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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 hereSection 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.

https://thinkculturalhealth.hhs.gov/Registration/GUIs/GUI_TCHRegister.asp?mode=new&site=5

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.

https://www.uhcprovider.com/en/resource-library/training.html

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 pdv@optum.com and reference “physical health validation form.” 

Additional Resource(s):

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:

  • Access AIM’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
  • Access AIM via the Availity Web Portal at availity.com.
  • Call the AIM Contact Center toll-free number at (800) 554-0580, Monday through Friday, 8:30 a.m. to 7:00 p.m. ET.

 

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
April 23, 2019

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:

  • The policy was effective 1/1/18 but Humana only recently began implementing it in early 2019
  • The policy impacts Humana Individual policies and Small Group policies
  • The policy coincides with new modifiers created by the American Medical Association effective 1/1/18 to distinguish between rehabilitative and habilitative services.
  • Modifier 96 identifies habilitative services; modifier 97 identifies rehabilitative services.
  • Habilitative services are, “Health care services and devices that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical therapy, occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.”
  • Rehabilitative services are, “Health care services and devices that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.”
  • Simply put, rehabilitative services help patients restore functions or skills that have been lost, while habilitative services develop skills and functions that had not been developed previously.
  • Since a chiropractor most often will administer rehabilitative services, then the modifier 97 will be used for Humana Commercial plans.  Modifier 96 and 97 should not be used together on the same claim.
  • Humana plans in the individual and small group markets have separate limits on rehabilitative and habilitative services.
  • For dates of service beginning on or after January 1, 2019, providers must append modifier 96 to procedure codes for habilitative services submitted for reimbursement & modifier 97 to procedure codes for rehabilitative services submitted for reimbursement. Claims submitted without these modifiers will be denied for lack of modifier.
  • Denied claims should be appealed. Click here for Humana's appeal process.
  • These modifiers should only be used for Humana individual and small group policies. We are not advising that you append modifier -97 to therapy claims for other insurance companies at this time.

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.

  • Resolution: Denials were incorrect and an Appeal must be submitted in order to have the claim reprocess for payment.

2. Change in documentation guidelines to follow Medicare guidelines (i.e. documentation show pain, Outcome Assessments and functional improvement for all patients).

  • Resolution: We are still confirming if this applies in Wisconsin, since Anthem BCBS has different requirements by State. However, consider performing an internal audit on your Anthem BCBS documentation to ensure it is up to Medicare standards-this can only help you to show medical necessity.

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

  • Resolution: The Network Relations person we have been working with at Anthem states that Anthem updated their coding guidelines in December and communicated this with contracted providers. They specifically updated some codes which are considered mutually exclusive codes. This can often occur with the S codes. If you have any claim denials due to mutually exclusive diagnosis codes, the best fix would be to remove the code causing the error, replacing with another code that would be appropriate, and resubmit the claim. According to ChiroCode, “the S33.1- codes are controversial to many. Some feel that CMT is contraindicated for this diagnosis. Click here to read a ChiroCode article about the problem. Using the “S” diagnosis codes with other codes could appear to be contradictory since the "S" codes are for injuries. For example, if used with M51.37 Other intervertebral disc degeneration, lumbosacral region, the insurance carrier may question if this was this an injury or a degenerative condition? If the patient really did satisfy BOTH, you could appeal with the documentation of both conditions. However, it might be easier to simply submit a corrected claim with an M99- as the primary diagnosis.

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:

  • reflect the addition of new, and revised codes (e.g. CPT, HCPCS, ICD-10, modifiers) and their associated edits
  • include updates to National Correct Coding Initiative (NCCI) edits
  • include updates to incidental, mutually exclusive, and unbundled (rebundle) edits
  • include assistant surgeon eligibility in accordance with the policy
  • include edits associated with reimbursement policies including, but not limited to, frequency edits, bundled services and global surgery preoperative and post-operative periods assigned by The Centers for Medicare & Medicaid Services (CMS)

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.com/wisconsin and at the top of this page, click on “Subscribe to Email”.

4. Vague claim denials with explanation codes 066 and/or 45:

  • Resolution: Anthem has an analytics company called Cotiviti, who assists Anthem BCBS is implementing correct coding guidelines. Anthem is aware that there is an issue with the denial reasons not appearing on the EOB’s for claims that Cotiviti is examining. They state that this is a project that is being worked on and they are looking at resolution by the end of 2nd quarter (June 30th). In the meantime, if you receive any claim denials, we suggest contacting customer service and asking for clarification. Medical records may be needed.

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://wisconsinchiropractic.site-ym.com/page/HD_practiceresources for the template appeal letters (Note: you must be signed in with your WCA member user name and password to access).


CBD Oil Update

February 7, 2019

With the recent passage of the 2018 Federal Farm Bill which contained a provision on agricultural Hemp, the WCA Help Desk has been receiving questions on whether this will allow Wisconsin Chiropractors to sell hemp oil products, including hemp-derived CBD oil. The Farm Bill was signed by the President at the end of December, and legalizes hemp at the Federal level, provided that it contains no more than 0.3% tetrahydrocannabinol (THC).

However, the Farm Bill does not alter the Food, Drug and Cosmetic Act nor does it affect the FDA’s authority.  As a result, changing the status of Hemp from a controlled substance does not affect the FDA’s conclusion that CBD products are classified as a drug, and not a nutritional product.

Following the passage of the 2018 Federal Farm Bill, the FDA issued a statement reminding people that, “it’s unlawful under the FD&C Act to introduce food containing added CBD or THC into interstate commerce, or to market CBD or THC products as, or in, dietary supplements,regardless of whether the substances are hemp-derived. This is because both CBD and THC are active ingredients in FDA-approved drugs and were the subject of substantial clinical investigations before they were marketed as foods or dietary supplements. Under the FD&C Act, it’s illegal to introduce drug ingredients like these into the food supply, or to market them as dietary supplements.”

The statement also clarified that, “...some foods are derived from parts of the hemp plant that may not contain CBD or THC, meaning that their addition to foods might not raise the same issues as the addition of drug ingredients like CBD and THC. We are able to advance the lawful marketing of three such ingredients today. We are announcing that the agency has completed our evaluation of three Generally Recognized as Safe (GRAS) notices related to hulled hemp seeds, hemp seed protein and hemp seed oil and that the agency had no questions regarding the company’s conclusion that the use of such products as described in the notices is safe. Therefore, these products can be legally marketed in human foods for these uses without food additive approval, provided they comply with all other requirements and do not make disease treatment claims.”

[Emphasis has been added, you can read the full statement here: https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm628988.htm]

Until the law (or legal authorities) label CDB as a dietary supplement or food, and not a drug, Wisconsin-based DCs take a risk with practicing outside their scope by selling or prescribing CBD products, including hemp oil, hemp cream and hemp complexes that contain CBD.  Currently, Wisconsin chiropractors are prohibited from prescribing, dispensing, delivery or administration of drugs as defined in Wis Stat. s. 450.01(10), which defines drugs as including any substance intended for use in the diagnosis, cure, mitigation, treatment or prevention of disease or other conditions in persons or other animals.  The chiropractic code excludes from drugs vitamins, herbs or nutritional supplements consistent with the chiropractic nutritional counseling certification law, also see Wis. Admin. Code s. 4.05(d).The FDA has deemed CBD oil a drug, not a food or nutritional supplement. The FDA has issued warning letters to many manufacturers of CBD products for misrepresentations of their products, and will likely continue to do so, seehttps://www.fda.gov/newsevents/publichealthfocus/ucm484109.htm
 
 At this point in time, the WCA does not recommend that you sell CBD oil products, due to the potential risk it could pose to your license. If you are interested in learning more about hemp products which do not contain CBD or THC, we encourage you to consult with potential vendors and distributors to verify that their products do not contain these substances.