Kaiser-ASH Situation

ASH just posted a reiteration of how the whole Kaiser arrangement works, I would like to recap it here for you since it is important if you see Kaiser patients via ASH.

1) The current referral situation is this:  Kaiser generates a referral for acupuncture.  This referral is good for 1 year.  The patient must have a referral on file while using their ASH benefits. When it ends, they should go back to Kaiser.

2) From this initial referral, the patient has 5 visits (like the threshold many pracitioners have) that they get which do NOT require authorization.

3) After the 5 visits are used, and with the referral in place, the practitioner now can request additional visits through ASHLINK.

4) Always, always ONLY discuss treatment for the REFERRED condition.  Kaiser is referring the patient for a specific condition and so you can only request more visits FOR THAT condition, so do not discuss other conditions (even if you are treating something other than the referred condition) when requesting authorization.  It will be denied.  To locate the condition Kaiser referred the patient for, search for the patient on ashlink. View the eligibility information,  under BENEFIT NOTES, there is a link to search for the patients referral (when required it will say this). Follow the prompts until you get to the referral info, it will list the ICD-9 code with a description of that code.  This is why the patient was referred and so you can ONLY address this condition when communicating with Kaiser/ASH.  When billing, you should only use these codes also.

5) When requesting authorization, documenting progress is paramount to being granted additional visits.  Below is a message from ASH (almost verbatim) regarding documentation requirements for Kaiser patients specifically, when submitting a CTF.

Though acupuncture is proven to be effective in treating chronic pains, its success in treating a specific patient is measured by your clinical documentation.Kaiser physicians ask the treating acupuncture providers to use the following 1) the pain reduction 2) the functional improvement  and 3) reduction of pain medication in determining the effectiveness of treatment intervention. In order to document the progress that treatment has made, you must record at the first visit: the pain level on a VAS (0-10), clearly describe the functional limitations such as patient can’t walk for more than 10 minutes or patient cannot use right hand to comb hair, and report the pain medication the patient is currently taking (include amounts). After each course of care, all three of these area’s should be re-evaluated and reported to support continuation of acupuncture treatment.

6)  Not sure if this last one is NEW or if it has existed and is just never utilized; they are saying that Kaiser has an additional rider that may NOT require a referral.  So, just because a patient has Kaiser doesn’t automatically mean that they need a referral.  A patient’s eligibility and benefits should be looked up on ashlink at which time it will tell you if a referral is required.  In my mind when a patient has Kaiser, they always need a referral, since this is no longer the case, we will always check ashlink before concluding this.  Last but not least, they wanted to reiterate that all Kaiser/ASH benefits are eligible for the ChooseHealthy Affinity program that entitles cash paying patients to a discounted fee schedule.  You would find these allowed amounts on ASH’s website.  Search for the affinity program maximum fee schedule, it lists  things such as a 97810 (acu) maximum charge of $35 and a 97811 (addl 15 min acu with re-insertion) max charge of $15, so if you do both, you can charge a max of $50 for the acupuncture treatment to the patient. It further lists a bunch of therapies (heat, infrared, etc.) with a max fee schedule of 11.25 each.

That’s basically it.  To successfully treat Kaiser patients these are the things you need to do. From a paperwork standpoint, they should fill out an ASH initial health status form on their first visit.  After completing their 5th visit, the patient should complete a progress report.  This will accompany your CTF requesting additional visits.  After the patient completes the next authorized course of treatment, they would again complete a progress report that will accompany your CTF until the patient reaches maximum medical improvement.  Once this happens and ASH will no longer authorize care, the patient may continue care on their own and receive the choosehealthy affinity program discount. This would apply to any other condition the patient is treated for and chooses to pay cash.

I hope this helps make the Kaiser/ASH situation clearer.  For a while, we were confused.  This new update has really helped to clarify things for the offices I work for as well.

 

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