Turning the Corner

Novitas Gets a Rough Start

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Medical Economics Feature – April 2013

Tex Med. 2013;109(4):45-48.

 By Amy Lynn Sorrel 
Associate Editor

The ordeal was scary enough when last April, Imran Mohiuddin, MD, learned TrailBlazer Enterprises, Texas' Medicare carrier at the time, began recouping money because its records erroneously showed he did not participate in Medicare. In fact, the Sugarland vascular surgeon had the same Medicare ID for at least three years.

Fortunately, TrailBlazer corrected the mistake within a few weeks and promptly reimbursed Dr. Mohiuddin with no lapse in coverage.

So it came as a surprise when the physician found himself in the same scenario not long after Novitas Solutions Inc. took over from TrailBlazer last November – only this time the consequences were much direr.

Without notice, Novitas began recouping money from Dr. Mohiuddin – more than $40,000 between December and February – for what turned out to be the same error. Because nearly two years had lapsed from when the error first occurred, however, the supposed amount he owed was up to $600,000 in Medicare overpayments.

Dr. Mohiuddin didn't find all of this out until he noticed that the Treasury Department had placed a tax withhold on his Medicare bills until he repaid the money.

He and his staff started an avalanche of calls to Novitas. But between the long wait times and various representatives who appeared unaware of and unprepared to handle the issue, "we weren't getting anywhere," he said.

During the two months it took Novitas to sort things out, the payment holds took a toll. His practice made plans to shut down. Dr. Mohiuddin dipped into a line of credit to avoid that, but has since foregone his own salary to keep the practice afloat.

"I understand things can happen with any change. But even small mistakes are affecting people's lives, and there has got to be better communication," he said. "I'm not doing elective surgery. All my patients are very sick. What would happen to them if the practice closed? To my employees?"

After Dr. Mohiuddin used the Texas Medical Association's Hassle Factor Log to enlist help from the Payment Advocacy Department, and got a lawyer, Novitas stopped holding back payments and is on its way to reimbursing the surgeon.

Apparently when Novitas took over TrailBlazer's records, the transfer did not reflect the earlier resolution of the matter.

The same issue nearly cost Ricardo Abreu, MD, $80,000 – twice. The Weslaco pulmonologist returned the overpayment under TrailBlazer when the region he practices in no longer qualified as an underserved area eligible for Medicare bonus payments.

Yet Novitas claimed the money again last December, also without notice. For two months, Dr. Abreu and his staff called day after day with little response, during which time the doctor also collected no salary so he could pay his employees.

Again, it wasn't until TMA's Payment Advocacy Department intervened that his case sped along and he finally was paid.

"We knew there was going to be a transition," Dr. Abreu said. But it was the lack of notice and urgency in investigating the matter before penalizing him that made the scenario "very stressful."

The issue was just one among a number that physicians endured during the switch – some of them costly and others just plain frustrating. Despite the variety of problems, one theme persists.

"There are practices that rely on payment from Medicare. They [Novitas] have to communicate better with physicians," Dr. Abreu said.

Novitas Chief Executive Officer Sandy Coston acknowledges the company fell short in some areas, with customer service challenges and delays in appeals processing being the main ones.

But now that the transition is ending, and Novitas is well on its way to fully implementing its own policies and procedures, Ms. Coston says the ride will be smoother.

"Our No. 1 goal was to not interrupt cash flow. We educated folks on what they needed to do and what we needed to make that happen and overall, while there were pockets of physicians with unique situations, we think implementation was a success," she said. "Whatever problems there are, we will continue to be transparent. Was it rough the first few months? Absolutely. Have we turned the corner? Absolutely."

TMA's Payment Advocacy staff members continue to closely monitor Novitas' operations. They remain in regular conversations with the carrier and the Centers for Medicare & Medicaid Services (CMS), which approved Novitas as the regional Medicare contractor in 2011.

For the most part, payments were not disrupted, says Lee Spangler, JD, TMA vice president for medical economics.

"As problems surfaced, TMA stepped in to mitigate them, and Novitas responded," he said. "To expect a transition of this scale to happen without issue is unrealistic. There will continue to be challenges as the transition progresses, and Novitas has been open to addressing issues that we have brought to their attention."

 Falling Short

Novitas landed in Texas after CMS rebid the contract for Jurisdiction H (JH), which includes Texas, Arkansas, Colorado, Louisiana, Mississippi, New Mexico, and Oklahoma. The company, formerly Pennsylvania-based Highmark Medicare Services Inc., took over from TrailBlazer on Nov. 19, 2012.

Novitas also administers Part A and Part B claims for Jurisdiction 12 (J12), which includes Delaware, New Jersey, Pennsylvania, Maryland, and the District of Columbia.

Novitas representatives say some of the issues physicians experienced post-transition are typical as a new carrier gets settled, for example, assimilating an outgoing contractor's records and fine-tuning edits of old TrailBlazer policies.

In the big picture, the company was able to keep payments stable, and any issues were "relatively small in impact and short-lived," said David Vaughan, vice president and transition manager. On the other hand, unique issues like the mismatch in records Drs. Mohiuddin and Abreu experienced are not indicative of a wholesale problem, but if it's still occurring, "we want to know."

However, one look at the Novitas website revealed what Mr. Vaughan acknowledged was an inordinate number of "system alerts," notifications relating to incorrect claims denials, long call wait times, and new enrollment delays – all areas the company has targeted for improvement.

The majority of the alerts, including incorrect denials, stemmed from policy edits during transition, others from national issues that affected all Medicare contractors.

"In sheer numbers, those [alerts] are not indicative of our typical performance, and it's something that will not persist," Mr. Vaughan said. Nor did they affect a large swath of providers or claims.

But those and other factors contributed to higher-than-expected call volumes that caught the company off guard and impacted customer service quality. Questions related to a new national policy that took effect just before the transition also consumed 20 percent of the call center's capacity.

"The notable area where we have fallen short is in the Contact Center. Rightfully so, providers have cited customer service components most often as a source of frustration. But this is also the same area that has shown remarkable improvement as measured by shorter wait times and fewer busy signals," Mr. Vaughan said.

Novitas continues to increase staff and training to adjust and improve quality so agents don't have to bounce doctors around to various departments. The company also plans to enhance its website to make it more user-friendly. For example, a new status inquiry tool is now available for physicians to check their enrollment applications.

Before CMS approved the transition, TMA and other state medical societies expressed concern that Novitas would be taking twice as many claims as it handled when it serviced only J12.

Mr. Vaughan says the increased workload has not been an issue.

However, an unprecedented surge in appeals has been a problem that has affected service and processing timeliness. Most of those appeals carried over from TrailBlazer, but the trend has continued with new appeals, perhaps because practices held on to them knowing the transition was at hand, he says.

For Austin orthopedist and past TMA President C. Bruce Malone, MD, that meant months of delay while his practice awaited resolution on $6,000 in appeals left pending with TrailBlazer.

His insurance coordinator, Jackie Brown, did her part to follow the rules, research each individual appeal, and provide the supporting documentation. That time and effort, she felt, was not reciprocated when she called dozens of times to follow up and received little response as to why the claims were denied. Until TMA's Payment Advocacy Department stepped in, that is.

"These appeals took so much time, and I expect a trained medical billing professional to answer my questions when I call," Ms. Brown said, adding that each claim was successfully appealed. "Yes, we got our money back, but where's our interest for not timely refunding us?"

Having to jump through hoops even on smaller claims can be a big hit to practices that may perceive the burdens to outweigh the benefits, Dr. Malone added. "We do our best to provide services to patients when they need them. But every time these bureaucracies are inserted, physicians are less likely and less able to do this for patients."

Meanwhile, some physicians have expressed concern about heavy auditing of high-level evaluation and management (E&M) procedures for Medicare exams, an issue TMA's Payment Advocacy staff is tracking.

When it comes to appeals, Mr. Vaughan said Novitas' contract requires the carrier to process old TrailBlazer claims using the same policies in effect when the original claim was processed. That means "the work is more cumbersome for us to adjudicate at the appeal level given our lack of familiarity with those policies and the extra effort to locate pertinent records needed for the review."

Novitas also added staff and training in this area early on, an indication that the carrier's monitoring efforts and contingency planning worked, he says. "We did not copy TrailBlazer's policies. But we still have a foot in both worlds for a little while longer."

As for E&M codes, at present, physicians can expect higher level codes to get some scrutiny.

That's because Novitas is required to pay claims accurately, and JH exceeds the national average for error rates when it comes to E&M codes. In other words, if doctors aren't billing properly, the carrier is penalized for incorrectly processing the claim.

That doesn't mean Novitas audits those codes across the board, rather it is sampling doctors' bills for evaluation, Mr. Vaughan says.

"We have to look at what's driving that utilization, and often times there is very good reason behind it. Because Texas has a lot of teaching hospitals and specialty hospitals, we know we have that in the mix, as well," he said. "We don't have a preconceived notion that [these codes] need to fit a certain distribution. But we are looking for assurances that doctors are coding properly, and once we get that, we'll move on."

Mr. Vaughan recommends doctors familiarize themselves with the E&M documentation guidelines available on the Novitas website. TMA's website also has information on E&M specialty exam score sheets available online.

 Making Progress

Other parts of the transition have revealed improvements.

Ms. Brown says some of Novitas' newly instituted procedures now save the practice time and money, including the ability to fax versus mail the appeals, correct claims over the phone, and check doctors' eligibility status online.

Despite some shortfalls, CMS regional office officials say Novitas' performance to date is relatively consistent with past transitions and confirmed that the carrier did rise to the occasion in what CMS called the "critical area of claims-processing timeliness." Meanwhile, the erroneous recoupments have not been an ongoing issue.

CMS expects Medicare carriers to process 95 percent of clean claims – claims that contain all the necessary information – within 30 days of receipt. From Sept. 1, 2012, through Jan. 31, 2013, which included the transition timeframe, Novitas processed more than 30 million Part B claims, with 99 percent of clean claims processed within 30 days, according to CMS data.

However, Novitas' performance regarding its Provider Contact Center – a top functional area of concern for CMS and the most persistent complaint reported to CMS – reached its nadir last December with average answer time longer than 10 minutes and call completion rates of 50 percent.

As of late February, those figures improved dramatically, and Novitas is on track to meet CMS performance standards regarding the call center and timely appeals processing by spring, regional officials say.

They added that they are "in agreement" with the carrier's review strategy regarding high-level E&M codes.

CMS staff actively monitor the carrier through regular meetings, reports, and site visits, and "when necessary and appropriate, intervene to ensure a specific provider's concern is resolved to the extent allowed by law and any applicable regulations," regional officials said.

Indeed, the transition for the JH region was the largest CMS has overseen. The agency acknowledges that it had underestimated the appeals workload – an issue that came up in earlier transitions, according to a 2010 Government Accountability Office report.

CMS said it was limited by the historical data it had to go on, and estimating workloads for transitions is an activity it constantly refines.

As for Novitas, "to be sure, there is a learning curve in some very visible functional areas such as their Provider Contact Center, but transitioning work from one [Medicare carrier] to another is a very complex undertaking, and no transition has gone without some degree of complications," CMS regional officials said. "The critical part is how quickly and accurately a contractor responds to issues as they arise. From our perspective, Novitas has done a relatively good job managing all the transition issues that have surfaced."

Amy Lynn Sorrel can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.


Recoupment Audits to Resume

When Novitas took over from TrailBlazer as the new Medicare carrier for Texas, the Centers for Medicare & Medicaid Services imposed a moratorium on pursuing recoupments for overpayments, known as recovery audit activities. The blackout period is generally instituted 90 days before and after the cutover date – in this case, Nov. 19, 2012.

The post-transition 90-day window recently expired at the end of February, which means physicians should expect Novitas to resume actively pursuing overpayments.

Novitas representatives said its process to handle overpayment recovery and appeals follows the same requirements that applied to TrailBlazer, so physicians should not experience any changes in that process.


TMA Hassle Factor Log to the Rescue

Physician members got help with their Novitas issues by using the TMA Payment Advocacy Department's Hassle Factor Log. The program helps doctors bring their insurance-related issues to TMA's attention so staff can investigate problems and work with private health plans, Medicaid, and Medicare to get claims paid correctly.

The Payment Advocacy Department's work has paid off over the years. In 2012 alone, the department helped TMA members recover nearly $50 million.

Physicians can use the Hassle Factor Log to document their dispute, the type of payer they are dealing with, and the reasonable attempts they have made to resolve claim issues, including the appeals process.

Download the Hassle Factor Log and learn more about the program, or email the TMA Payment Advocacy staff for assistance. You also can contact the TMA Knowledge Center at (800) 880-7955.  

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