Mar 29, 2013 | Uncategorized
CAQH recently launched a new solution to enroll in EFT with participating payers through a universal process! Enrollment is easy!nnUsing CAQH’s EFT Enrollment utility, providers can securely enroll in electronic payment programs with payers. The site streamlines enrollment in these programs by eliminating the multiple and different forms required by each payer, and centralizing EFT enrollment between multiple payers. Once the information is entered, making changes for your practice can be done quickly and easily.n
Go to https://solutions.caqh.org for more information.
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Source: www.caqh.org; January 30, 2013.
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Healthcare and Reimbursement Updates
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Mar 29, 2013 | Uncategorized
On March 13, 2013, the Centers for Medicare & Medicaid Services (CMS) issued a ruling contrary to its traditional billing policy regarding payment of Part B inpatient services following denial of a Part A claim. Ruling CMS-1455-R came about in response to an increasing number of Administrative Law Judge (ALJ) and Medicare Appeals Council decisions relating to RAC audit appeals which, while upholding Part A denials based on determinations that inpatient admissions were not reasonable and necessary, ordered payment under Part B as if services were rendered at an outpatient or “observation level” of care. The Ruling allows providers to submit Part B inpatient claims for a more expansive range of services upon denial of Part A claims during RAC appeals.nnUnder the Ruling, a hospital may submit Part B inpatient claims for services beyond those listed in the Medicare Benefit Policy Manual (MBPM) when:n
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- A Medicare review contractor denies the Part A inpatient claim upon finding that the inpatient admission was not reasonable and necessary;
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- The Part B services would have been payable to the hospital if the beneficiary was treated initially as an outpatient; and
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- The billed services do not require outpatient status, e.g. outpatient visits, emergency department visits, and observation services.
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nThe Ruling allows hospitals to submit Part B claims for payment provided the hospital withdraws its appeal on the corresponding Part A claim. The Ruling applies to Medicare claims denied by RAC auditors after March 13, 2013, or Medicare claims in a pending RAC appeal at any level as of March 13, 2013. Going forward from this Ruling, the scope of RAC appeals will be limited to review of Part A inpatient claims, and ALJs are not to order Part B payment or remand for consideration of Part B payment.nnLastly, the Ruling sets forth the time period within which a provider must bill the Part B claims. Generally speaking, hospitals must submit Part B claims within 180 days of receipt of an appeal dismissal notice, final or binding unfavorable appeal decision, or determination of a Part A inpatient claim for which there is no pending appeal and for which the hospital does not appeal. Further, Part B inpatient and outpatient claims filed later than one year after the date of service will not be rejected as untimely, provided the denied Part A inpatient claim was timely filed.n
CMS Proposed Rule
nConcurrent with the Ruling, CMS released a proposed rule on Part B inpatient billing that would apply on a prospective basis. Following a Part A claims denial due to inpatient admissions that are not reasonable and necessary, the proposed rule similarly allows payment for reasonable and necessary Part B services had the beneficiary been treated as an outpatient. Likewise, the proposed rule excludes payment for services that require outpatient status. However, unlike the Ruling, the proposed rule also applies when a hospital determines after discharge that a beneficiary’s inpatient admission was not reasonable and necessary. Further, the proposed rule continues to apply timely filing restrictions on Part B billing for inpatient services; contrary to the Ruling, any Part B services must be filed within one year from the date of service.n
What Providers Should Know
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- Providers should keep this Ruling in mind when reviewing RAC denials to make strategic decisions, that is, the choice between 1) pursuing Part A payments by arguing that inpatient admission was reasonable and necessary versus 2) dropping the appeal and re-billing the claim as Part B inpatient.
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- Because hospitals still cannot bill for observation services when an inpatient admission is denied, the Ruling will not significantly affect medical services billing but may affect billing for procedures.
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nSource: www.polsinelli.com; March 13, 2013.n
Healthcare and Reimbursement Updates
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Mar 29, 2013 | Uncategorized
Health care providers are REQUIRED to complete Compliance Certification! The Centers for Medicare & Medicaid Services (CMS) requires that all Humana business partners, including health care providers, complete required compliance training and certifications.
nHealth care providers can complete this information online via Humana’s secure Compliance website, which requires internet access. To access the website, health care providers must be registered on Humana.com or Availity.com. Detailed instructions and additional information on completing these requirements, including registration, are available here. While health care providers are encouraged to complete the compliance requirements within 30 days of notification, these requirements must be completed no later than December 31, 2013.nnSource: www.humana.com; February 2, 2013.n
Healthcare and Reimbursement Updates
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Mar 29, 2013 | Uncategorized
In what appears to be a shift in policy, the Centers for Medicare & Medicaid Services has begun auditing providers attesting to Meaningful Use of their electronic health record systems before doling out incentive payments, according to a report from the American Academy of Family Physicians (AAFP).
nCMS has targeted 5 to 10 percent of those who attested to Meaningful Use in January 2013, according to Elizabeth Holland, director of the Health IT Initiative Group’s Office of E-Health Standards and Services. Eligible professionals selected for audit were chosen both “randomly” and “based on protocols that identify suspicious or anomalous attestation data,” according to the AAFP News Now article.nnAn additional 5 to 10 percent of physicians and others will be subject to post-payment audits, according to Holland. The audits are being conducted by Garden City, NY-based CPA firm Figliozzi and Company.nnCMS is required to conduct audits of providers attesting under the EHR incentive program, and began postpayment audits in July 2012. However, the U.S. Department of Health & Human Services’ Office of Inspector General (OIG) chastised CMS in November 2012 for poor auditing of the incentive program, a concern echoed by the Government Accountability Office.nnOIG specifically recommended that CMS conduct prepayment audits of a select number of providers before issuing their incentive payments. At that time, CMS would not concur with the OIG’s recommendation, saying that prepayment audits would impose a “huge new burden” on providers and impede EHR adoption.nnOther CMS programs are moving from “pay and chase” to prepayment review. GAO recently reported that expanding prepayment audits could save Medicare $115 million.nnTo learn more, here’s the AAFP New Now articlennSource: www.fierceemr.com; Marla Durben Hirsch; March 24, 2013.n
Healthcare and Reimbursement Updates
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Mar 29, 2013 | Uncategorized
Be on the lookout! Humana staff members regularly conduct medical record audits in randomly selected physician offices to help satisfy regulatory compliance by evaluating physician compliance with adopted medical record documentation guidelines. The minimum passing score is 85 percent compliance with the guidelines, with a goal of 90 percent. These guidelines are available for downloading and printing at Humana.com; click on the PDF entitled “Medical Records Guidelines” under the list of Clinical Practice Guidelines.nnSource: www.humana.com; February 2, 2013.n
Healthcare and Reimbursement Updates
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Mar 21, 2013 | Uncategorized
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Reimbursement Issues (denials, late payments, incorrect payments, inaccurate information)n
- Expanded insurance coverage provisions through the Affordable Care Act (ACA)
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- Data collection for meaningful use and reimbursement incentives
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- Expanded credentialing requirements create a new and more complex environment for providers and healthcare facilities
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Reimbursement models are changing and Payer Relationship Management (PRM) is more important than ever!
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- A strategic approach to understanding and cultivating payer relationships is the key to success. They need you and you need them!
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- Understanding your own data will assist in cultivating financially positive relationships – knowledge is power!
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Take control of your Payer Relationships!
nPRM supports your providers, practices and facilities to capture, store, monitor, track and leverage all information related to the billing and reimbursement processes. This information includes detailed and up-to-date provider profiles (credentialing), practice profiles (leverage), payer profiles (market research), reimbursement activities (proper payments), and patient care activities and efforts (data collection).n
PRM is the lifeline of your practice and facility—
n—and requires expertise, knowledge, and a multidisciplinary approach of professionals who understand and stay ahead of the changing healthcare environment and requirements. Every practice and facility should focus on PRM to maximize revenue by:n
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- Incorporating tools and systems to report and understand your practice’s financial health, financial needs, and patient care data
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- Understanding the current relationship with reimbursement sources (i.e. payers), including language, rates, etc.
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- Understanding your market, your competition, and most importantly your value!
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- Identifying opportunities to increase reimbursement (leverage)
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- Verifying all provider and contract information is loaded correctly in payer systems to ensure proper and timely payments (credentialing)
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- Understanding new reimbursement models to obtain additional payments (i.e. incentive payments), and avoid penalties that will decrease revenue
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- Ensuring efficient reimbursement processes to maximize cash flow (i.e. EFT, ERA)
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nNeed Assistance with your PRM? Click here…
