Health Insurance Program (LaCHIP) and who enrolled in similar programs in other states as a result of being displaced by Hurricanes Katrina or Rita will receive notice that they will no longer be covered by Louisiana Medicaid.
Under guidance from the Centers for Medicare and Medicaid Services (CMS), the Department of Health and Hospitals will send letters to Medicaid and LaCHIP recipients living in other states explaining that they have 45 days before their Medicaid coverage in Louisiana ends. This is an extension from the 10 days notice Medicaid normally gives to people when coverage is ending.
Louisiana Medicaid will send the first group of letters to recipients who have signed up for Medicaid in fifteen states that shared their enrollment files with Louisiana. Efforts are still underway to obtain similar files from other states that offered temporary coverage to hurricane evacuees so that similar mailings can be done to those individuals in the coming months. Excluded from this process are enrollees in the Home and Community Based Services Waiver, SSI, and the Medicare Savings Program.
Since each state has its own Medicaid program with different applications and eligibility requirements, individuals must submit a new application for coverage in the state where they are residing. Louisiana will include a list of contact numbers for each state Medicaid program with the letter sent to recipients.
Every state program has different eligibility criteria and covers different services, so questions about coverage in that state should be addressed to that state's program office. All states have
programs for children that are similar to LaCHIP and parents can call 1-877-KIDS-NOW
(1-877-543-7669) toll free to be connected to the program for children in the state where they are residing. More information is available online at:
www.insurekidsnow.gov.
In order for the Medicaid Program to cover a medical service, the provider rendering the service must be enrolled as a Louisiana Medicaid provider. Recipients living out of state are having difficulty finding doctors who will accept the Louisiana Medicaid card.
If an evacuee returns to Louisiana after enrolling in another state's Medicaid program, he or she must re-apply for Louisiana Medicaid. To request an application, people can call the toll free Louisiana Medicaid hotline at 1-888-342-6207 or visit:
www.medicaid.dhh.louisiana.gov.
CommunityCARE Information Update
Due to Hurricanes Katrina and Rita, many CommunityCARE primary care providers (PCPs) have
relocated and may be practicing in different locations. CommunityCARE PCPs are responsible for
providing a medical home to an assigned group of enrollees. If the enrollees cannot locate their PCP, they may not be able to obtain necessary
medical services. In an effort to maintain accurate information to assist enrollees with locating displaced PCPs, it is imperative that the PCPs notify the CommunityCARE Program of changes in their office location, telephone number, mailing address, etc.
CommunityCARE policy states "PCPs must keep the CommunityCARE Program and their CommunityCARE
patients informed of changes that may affect enrollment. Participation in the CommunityCARE Program and the
choices made by enrollees to become linked to a particular PCP were based on the PCP's practice and qualifications at the time of enrollment." PCPs who have a change in address, telephone number, staff, etc. must immediately notify the CommunityCARE Program office by calling the CommunityCARE/Kidmed contractor at 800-609-3888.
Physicians, who are not participating in the CommunityCARE Program, but need to update their provider enrollment information, may obtain the necessary forms in the Address/Telephone Number Change Packet located on
www.lamedicaid.com. All forms and instructions necessary to update the information on the provider's file are contained in this packet.
RA Messages
Sterilization Consent Clarification
In order to facilitate correct submission of the sterilization consent when a premature delivery occurs, the following clarification is provided. "Prematurity" is defined as the state of an infant born prior to the 37th week of gestation. Physicians should use this definition in the completion of the sterilization consent when premature delivery is a factor.
CPT Codes That Require A QW Modifier
Effective with the date of service January 1, 2006, the following CPT codes will be added to the list of codes which require a QW modifier: 80178(Lithium), 86880(Antihuman globulin test [Coombs test]; direct, each antiserum), 83037 (Hemoglobin; glycosylated [A1C] by device cleared by FDA for home use), and 82271(Blood, occult, by peroxidase activity, qualitative; other sources).
Immunization Records Retrieval Center For Hurricane Affected Medicaid Recipients
DHH has established an Immunization Records Retrieval Center to assist Medicaid recipients affected by the hurricanes to access immunization records lost in the hurricanes. Recipients affected by the hurricanes may telephone the Louisiana CommunityCARE/Kidmed hotline 1-800-259-4444 and follow the prompt.
To request a history of immunization claims processed and paid by Medicaid, Medicaid providers may inform Medicaid recipients of this Immunization Records Retrieval Center if records were lost in the hurricanes. Only the recipient, parent, or legal guardian may call to request the records.
Ambulatory Surgical Center Billing
Louisiana Medicaid identified a problem where facility fees for ambulatory surgical centers were being reimbursed at the fee rate for physician services or not assigned to a surgical grouping. Programming is being updated to assign each procedure to a grouping which may result in
reimbursement changes.
Questions & Answer Corner
The Provider Update has established a question and answer corner
to answer questions frequently asked by Medicaid providers.
Question
If a physician provides non-emergent/routine care (i.e. office visit) to a CommunityCARE (CC) enrollee, can I get a CommunityCARE referral/authorization after the fact?
Answer
Providers should not request referral authorization for non-emergent services after the fact. CommunityCARE policy states that providers who are not an enrollee's PCP shall obtain referral/authorizations for non-emergent care from the PCP prior to providing services to a CommunityCARE enrollee. The intent of CommunityCARE is to provide enrollees with a medical home and to receive routine primary health services from that PCP. The linked PCP has the responsibility to coordinate that enrollee's care by referring the enrollee for specialty when medically indicated.
Question
If a provider requests a referral/authorization for services provided to a CommunityCARE enrollee and the PCP does not respond to the request, can the servicing provider bill the recipient?
Answer
The servicing provider cannot bill the recipient for services solely because the PCP did not respond to the request for referral authorization. In order to bill the recipient, the provider must have obtained a "denial or disapproval" of the request prior to providing the service and must have advised the enrollee prior to rendering the services that the enrollee will be responsible for
payment. After the fact referral/authorization for routine non-emergent care is not within program policy and is not considered a valid request.
Question
Can a physician provide services to a CC enrollee prior to receiving an approved referral/authorization from the PCP under the condition that the enrollee will be responsible for payment of the visit if the PCP does not approve the referral/authorization?
Answer
No, policy states referral/authorization for non-emergent services shall be obtained prior to
rendering the service. The recipient's responsibility for payment should be determined prior to
rendering the service.
USEFUL TELEPHONE NUMBERS AND WEBSITES FOR PROVIDERS AND RECIPIENTS
Medicaid
General Medicaid
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http://www.medicaid.dhh.louisiana.gov
Toll Free 1-888-342-6207
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LaCHIP
LaCHIP Hotline
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http://www.lachip.org
Toll Free 1-877-2LaChip (252-2447)
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MMIS/Claims Processing/Resolution Unit:
MMIS/Recipient Retroactive Reimbursement:
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Local (225) 342-3855
Local (225) 342-1739
Toll Free 1 (866) 640-3905
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Medicare Savings Program (MSP) hotline
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Toll Free 1-888-544-7996
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Kidmed and COMMUNITYCARE: ACS
For Hearing Impaired:
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Toll Free 1-800-259-4444
Toll Free 1-877-544-9544
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UNISYS-Provider Relations:
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Toll Free 1-800-473-2783
Local 225-924-5040 |
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| Pharmacy Hot Line: |
Toll Free 1-800-437-9101 |
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Louisiana Drug Utilization Review (LADUR) Education
Identifying the Risks Associated with Nonsteroidal Anti-Inflammatory Drugs And Heart Failure
By: Kelli Sorrells, Pharm. D., B.C.P.S.
Issues
� ...approximately five million people in the U.S. have heart failure with an expected 550,000 new cases annually.
� Much controversy exists associating nonsteroidal anti-inflammatory drugs (NSAIDs) or selective cyclooxygenase-2 (COX-2) inhibitors in exacerbating new-onset heart failure and/or relapses of heart failure.
Introduction
The prevalence of heart failure is increasing as the population ages in the United States. Now, approximately five million people in the U.S. have heart failure with an expected 550,000 new cases annually. The incidence of heart failure doubles with every decade reaching 10% by age 75. Five-year mortality rates remain high at 50% regardless of medical advances.
Heart failure is a progressive disorder of the myocardium that leads to the inability of the heart to meet the metabolic demands of tissues in the body. Systolic (contraction) dysfunction is the most common abnormality followed by diastolic (relaxation) dysfunction. Frequently, systolic and diastolic dysfunctions co-exist in heart failure patients. Coronary heart disease is the most common condition leading to heart failure.
In the setting of heart failure, the body depends upon compensatory mechanisms for maintaining adequate cardiac output such as neurohormonal (norepinephrine) and neuroendocrine (renin-angiotensin-aldosterone system) changes, vasoconstriction, an increase in pre-load that will lead to an increase in cardiac output, and ventricular hypertrophy and remodeling of the myocardium. Sudden death in heart failure occurs in about 40% of patients, possibly caused by serious ventricular arrythmias, contributing substantially to the cause of death for this patient population. Of note, prostaglandins play a significant role in maintaining peripheral blood flow and renal function in chronic heart failure.
Much controversy exists associating nonsteroidal anti-inflammatory drugs (NSAIDs) or selective cyclooxygenase-2 (COX-2) inhibitors in exacerbating new-onset heart failure and/or relapses of heart failure. NSAIDs have been implicated in increasing the risk of heart failure hospitalization by two-fold in patients with underlying cardiovascular disease. The beneficial and harmful effects of NSAIDs are directly related to their inhibition of prostaglandin synthesis, as many elderly patients may be dependent upon prostaglandins for maintenance of their renal function previous to NSAID usage, leading to a decrease in renal function and possibly causing heart failure to precipitate. Inhibition of prostaglandins can also lead to an increased systemic vascular resistance. Hypertension and renal insufficiency have been well recognized as precipitous causes of heart failure.
Adverse drug reactions (ADRs) account for significant morbidity and mortality in patients every year. Reportedly, on an annual basis there are about 2 million ADRs with as many as 100,000 deaths nationally, making ADRs the fourth leading cause of death and costing 136 billion dollars. Many epidemiological studies have been conducted identifying several risk factors of heart failure development with NSAID usage (Table 1).
Table 1: Identified Risk Factors for Heart Failure with NSAID Usage:
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Risk Factor:
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Age > 65
years
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Cardiovascular
disease
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Respiratory
disease
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First 30
days of NSAID therapy
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>2 grams
of Acetaminophen daily
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Hypertension
due to an underlying renal cause
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Obesity
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Current or
past smoking history
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Studies
Rodriguez, et al., (Epidemiology 2003; 14:240-46) conducted a nested, case-control, observational study of newly diagnosed heart failure patients in the United Kingdom. They studied 857 confirmed cases of new-onset heart failure and 5000 controls. The authors concluded that risk factors for developing heart failure included obesity (BMI>30), current or past smoking history, and heart and respiratory disease. Alcohol intake was not a factor; furthermore, renal failure was not significant (CI 0.91-3.54). However, there were few patients (n=46) in this group.
The most common indication for NSAID usage in the study group was osteoarthritis, 52% were male, and 70% were more than 69 years of age. NSAID usage was associated with a 60% increased risk of heart failure, with the greatest risk in the first 30 days of NSAID therapy (RR = 2.1; 1.4-3.3). Risks based on chemical class of NSAIDs can be found in Table 2. The longer the duration (>30 days) of NSAID therapy resulted in a decreased risk of heart failure and fell quickly upon NSAID discontinuation. Half-life and level of dosage were insignificant as risk factors for causing heart failure.
Table 2: Relative Risks of Heart Failure Based on NSAID Chemical Class:
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Chemical
Class:
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RR
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95%
Confidence Interval
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Propionic
Acid derivatives
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1.7
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1.2-2.4
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Hetoaryl
acetic acids
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1.1
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0.7-1.8
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Indole and
Indene acetic
Acids
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2.4
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1.1-5.3
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Other
Classes
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2.6
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1.2-5.4
|
Regarding the users of antihypertensive medications and NSAIDs, the RR was 1.6 (CI 1.2-2.3) versus only 1.3 (CI: 0.8-2.1) for patients using NSAIDs but not currently on any antihypertensives. Furthermore, when the cause of the heart failure was hypertension, the risk associated with NSAIDs was increased, and even more so when the hypertension is related to a renal versus a non-renal cause. Regarding antihypertensive medications, angiotensin converting enzyme (ACE) inhibitors used concurrently with NSAIDs had the greatest risk of developing heart failure compared to other antihypertensive medications.
Acetaminophen, in doses greater than two grams/day as compared to lower doses (RR 1.77; 1.35-2.31), was observed as a significant risk factor for heart failure in the first month of use (RR 1.33; 1.06-1.67) when compared to non-users. This may be explained by the fact that in-vitro analysis of acetaminophen doses greater than two grams has exhibited substantial inhibition of cyclooxygenase. The risk of heart failure with acetaminophen was found when the drug was used as a single entity or when used in combination products. However, aspirin has not been shown to have an increased incidence of heart failure.
Cyclooxygenase-2 (COX-2) inhibitors became immensely popular upon their introduction into the marketplace, rapidly replacing their non-selective counterparts due to the expectation of lower gastrointestinal side effects. Studies comparing selective COX-2 inhibitors and their effect on heart failure have been conducted.
In two retrospective cohort trials, celecoxib was found to be safer than rofecoxib and non-selective NSAIDs for heart failure admissions.
Furthermore, the authors speculate that there is not a class effect with COX-2 inhibitors. It should be noted that these trials were criticized for not adequately accounting for confounders.
Conclusion
Elderly patients may have many reasons to require NSAID therapy, such as osteoarthritis, but are also at an increased risk for heart failure as they age. Non- specific NSAIDs, regardless of chemical class, can lead to new-onset heart failure, especially in the first thirty days of therapy in elderly patients. Caution is warranted in patients with diabetes, hypertension, renal disease, cardiovascular disease and pulmonary disease when starting NSAID therapy. Other risk factors to be taken into consideration are age greater than 65 years, past or current smoking history, and obesity. Aspirin usage is not a factor in new onset heart failure. COX-2 inhibitors have also been studied, and rofecoxib, which has been withdrawn from the market, appears to have a higher incidence of heart failure than celecoxib, possibly indicating that the risk is not a class effect.
References Available Upon Request