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Compliance Newsletter: Q3 2014

Compliance Newsletter: Q3 2014

Affordable Care Act (ACA): New Requirement for Providers who Order, Refer, or Prescribe Only (Medicaid)

The ACA now requires that all Medicaid prescription be writen by a credentialed Medicaid provider. This means if a new hire starts to work before they are credentialed with Medicaid that their scripts for those patients might not be filled and the patient will be asked to pay in full. The claims are held until the credentialing is complete so the group will eventually be paid for their services performed in the ED. This is a new requirement in which all 50 states are all over the map about when it went into affect.

Ohio: Jan. 1,2014 | Georgia: August 1, 2013 | Connecticut: Oct. 1,2013

These are just a few examples; check with your own states Medicaid office. This can clearly affect new hires when they start working.

CMS–Open Payment (The Sunshine Act): Physician Financial Transparency Reports

This is a national program that promotes transparency by making public information about financial interactions between industry and individual physicians and teaching hospitals. The Open Payments program allows physicians and teaching hospitals to register and review the financial data submitted by applicable manufacturers and group purchasing organizations and to initiate disputes if necessary before the data is made public. The data will become public Sep. 30, 2014. This is 2013 data and can be contested until the end of the year but will not be changed on the website until 2015.

The program requires that the following information be reported annually to CMS:

  • Applicable manufacturers of covered drugs, devices, biologicals, and medical supplies to report payments or other transfers of value they make to physicians and teaching hospitals to CMS.
  • Applicable manufacturers and applicable group purchasing organizations (GPOs) to report to CMS certain ownership or investment interests held by physicians or their immediate family members.
  • Applicable GPOs to report to CMS payments or other transfers of value made to physician owners or investors if they held ownership or an investment interest at any point during the reporting year.

Registration is voluntary; however, it becomes necessary if you wish to see the information before it is made public and dispute anything inaccurate or incomplete.


  • Register in CMS’ Enterprise Portal (Enterprise Identification Management system—EIDM) to receive your CMS user ID.

  • Register in the Open Payments system using your CMS user ID to review your payment records.


If you plan to review the information that has been submitted, we encourage you to first review the quick reference guides and helpful tips below to ensure that your registration experience is as efficient as possible.

Reviewing and Disputing Data

  • To register in Open Payments you will want to have your NPI, DEA and state license numbers available.
  • The entire registration process should take about 30 minutes to complete and
    must be finished in a single session.
  • Users cannot save entries or complete their profiles at later times.
  • The system times out after 15 minutes of inactivity, and it does not have an auto-save feature.
  • Use Internet Explorer versions 8-10. Currently, the Open Payments system is not optimized for the Safari, Firefox, or Chrome browsers.

For more information about the review and dispute process, visit the Physicians page on the Open Payments website.

For assistance with the registration process, please call CMS live Help Desk at 1-855-326-8366, Monday through Friday, from 7:30 a.m. to 6:30 p.m. (CT), excluding Federal holidays. Questions can also be submitted to the Help Desk via email, at

New Legislation, Secretary for the VA

On August 7, President Obama signed legislation giving a $16.3 billion boost to the Department of Veterans Affairs (VA), in response to whistleblower allegations that VA officials deliberately manipulated appointment and scheduling records to give the appearance of shorter waiting times for veterans seeking medical care. The new legislation will enable veterans to seek reimbursable services from non-VA providers; give VA hospitals and clinics money to hire physicians and nurses; and help the VA lease 27 new clinics.

Medicaid Parity

As you all know the ACA was partially about the expansion of Medicaid. To encourage the outpatient primary care physicians to open their practices to Medicaid the government      agree to pay Medicare rates for Medicaid patients from 1-1-13 to 12-31-14. This program was only for Pediatrics, Internal Medicine and Family Medicine and their specialties. There is a push by the primary care physician organizations to continue these improved payments. So far       six states have agreed to continue (Alabama and Mississippi – which never expanded      Medicaid – and Colorado, New Mexico, Maryland and Iowa) paying at the Medicare rate. Other states are considering paying between the two rates. President Obama in his budget proposal wants to extend until the end of 2015 and include MLPs. This does not apply to Emergency Physicians who have that as their specialty; however, it does affect our Pediatric EM physicians.

Noncontributary for the Family History

22. Under limited circumstances, could the term “noncontributory” be used as appropriate documentation to support the review of systems (ROS) and family history sections of the history component of an evaluation and management service (E/M)?

It is understood that there may be circumstances where the term “noncontributory” may be appropriate documentation when referring to the ROS and/or family history sections of the history component of an E/M service. Under the E&M documentation guidelines, it is noted that, “those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented.” The use of the term “noncontributory” may be permissible documentation when referring to the remaining negative review of systems. The term “noncontributory” may also be appropriate documentation when referring to a patient’s family history during an E/M visit, if the family history is not pertinent to the presenting problem.

Date Posted: 10/16/2009, Date Revised: 07/25/2014

This is copied from a recent revision of FAQs from Novitas a Medicare payer. A statement such as (Family Hx is noncontributory for this patients presentation) is acceptable. Examples could be trauma or presentation where the patient has no FHx in the area of the presentation.

ROS this would be like all other systems are negative. It is not meant as a standalone but after the positive and pertinent negatives have been documented.


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