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December 30, 2019
What is Cultural Competency Training and is it Required?
August 5, 2019
Last week, an email was sent by Optum Physical Health to Participating Providers asking them to re-validate their contact information as well as attest to whether or not they had undergone "cultural competency training." Other than stating that cultural competency training was a CMS requirement, the automated email provided no additional information and required recipients to electronically sign, or attest to whether or not they had taken this training. The WCA Help Desk reached out to Optum for additional information on this communication. We also asked our health care lawyer for her expert opinion.
The groundwork was laid for cultural competency to become a requirement by Title VI of the Civil Rights Act of 1964 as well as section 1557 of the Affordable Care Act. Both apply to any providers who receive Federal financial assistance, which would include payment from Medicare and Medicaid.
Title VI of the Civil Rights Act of 1964 mandates no discrimination in Federally subsidized programs or activities. Title VI applies no matter what amount of Federal money is involved. Protected classes include, but are not limited to: Race, Color, or National Origin (this includes primary language spoken in the household). When it comes to language, Title VI Requires “Meaningful Access” to Services for those whose primary language is not English. This is where the requirement to provide translation services (which applies to DCs) stems from. For more information on the requirement to provide translation to Limited English Proficient (LEP) individuals and those who are deaf/hard of hearing click here. Section 1557 of the Affordable Care Act protects against discrimination based on sex, age and disability.
Furthermore, 42 CFR § 438.10 mandates that health plans (such as UHC/Optum) that provide services to Medicare or Medicaid recipients must make available in paper form upon request and electronic form, the following information about its network providers:
(i) The provider's name as well as any group affiliation.
(ii) Street address(es).
(iii) Telephone number(s).
(iv) Web site URL, as appropriate.
(v) Specialty, as appropriate.
(vi) Whether the provider will accept new enrollees.
(vii) The provider's cultural and linguistic capabilities, including languages (including American Sign Language) offered by the provider or a skilled medical interpreter at the provider's office, and whether the provider has completed cultural competence training.
(viii) Whether the provider's office/facility has accommodations for people with physical disabilities, including offices, exam room(s) and equipment.
All of this leads one to wonder what standards apply to cultural competency training, and how does one determine if a particular training program is adequate? There are National Standards for Culturally and Linguistically Appropriate Services, or CLAS. These standards exist to inform health care providers about cultural differences in people, and how these differences impact the healthcare system.
“Published research from organizations like the Institute of Medicine, the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention and more has shown that not only do people from different backgrounds have unequal access to care, but they also have disparities in health outcomes and in healthcare itself.” SOURCE: A Failure to Communicate - Caring for Patients with Limited English Proficiency – Dr. Robert Like, MD
Below are some different resources for cultural competency training. Regardless of the resource you use, you should document when you underwent the training in your compliance manual. Document when your staff takes the training as well, if applicable.
1) US Department of Health and Human Services (DHHS) National Standards for Culturally and Linguistically Appropriate Services (CLAS). Select the Administrators and Providers – Guide to Providing Effective Communication and Language Assistance Services.
2) UHC does offer online training on the UHC On Air site for participating providers including a course called, Impact of Cultural Competency and Americans with Disability Act Training. You must log in with your Optum ID to take this training.
3) The Wisconsin Department of Health Services offers various resources and training on cultural competency here: https://www.dhs.wisconsin.gov/minority-health/clas.htm
4) U. S. National Library of Medicine - Health Services Research Information Central website. Health Literacy and Cultural Competence information including: News, Data, Tools and Statistics, Guidelines and Journals, Education, Meetings, Conferences and Webinars, Key Organizations. https://hsric.nlm.nih.gov/hsric_public/topic/health_literacy/
***The bottom line is that while there is not a specific mandated cultural competency training class that healthcare providers must take, health plans are required by law to ask if participating providers have undergone this training on an annual basis. It is not a mandatory training nor will it remove providers from the network if not completed, it is only required for Optum to ask if it has been completed or not. Our advice at the WCA Help Desk is that cultural competency training is advisable to take from both a compliance as well as an ethical standpoint.
If you have specific questions on the Optum email that was sent to you, please contact Optum directly at 877-293-2046 or email firstname.lastname@example.org and reference “physical health validation form.”
Optum webpage on Cultural Competency: https://www.providerexpress.com/content/ope-provexpr/us/en/clinical-resources/culturalCompetency.html
UPDATE: Prior Authorization Requirement for PT Modalities "Delayed Temporarily" by Anthem BCBS
July 17, 2019
A July Wisconsin Provider Communications from Anthem BCBS informed Participating Providers that effective August 1, Physical Therapy, Occupational Therapy and Speech Therapy services will be subject to prior authorization review by AIM Specialty Health® (AIM).Just a short time later, a follow up communication dated July 16th from Anthem announced that the prior authorization requirement would be postponed until sometime after September.
The WCA reached out to Anthem BCBS to request additional information on the prior authorization review process and whether it applies to chiropractors performing physical therapy modality services, as well as what types of Anthem insurance plans it applies to. According to Anthem BCBS, the prior authorization requirement is code specific, not provider specific. Any qualified provider performing procedures contained within the list of impacted physical therapy CPT codes will be subject to the prior authorization requirement. Examples of CPT codes subject to the requirement include: 97010, 97012, 97014, 97110, 97112, 97124, 97140. So while the prior auth requirement for PT modalities does not apply at this point in time, we are monitoring communications from Anthem and will update members as information becomes available.
Below is more information about the policy that we have learned; however, keep in mind that it is not currently in effect & is subject to change:
As far as a timeframe for the prior auth process, AIM states that if the necessary information is provided, determinations are immediate in most cases. For more information, please see the AIM FAQs here.
AIM Prior Authorization Reviews of PT Modalities will utilize the Anthem Clinical Guidelines outlined here.
Providers may submit prior authorization requests to AIM in one of several ways:
A complete list of the CPT codes that will be subject to prior authorization review can be found at the following link: http://aimproviders.com/rehabilitation/pdf/2018/Oct02/RehabCPTCodeList-PhysicalTherapy.pdf
Humana Denying Therapy Codes for Lack of Modifier
A recent policy (click here to view) implemented by Humana requiring the -96 or -97 modifier on therapy codes has started to result in denials just this month. Here is what we know so far:
Click here to read an article from Find-A-Code on the -96 and -97 modifiers.
Anthem Denials Update
April 29, 2019 (updates are in RED)
Anthem BCBS has been keeping chiropractic offices across the state especially busy in early 2019. There have been a number of issues which have been resulting in claim denials.
1. Denials of procedure code G0283 being denied as investigational/experimental. G0283 is Electrical Stimulation, Unattended, one or more areas and is a covered code for Anthem BCBS.
2. Change in documentation guidelines to follow Medicare guidelines (i.e. documentation show pain, Outcome Assessments and functional improvement for all patients).
3. Claim denials from Anthem BCBS due to the combination of diagnosis codes used being considered mutually exclusive.
Some of the code combinations that have been resulting in claim denials are:
S33.140D and M53.2X7
S33.5XXA and M51.26 and also M51.36
The ICD-10 coding guideline was updated and communicated in December 2018 (see below communication from Anthem):
System updates for 2019 – Professional
As a reminder, our claim editing software will be updated monthly throughout 2019 with the most common updates occurring in quarterly in February, May, August and November of 2019. These updates will:
Here is the reminder which was sent in February 2019 via Anthem's electronic Provider Updates:
Reminder: Review ICD-10-CM Coding Guidelines – Professional
To help ensure the accurate processing of submitted claims, keep in mind ICD-10-CM Coding Guidelines when selecting the most appropriate diagnosis for patient encounters. Remember ICD-10-CM has two different types of excludes notes and each type has a different definition. In particular, one of the unique attributes of the ICD-10 code set and coding conventions is the concept of Excludes 1 Notes. An Excludes 1 Note is used to indicate when two conditions cannot occur together (Congenital form versus an acquired form of the same condition). An Excludes 1 Note indicates that the excluded code identified in the note should not be used at the same time as the code or code range listed above the Excludes 1 Note. These notes are located under the applicable section heading or specific ICD-10-CM code to which the note is applicable. When the note is located following a section heading, then the note applies to all codes in the section.
Hopefully you are signed up to receive the electronic updates from Anthem. If not, you can do so by visiting this link: https://providernews.anthem.
4. Vague claim denials with explanation codes 066 and/or 45:
5. E/M codes being denied when billed with an adjustment code
When billing an E/M code with an adjustment, it is necessary to append the -25 modifier to the E/M code. However, many payors will audit claims with modifiers such as 25, 51 and 59 to ensure that the code with the modifier in question meets the criteria for using that modifier.
Anthem BCBS states they are implementing this policy and that it applies to all providers.
Click here to read a recent article from Find-A-Code on E/M bundling.
We suggest appealing any denied exams. You may use our template appeal letters to help save time, click here https://