Practice Management

Hi Everyone,

Does anyone know if Medicare is Secondary (to any insurance, including Auto/Work Comp), does a CDSM need to be consulted?

Also, we have a few outlier offices that are simply refusing to comply and return everything to us with MH written on. Will MH still be a valid modifier in 2021? Or is the bottom line, without proof of actual CDSM consultation by the referring physician office, outpatient radiology practices won't get paid?

Thanks for your help!

------------------------------
Vicki Parikh
Practice Administrator
Mid-Delaware Imaging
------------------------------

Original Message------

Hi Everyone,

Does anyone know if Medicare is Secondary (to any insurance, including Auto/Work Comp), does a CDSM need to be consulted?

Also, we have a few outlier offices that are simply refusing to comply and return everything to us with MH written on. Will MH still be a valid modifier in 2021? Or is the bottom line, without proof of actual CDSM consultation by the referring physician office, outpatient radiology practices won't get paid?

Thanks for your help!

------------------------------
Vicki Parikh
Practice Administrator
Mid-Delaware Imaging
------------------------------

Original Message------

Hi Vicki,

 

I do not believe there has been an answer on either of your questions. It does not make sense, from a process perspective, to require AUC/CDS information on secondary claims since the purpose is to help the ordering professional order the most appropriate study prior to the exam taking place.  I suspect the MH modifier will still apply in 2021, since CMS will need to identify non-compliance so they can implement the requirement that up to 5% of ordering professionals who fail to comply with AUC/CDS will be subject to prior authorization.   

 

Barbara F. Rubel MBA, FRBMA

Senior VP, Marketing & Client Services

President, FRBMA

 

brubel@msnllc.com

904-657-2038 (Office) | 770-823-3597 (Cell)
MSNLLC.com

 

Vicki,

Upon being posed the same question and the ongoing lack of clarity on this question I had sent an inquiry through the CMS Imaging AUC at <ImagingAUC@cms.hhs.gov>. Below their response. As I understand that the validity of this type of ticketed response may certainly be reliable, I would be more comfortable finding additional supporting published literature that may better answer your question.
​

Subject: AUC when Medicare is a Secondary Payor

Does AUC/CDSM apply when Medicare is the Secondary Payor?

 

The Medicare AUC program requirements apply when Medicare is the secondary payor.

Thank you,

The CMS AUC Team

As far as the MH modifier's use in 2021, it is my hope that CMS will address any changes from the previous MLN Matters notification published in late November 2019 that defined this MH modifier and it's use in respond to AUC. It is my sense that it would be used beyond the 2020 "Educational and Operations" testing period to identify non-adherence of ordering providers to identify the 5% that may be subject to Medicare pre-authorization.

------------------------------
Gregory Wertz MS
Director of Industry Research and Relations
MBMS, LLC
State College PA
(814) 203-0088
gwertz@mbms.net
------------------------------

Original Message:
Sent: 01-08-2020 12:09
From: Vicki Parikh
Subject: AUC Questions

Hi Everyone,

Does anyone know if Medicare is Secondary (to any insurance, including Auto/Work Comp), does a CDSM need to be consulted?

Also, we have a few outlier offices that are simply refusing to comply and return everything to us with MH written on. Will MH still be a valid modifier in 2021? Or is the bottom line, without proof of actual CDSM consultation by the referring physician office, outpatient radiology practices won't get paid?

Thanks for your help!

------------------------------
Vicki Parikh
Practice Administrator
Mid-Delaware Imaging
------------------------------

Thank you both for your responses. I have posed the question to others and the consensus regarding the requirements for Medicare being secondary is vague at best. If anyone has located documentation, please share!

About the MH modifier, if it is still in use by 2021, will we, the furnishing provider be paid on claims showing MH? If there is no penalty, that would certainly make our lives easier! But then wouldn't everyone just use the MH modifier instead of going through all the pain of getting our referring physicians to comply?

I'm afraid all this AUC 'education' is negatively impacting us as we are the only facility in the area providing information about AUC compliance. Anyone else have a similar experience? And how did you overcome it?

------------------------------
Vicki Parikh
Practice Administrator
Mid-Delaware Imaging
------------------------------

Original Message:
Sent: 01-09-2020 08:31
From: Gregory Wertz
Subject: AUC Questions

Vicki,

Upon being posed the same question and the ongoing lack of clarity on this question I had sent an inquiry through the CMS Imaging AUC at <ImagingAUC@cms.hhs.gov>. Below their response. As I understand that the validity of this type of ticketed response may certainly be reliable, I would be more comfortable finding additional supporting published literature that may better answer your question.
​

Subject: AUC when Medicare is a Secondary Payor

Does AUC/CDSM apply when Medicare is the Secondary Payor?

 

The Medicare AUC program requirements apply when Medicare is the secondary payor.

Thank you,

The CMS AUC Team

As far as the MH modifier's use in 2021, it is my hope that CMS will address any changes from the previous MLN Matters notification published in late November 2019 that defined this MH modifier and it's use in respond to AUC. It is my sense that it would be used beyond the 2020 "Educational and Operations" testing period to identify non-adherence of ordering providers to identify the 5% that may be subject to Medicare pre-authorization.

------------------------------
Gregory Wertz MS
Director of Industry Research and Relations
MBMS, LLC
State College PA
(814) 203-0088
gwertz@mbms.net

Original Message:
Sent: 01-08-2020 12:09
From: Vicki Parikh
Subject: AUC Questions

Hi Everyone,

Does anyone know if Medicare is Secondary (to any insurance, including Auto/Work Comp), does a CDSM need to be consulted?

Also, we have a few outlier offices that are simply refusing to comply and return everything to us with MH written on. Will MH still be a valid modifier in 2021? Or is the bottom line, without proof of actual CDSM consultation by the referring physician office, outpatient radiology practices won't get paid?

Thanks for your help!

------------------------------
Vicki Parikh
Practice Administrator
Mid-Delaware Imaging
------------------------------

Original Message------

Thank you both for your responses. I have posed the question to others and the consensus regarding the requirements for Medicare being secondary is vague at best. If anyone has located documentation, please share!

About the MH modifier, if it is still in use by 2021, will we, the furnishing provider be paid on claims showing MH? If there is no penalty, that would certainly make our lives easier! But then wouldn't everyone just use the MH modifier instead of going through all the pain of getting our referring physicians to comply?

I'm afraid all this AUC 'education' is negatively impacting us as we are the only facility in the area providing information about AUC compliance. Anyone else have a similar experience? And how did you overcome it?

------------------------------
Vicki Parikh
Practice Administrator
Mid-Delaware Imaging
------------------------------

If using the MH modifier means the furnishing provider won't get paid, then why would anyone use it? Seems like it would be better to refuse service than do all the work for free. And if MH is not used, how will CMS identify those outliers? I guess the risk to any ordering provider would be that if no facility will do imaging studies on their patients, they might lose their Medicare patients?

If the ordering provider chooses not to participate and wants to take the risk of being subjected to the prior authorization requirements as a result of their own actions, why should the furnishing provider be financially penalized? 

Hopefully CMS will clarify these issues soon so we can provide more direction to our ordering base. If anyone has any existing supporting documentation, please share! Thank you again Barbara and Gregory for your responses!




------------------------------
Vicki Parikh
Practice Administrator
Mid-Delaware Imaging
------------------------------

Original Message:
Sent: 01-09-2020 16:10
From: Barbara Rubel
Subject: AUC Questions

Vicki,

 

My understanding is the MH modifier will not relieve us from non-payment beginning in 2021.

 

Barbara F. Rubel MBA, FRBMA

Senior VP, Marketing & Client Services

President, FRBMA

 

brubel@msnllc.com

904-657-2038 (Office) | 770-823-3597 (Cell)
MSNLLC.com

 

Original Message------

Thank you both for your responses. I have posed the question to others and the consensus regarding the requirements for Medicare being secondary is vague at best. If anyone has located documentation, please share!

About the MH modifier, if it is still in use by 2021, will we, the furnishing provider be paid on claims showing MH? If there is no penalty, that would certainly make our lives easier! But then wouldn't everyone just use the MH modifier instead of going through all the pain of getting our referring physicians to comply?

I'm afraid all this AUC 'education' is negatively impacting us as we are the only facility in the area providing information about AUC compliance. Anyone else have a similar experience? And how did you overcome it?

------------------------------
Vicki Parikh
Practice Administrator
Mid-Delaware Imaging
------------------------------

Vicki,

Unless new rulemaking is governed by CMS this year then beginning in 2021 financial risk will be in play. At this time CMS would require the use of the MH modifier defining that it is unknown if ordering professional consulted a CDSM for this service, related information was not provided to the furnishing professional or provider. As I understand, the use of this modifier with not only be tagged to the ordering NPI to track "outliers" that will be subject to prior authorization in the future but would also result in non-payment for the radiologist.

While the stakes for financial risk heat up as we approach 2021, radiology groups could reserve the right to put a "hard stop" on orders that do not include the mandated AUC information required to be placed on relevant Medicare claims. Some groups have already began to adopt this philosophy and have implemented this as a SOP for 2020. Some groups have even programmed an automated response back to the ordering providers that send orders electronically when the required AUC information is not included. In these instances the ordering provider would be informed that the study will not be scheduled until information is received.

Many radiology groups are using the 2020 testing year to gather data on their ordering practices compliance and providing targeting marketing toward the high volume non-compliant groups. In some instances radiology groups will work directly with ordering practices who lack the means to implement and integrate their own qCDSM by providing a portal to the hospital or radiology facility's qCDSM where these referrers can consult with AUC and provide the information on their orders.

------------------------------
Gregory Wertz MS
Director of Industry Research and Relations
Practice Manager
MBMS, LLC
State College PA
(814) 203-0088
------------------------------

Original Message:
Sent: 01-10-2020 13:49
From: Vicki Parikh
Subject: AUC Questions

If using the MH modifier means the furnishing provider won't get paid, then why would anyone use it? Seems like it would be better to refuse service than do all the work for free. And if MH is not used, how will CMS identify those outliers? I guess the risk to any ordering provider would be that if no facility will do imaging studies on their patients, they might lose their Medicare patients?

If the ordering provider chooses not to participate and wants to take the risk of being subjected to the prior authorization requirements as a result of their own actions, why should the furnishing provider be financially penalized?

Hopefully CMS will clarify these issues soon so we can provide more direction to our ordering base. If anyone has any existing supporting documentation, please share! Thank you again Barbara and Gregory for your responses!




------------------------------
Vicki Parikh
Practice Administrator
Mid-Delaware Imaging

Original Message:
Sent: 01-09-2020 16:10
From: Barbara Rubel
Subject: AUC Questions

Vicki,

 

My understanding is the MH modifier will not relieve us from non-payment beginning in 2021.

 

Barbara F. Rubel MBA, FRBMA

Senior VP, Marketing & Client Services

President, FRBMA

 

brubel@msnllc.com

904-657-2038 (Office) | 770-823-3597 (Cell)
MSNLLC.com

 

Original Message------

Thank you both for your responses. I have posed the question to others and the consensus regarding the requirements for Medicare being secondary is vague at best. If anyone has located documentation, please share!

About the MH modifier, if it is still in use by 2021, will we, the furnishing provider be paid on claims showing MH? If there is no penalty, that would certainly make our lives easier! But then wouldn't everyone just use the MH modifier instead of going through all the pain of getting our referring physicians to comply?

I'm afraid all this AUC 'education' is negatively impacting us as we are the only facility in the area providing information about AUC compliance. Anyone else have a similar experience? And how did you overcome it?

------------------------------
Vicki Parikh
Practice Administrator
Mid-Delaware Imaging
------------------------------

Gregory/Michael - thank you both for your input. 

It is very difficult for us to put a 'hard stop' on any referrals, especially this year since there will not be any financial penalty. Majority of offices are allowing us to help them and being very cooperative, but there are some that simply want nothing to do with the program. The question of using MH next year keeps coming up and with no firm direction, we are simply trying to steer offices away from using it.

Hopefully clarification will come soon so we can give people a concrete answer.


------------------------------
Vicki Parikh
Practice Administrator
Mid-Delaware Imaging
------------------------------

Original Message:
Sent: 01-14-2020 10:14
From: Gregory Wertz
Subject: AUC Questions

Vicki,

Unless new rulemaking is governed by CMS this year then beginning in 2021 financial risk will be in play. At this time CMS would require the use of the MH modifier defining that it is unknown if ordering professional consulted a CDSM for this service, related information was not provided to the furnishing professional or provider. As I understand, the use of this modifier with not only be tagged to the ordering NPI to track "outliers" that will be subject to prior authorization in the future but would also result in non-payment for the radiologist.

While the stakes for financial risk heat up as we approach 2021, radiology groups could reserve the right to put a "hard stop" on orders that do not include the mandated AUC information required to be placed on relevant Medicare claims. Some groups have already began to adopt this philosophy and have implemented this as a SOP for 2020. Some groups have even programmed an automated response back to the ordering providers that send orders electronically when the required AUC information is not included. In these instances the ordering provider would be informed that the study will not be scheduled until information is received.

Many radiology groups are using the 2020 testing year to gather data on their ordering practices compliance and providing targeting marketing toward the high volume non-compliant groups. In some instances radiology groups will work directly with ordering practices who lack the means to implement and integrate their own qCDSM by providing a portal to the hospital or radiology facility's qCDSM where these referrers can consult with AUC and provide the information on their orders.

------------------------------
Gregory Wertz MS
Director of Industry Research and Relations
Practice Manager
MBMS, LLC
State College PA
(814) 203-0088

Original Message:
Sent: 01-10-2020 13:49
From: Vicki Parikh
Subject: AUC Questions

If using the MH modifier means the furnishing provider won't get paid, then why would anyone use it? Seems like it would be better to refuse service than do all the work for free. And if MH is not used, how will CMS identify those outliers? I guess the risk to any ordering provider would be that if no facility will do imaging studies on their patients, they might lose their Medicare patients?

If the ordering provider chooses not to participate and wants to take the risk of being subjected to the prior authorization requirements as a result of their own actions, why should the furnishing provider be financially penalized?

Hopefully CMS will clarify these issues soon so we can provide more direction to our ordering base. If anyone has any existing supporting documentation, please share! Thank you again Barbara and Gregory for your responses!




------------------------------
Vicki Parikh
Practice Administrator
Mid-Delaware Imaging

Original Message:
Sent: 01-09-2020 16:10
From: Barbara Rubel
Subject: AUC Questions

Vicki,

 

My understanding is the MH modifier will not relieve us from non-payment beginning in 2021.

 

Barbara F. Rubel MBA, FRBMA

Senior VP, Marketing & Client Services

President, FRBMA

 

brubel@msnllc.com

904-657-2038 (Office) | 770-823-3597 (Cell)
MSNLLC.com

 

Original Message------

Thank you both for your responses. I have posed the question to others and the consensus regarding the requirements for Medicare being secondary is vague at best. If anyone has located documentation, please share!

About the MH modifier, if it is still in use by 2021, will we, the furnishing provider be paid on claims showing MH? If there is no penalty, that would certainly make our lives easier! But then wouldn't everyone just use the MH modifier instead of going through all the pain of getting our referring physicians to comply?

I'm afraid all this AUC 'education' is negatively impacting us as we are the only facility in the area providing information about AUC compliance. Anyone else have a similar experience? And how did you overcome it?

------------------------------
Vicki Parikh
Practice Administrator
Mid-Delaware Imaging
------------------------------