Archive for the ‘Uncategorized’ Category

2016 Best of Winchester Award Given

Monday, March 21st, 2016

We are excited and honored to have been awarded the “2016 Best of Winchester” award, in the business category for Medical Provider Credentialing.

Each year, the “Winchester Awards Program” identifies companies that they believe have achieved exceptional marketing success in the local community and business category. These are local companies that enhance the positive image of small business through service to their customers and the community itself. Recognition is given to those companies that have shown the ability to use their best practices and implemented programs to generate competitive advantages and long-term value.

Various sources of information were gathered and analyzed to choose the winners in each category. The 2016 Winchester Award Program focused on quality, not quantity when naming the winners for each area. Winners were determined based on the information gathered both internally by the Winchester Award Program and data provided by third parties.

Again, we are very excited about this recognition, and will continue to strive to meet those goals and expectations by providing excellent customer service to our clients, and being a good civic partner in our community!

Medicare Sustainable Growth Rate

Tuesday, April 28th, 2015

In recent news, very exciting legislation regarding Medicare Sustainable Growth Rate (SGR) was passed this month. In the past, the SGR formula was enacted by the Balanced Budget Act of 1997 as a way to control Medicare spending. Each year, the annual change in Medicare spending per beneficiary is compared to GDP growth, and a conversion factor is implemented into the following year’s Annual Medicare Physician Fee Schedule that would raise or lower physician payments to balance this difference. During the first couple of years, this formula resulted in payment increases. However, with rising health care costs, it resulted negatively thereafter, reducing payments each year until 2002. Due to immense criticism, in 2002 Congress voted to temporarily “patch” the formula. During these short term “patches” that have occurred 17 times over the years, Congress basically suspends the automatic reduction and maintains current reimbursement levels. So, each year the budget shortfalls are just postponed and added to the next scheduled adjustment. As a result, now a 21% cut to Medicare physician payments would happen, if the Sustainable Growth Rate (SGR) is allowed to go into effect this year.

On March 26th the House of Representative passed legislation to permanently repeal the Medicare Sustainable Growth Rate (SGR) formula. Thereafter, Senate voted to approve the “Medicare Access and CHIP Reauthorization Act” on April 14, 2015. President Obama publicly stated that he will sign the bill into law.

With the “Medicare Access and CHIP Reauthorization Act”, the following items will be enacted:

  • All future SGR cuts will be erased, and it ensures that  a 5-year period of annual updates (of 0.5%) will help transition to the new payment system;
  • The Act provides additional financial incentives for providers who move into alternative payment models (APMs);
  • Medicare quality reporting programs will be streamlined into the Merit-Based Payment Incentive System (MIPS)
  • The Act reverses CMS’ decision to eliminate the use of 10 and 90–day global surgical codes in Medicare

For more information about the Medicare Sustainable Growth Rate, and recent “Medicare Access and CHIP Reauthorization Act”, please refer to:

Medicare Ordering/Referring Physician Updates

Friday, January 10th, 2014

Many changes have been implemented recently as part of the Affordable Healthcare Act.  One of these items is the passing of  the “Pathway to SGR Reform Act”, which affects Medicare payments and ordering/referring physicians. The law has been delayed for several years, but was passed and became effective 1/6/14. Medicare released the following statement: On December 26, 2013, President Obama signed into law the Pathway for SGR Reform Act of 2013. This new law prevents a scheduled payment reduction for physicians and other practitioners who treat Medicare patients from taking effect on January 1, 2014. The new law provides for a 0.5 percent update for such services through March 31, 2014…The new law extends several provisions of the Middle Class Tax Relief and Job Creation Act of 2012 (Job Creation Act) as well as provisions of the Affordable Care Act. Specifically, the following Medicare fee-for-service policies have been extended. We also have included Medicare billing and claims processing information associated with the new legislation. Please note that these provisions do not reflect all of the Medicare provisions in the new law, and more information about other provisions will be forthcoming. The new law provides for a 0.5 percent update on claims with dates of service on or after 1/16/14 through 3/31/14. CMS is currently revising the 2014 Medicare Physician Fee Schedule (MPFS) to reflect the new law’s requirements. The 2014 conversion factor is $35.8228. The existing 1.0 floor on the physician work geographic practice cost index is extended through 3/31/14, and will be reflected in the revised 2014 MPFS. An additional key part of the new law is that claims submitted by providers who render services which do not meet the agency’s “ordering and referring criteria” beginning on 1/6/14 will be denied. The “Ordering and Referring Physician Fact Sheet” was written in conjunction with the American Medical Association, and outlines key issues practices need to know in order to avoid claim denials. Some of those key criteria are: 1. Claims submitted for the ordering/referring provider, which do not accurately list the matching NPI will continue to be rejected 2. Physicians and other providers who are eligible to order and refer items or services, need to ensure that they are correctly enrolled with  Medicare to reflect their specialty, and ensure their specialty is one which is eligible to order and refer services. 3. The ordering/referring provider name on the claim must match what Medicare has on record. (Middle names, initials and suffixes, such as MD, APRN etc., should not be listed in the ordering/referring fields). For more information, please refer to the CMS website at:

Coventry/Aetna Merger and CHA update

Thursday, May 30th, 2013

Aetna acquired Coventry Health Care, Inc. on May 7, 2013. As a combined company, they are now the third largest health care benefits company in America based on membership. They serve an estimated 22 million medical members in the U.S. and around the world, and have started to fully integrate the two companies. Coventry Cares of Kentucky, (a KY Medicaid managed care organization), was also part of this merger. For now there will be no change in the provider enrollment process, benefits administration or claims processing. However, as integration continues new updates will made available on the Aetna website.

Also, CHA (a division of Humana in Kentucky) will no longer have active membership accessing their networks in Kentucky as of 6/1/2013.  As such, they will no longer contract new providers or continue making credentialing updates for changes that occur after 5/31/2013.

If clients have questions about any of these commercial payer changes, please feel free to contact the Bluegrass Credentialing office at 859-744-0263.

5010 Compliance Extension

Monday, March 19th, 2012

Once again, CMS has extended the time for entities to be fully compliant with HIPAA 5010 transaction standards. Please see the article below that was released by CMS on March 15th regarding this update:

Extension of Enforcement Discretion Period for Updated HIPAA transaction standards through June 30, 2012

(March 15, 2012) The Centers for Medicare & Medicaid Services’ Office of E-Health Standards and Services (OESS) is announcing that it will not initiate enforcement action for an additional three (3) months, through June 30, 2012, against any covered entity that is required to comply with the updated transactions standards adopted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA): ASC X12 Version 5010 and NCPDP Versions D.0 and 3.0.

On November 17, 2011, OESS announced that, for a 90-day period, it would not initiate enforcement action against any covered entity that was not compliant with the updated versions of the standards by the January 1, 2012 compliance date. This was referred to as enforcement discretion, and during this period, covered entities were encouraged to complete outstanding implementation activities including software installation, testing and training.

Health plans, clearinghouses, providers and software vendors have been making steady progress: the Medicare Fee-for-Service (FFS) program is currently reporting successful receipt and processing of over 70 percent of all Part A claims and over 90 percent of all Part B claims in the Version 5010 format. Commercial plans are reporting similar numbers. State Medicaid agencies are showing progress as well, and some have made a full transition to Version 5010.

Covered entities are making similar progress with Version D.0. At the same time, OESS is aware that there are still a number of outstanding issues and challenges impeding full implementation. OESS believes that these remaining issues warrant an extension of enforcement discretion to ensure that all entities can complete the transition. OESS expects that transition statistics will reach 98 percent industry wide by the end of the enforcement discretion period.

Given that OESS will not initiate enforcement actions through June 30, 2012, industry is urged to collaborate more closely on appropriate strategies to resolve remaining problems. OESS is stepping up its existing outreach to include more technical assistance for covered entities. OESS is also partnering with several industry groups as well as Medicare FFS and Medicaid to expand technical assistance opportunities and eliminate remaining barriers.

Medicare ERA Recipients

Wednesday, February 8th, 2012

New information has just been released about recipients of Medicare ERA’s (Electronic Remittance Advices)….and the changes take effect April 1, 2012. The following information is posted on the Cigna Government Services Medicare website:

Only One Electronic Remittance Advice Recipient per NPI / Legacy ID beginning Sunday, April 1st

Prior to the implementation of HIGLAS (the Healthcare Integrated General Ledger Accounting System), Medicare’s Multi-Carrier System (MCS) created just one check per sender, National Provider Identifier (NPI), or legacy ID.  Each sender / NPI / legacy ID was able to have multiple receivers of the electronic remittance; MCS would use the sender ID submitting each claim to aid in determining to whom the remit should be sent.  For each check that was created, MCS also created an electronic remittance advice (ERA), which accurately reported the payment amount for that ERA.

When a MAC transitions to HIGLAS, only one check can be produced per NPI/legacy ID.  The old MCS system logic, which took the sender information into account when generating the remit, was not changed when MACs began their transition to HIGLAS; in some instances, the result was a remittance advice that did not contain all of the claims processed in a given cycle or a remittance advice containing payments that did not total to the EFT/check amount.

In order to accurately produce electronic remittance advices to match the EFT/check amount, MCS will be changing their logic effective Sunday, April 1, 2012 – and will no longer consider the sender information when creating the ERA files.  MACs will allow only one receiver of an electronic remittance per NPI/legacy ID regardless of whether the provider submits their inbound files under different sender IDs.  Your respective MAC will be contacting you if you are set up on their files for multiple receivers of the ERA, in which case you will need to select one receiver for your electronic remittance.

Medicare & KY Medicaid Updates

Friday, November 11th, 2011

On November 2, the Centers for Medicare and Medicaid Services (CMS) announced that it will extend the timeframe of the Medicare revalidation initiative to 2015. The agency recently began revalidating Medicare providers and was scheduled to complete this large-scale effort by March 2013. However, there have been some issues with these early revalidations…..thus the deadline change.  Those providers who have already received a revalidation notice should still submit their revalidation application within the required 60 days. However, all other providers will still have a few years before having to revalidate their information.

KY Medicaid recently changed to a Managed Care model, with CoventryCares of Kentucky, Kentucky Spirit and Wellcare of Kentucky taking over administration of the program. The 3 MCO’s took over as of 11/01/2011. Because they are still working on getting providers enrolled, updating demographics changes, etc. we have been told by key representatives with each company that there will be a lot of leniency during the first 60 days, while they are “working through the kinks”. Contact information is as follows:

CoventryCares: 855-300-5528

Wellcare: 877-389-9457

Kentucky Spirit: 866-641-3153

For further information about Medicaid Managed Care changes and updates, please visit the Kentucky Medicaid website at

More Changes….

Wednesday, August 31st, 2011

The past 12 months have been very busy….with Medicare revalidation & PECOS enrollment, J15 conversion for KY & OH Medicare Part B Providers, and the recent change in KY Medicaid to a managed care model. (I won’t even mention EHR incentives, meaningful use and preparing for 5010!) But, it appears there is even more change on the horizon for Medicare participating providers.

All providers enrolled in the Medicare program prior to March 25, 2011 will be required to revalidate their enrollment, utilizing the new risk criteria under the Affordable Care Act (section 6401a). Providers will fall into one of three categories-limited, moderate, or high. Each represents the level of “risk” to the Medicare program for the particular category a provider or supplier falls under. For a complete list of these screening categories, and the provider types assigned to each, please refer to Chapter 15, Section 19.2.1 of the CMS “Program Integrity Manual”.  One major change will be that certain provider types will be required to pay an application fee when revalidating! Those specifically mentioned are institutional and supplier providers.

Medicare Administrators will begin sending out notices between now and March 2013. When notice is received, providers will have 60 days from the date on the letter to get their enrollment forms accurately completed and submitted for processing.

For more information about this topic, please refer to the Medicare Learning Network’s “Special Edition Article #SE1126″, titled “Further Details on the Revalidation of Provider Enrollment Information”, at

Credentialing Assistant Position

Monday, July 11th, 2011

Bluegrass Credentialing & Consulting is growing! Therefore, we are seeking a part-time Credentialing Assistant to work in our Winchester, KY office.  This entry level position consists of:

  • Data Entry
  • Daily verbal & written commuication with clients & insurance payers
  • research credentialing-related issues and changing healthcare policies
  • scanning, e-mailing, & faxing documents
  • creating spreadsheets
  • working with private payers, Medicare & Medicaid to ensure accurate client enrollment & maximum reimubursement.

Qualified candidates must posses the following:

  • Excellent communication & data entry skills
  • working knowledge of Word, Excel & Outlook
  • close attention to detail
  • organizational & time management skills
  • good work ethic & ability to function in a team-oriented environment

Interested candidates may e-mail or fax a resume to: or 859-745-0836.

KY Medicaid RFP

Wednesday, May 11th, 2011

Many providers across the state are beginning to receive letters from various Managed Care Organizations (MCO’s), who are bidding on the KY Department of Medicaid Services managed care contract.  As you may know, the KY Medicaid program is moving away from a Fee-For-Service delivery model to a statewide Managed Care program. In doing so, the Finance and Administration Cabinet recently released a Medicaid Managed Care “Request for Proposal” from qualified MCO’s.

There are several companies which are bidding on this contract. So far, providers have seen letters from Amerigroup, Wellcare, Optum Health and Coventry….but there may be more to come. These MCO’s are sending out applications and/or non-binding “Letters Of Intent” for each provider to complete.  This is a proactive way for these MCO’s to have an idea of how many providers they might have enroll for their network, (should they win the Medicaid contract), as well as provide them some “leverage” in the bid process.  Although it has not yet been determined how many MCO’s will qualify for this contract, Medicaid will be attempting to choose an MCO(s) by July 1, 2011. After this time, Medicaid will begin phasing in qualified members to the chosen MCO(s).

The decision of whether to take the time to submit a “Letter of Intent” for each provider, to each MCO is totally up to each practice. In this case there is no right or wrong answer. After the contract is awarded there will be an opportunity for providers to enroll with the MCO(s) who will be managing the KY Medicaid program. However, some companies are telling providers that if they fill out the Letter of Intent their enrollment will be given some “presedence”.  For more information about the Medicaid RFP, please go to: