Archive for: Billing and reimbursement
Court approves Medicare freeze on payments to Miami home healthcare companies
Medicare will continue to suspend payments to Miami home healthcare agencies suspected of fraud, according to a November 24 Miami Herald article.
A federal judge ruled Medicare’s refusal to pay reimbursement to companies suspected of overcharging for diabetic and other services, which began in October, is reasonable and appropriate.
A home healthcare company sued Medicare following the initial announcement claiming that the program was beyond Medicare’s scope of authority.
According to the article, Medicare estimates it spends $1.3 billion of its $16.5 billion national home healthcare budget on companies based in Miami-Dade County.
Click here to read the Miami Herald article.
Hospitals receive different reimbursements for identical procedures
Some Massachusetts hospitals earn much higher rates than other hospitals in the state for performing the same procedures, even though no proof exists that the care is better, The Boston Globe reports.
Insurance companies such as Blue Cross Blue Shield of Massachusetts and Harvard Pilgrim Health Care pay certain facilities 15% to 60% more than other hospitals on average, and sometimes even twice or three times as much for individual procedures, such as an angioplasty.
For example, Anna Jaques Hospital in Newburyport, MA, earns $75 for a chest x-ray while Massachusetts General Hospital in Boston earns $160 for the same.
The Globe says this process is usually kept under wraps because of confidentiality agreements between hospitals and payers. The newspaper called for more regulated healthcare policies to prevent reimbursement disparities from happening further.
Source: The Boston Globe
Cope with a new MAC
By Kimberly Anderwood Hoy, director of Medicare and compliance for HCPro
This week, CMS announced National Heritage Insurance Company (NHIC) as the A/B MAC for the New England jurisdiction (Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont). NHIC was primarily a Part B carrier prior to its selection as an A/B MAC for the northwest (Washington, Oregon, Idaho and Alaska), and now for New England. Many former students have discussed with me the difficulties they have experienced transitioning to a new contractor. This difficulty has been exaggerated in locations where the new contractor was formerly Part B carrier focused. This is presumably due to the very different coding, reimbursement, and even coverage environments of the services provided by suppliers (formerly billed to carriers) and those provided by institutional providers, such as hospitals.
I encourage everyone in these states, and anyone affected by a MAC transition, to review the Special Edition MLN Matters Article SE0837. It discusses steps providers can take to minimize problems during the transition, what to expect for process changes and possible disruptions to cash flow, and how to avoid them. I encourage everyone to pay particular attention to the possible changes to the local coverage determinations, including determinations of self-administered drugs. These may change under a new MAC, and the effective dates of changes can be confusing and have to be monitored closely to ensure you are notifying your patients appropriately of noncovered services.
2009 OPPS/ASC final rule published in Federal Register
On November 18, CMS published the CY 2009 OPPS/ASC final rule in the Federal Register. CMS had previously published a display copy of the final rule on its Web site.
View the CY 2009 OPPS final rule.
November 17-24: CMS and OIG Issuances
Frequently asked questions
On November 21, CMS issued 41 new/updated frequently asked questions related to Medicare fee-for-service payment.
View the frequently asked questions.
CMS selects A/B Medicare administrative contractor (MAC) for New England
On November 19, CMS announced its selection of National Heritage Insurance Corporation (NHIC) as the A/B MAC for Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont. As the A/B MAC contractor, NHIC will immediately begin implementation activities and will assume full responsibility for the claims processing work in its five-state jurisdiction no later than May 2009.
OIG issues report on Medicare billing for oxaliplatin at Franklin Memorial Hospital during calendar years (CY) 2004 and 2005
On November 19, the OIG issued a report in which it determined that Franklin Memorial billed Medicare incorrectly for oxaliplatin in CY 2004. These erroneous claims resulted in a net overbilling to Medicare of $97,968 for oxaliplatin furnished to hospital outpatients during CY 2004.
CMS issues proposed decision memo on surgery for diabetes
On November 17, CMS issued a proposed decision memo in which it proposed that type 2 diabetes mellitus is a comorbid condition related to obesity, as defined in NCD Manual 100.1 (Bariatric Surgery for Treatment of Morbid Obesity).
View the proposed decision memo.
CMS article discusses changes to deductibles, coinsurance rates
CMS has released a MLN Matters article related to changes in the deductible, coinsurance and premium rates for 2009.
To view the article, click here.
OIG issues report on allowable Medicare capital DSH payments for October 1, 2000 through September 30, 2006
On November 7, the OIG issued a report on disproportionate share hospital (DSH) capital payments for the period October 1, 2000, through September 30, 2006. The OIG found that a number of rural hospitals and hospitals with fewer than 100 beds claimed DSH capital payments during this period, even though those facilities were, according to federal requirements, ineligible for these payments.
To read the report, click here.
Patients don’t understand Medicare Part D coverage gap
Revenue cycle managers must continue to prepare their staff members to help confused patients with the Medicare Part D coverage gap.
More than 60% of patients who took a Medco Health Solutions survey do not fully understand the gap that forces patients to pay the entire cost of their prescription drugs, the Associated Press reports. And nearly 30% do not understand it at all, the survey says.
To read the full story in the Associated Press, click here.
Tip: Submission of claims for laboratory services
A hospital should ensure all claims for clinical and diagnostic laboratory testing services are accurate and correctly identify the services ordered by the physician (or other authorized requestor) and performed by the laboratory. The OIG recommends a hospital’s written policies and procedures require:
- The hospital bill for laboratory services only after they are performed
- The hospital bill only for medically necessary services
- The hospital bill only for tests actually ordered by a physician and provided by the hospital laboratory
- The CPT or HCPCS code used by the billing staff accurately describe the service ordered
- The coding staff only submit diagnostic information obtained from qualified personnel
- The coding staff contact the appropriate personnel to obtain diagnostic information when the individual who ordered the test has failed to provide such information
- The hospital document receipt of diagnostic information obtained from a physician or the physician’s staff after receiving the specimen and request for services
- The hospital conduct routine audits to assess billing compliance with the regulations
This tip was adapted from The Compliance Officer’s Handbook. For more information about the book or to order your copy, click here.
Tip: Understand the difference between a Medicare appeal and a Medicare reopening
By Deborah K. Hale, CCS
When facing a denied claim, organizations have two options if they believe the denial is wrong: file an appeal or ask for a reopening. A reopening can be used instead of an appeal if there is a minor clerical error on the claim. The basis of a reopening is to correct the minor clerical error or omission that resulted in the initial claim denial. If there were no clerical errors, and you disagree with a Medicare decision or policy, then an appeal must be made.
If you are unsure whether the issue on your claim is based on a minor error, it’s best to file initially for a reopening. You have the right to file for an appeal if your reopening request is denied. Do not file for both a reopening and an appeal at the same time; doing so will cause your request for a reopening to be considered null and void.
Valid reopening errors include:
- Mathematical or computational mistakes
- Transposed procedure or diagnostic codes
- Inaccurate data entry
- Misapplication of a fee schedule
- Computer error
- Denial of claims as duplicates, which the party believes were incorrectly identified as a duplicate
- Incorrect data items, such as provider number, use of a modifier, or date of service
A federal judge ruled Medicare’s refusal to pay reimbursement to companies suspected of overcharging for diabetic and other services, which began in October, is reasonable and appropriate.
A home healthcare company sued Medicare following the initial announcement claiming that the program was beyond Medicare’s scope of authority.
According to the article, Medicare estimates it spends $1.3 billion of its $16.5 billion national home healthcare budget on companies based in Miami-Dade County.
Click here to read the Miami Herald article.
Hospitals receive different reimbursements for identical procedures
Some Massachusetts hospitals earn much higher rates than other hospitals in the state for performing the same procedures, even though no proof exists that the care is better, The Boston Globe reports.
Insurance companies such as Blue Cross Blue Shield of Massachusetts and Harvard Pilgrim Health Care pay certain facilities 15% to 60% more than other hospitals on average, and sometimes even twice or three times as much for individual procedures, such as an angioplasty.
For example, Anna Jaques Hospital in Newburyport, MA, earns $75 for a chest x-ray while Massachusetts General Hospital in Boston earns $160 for the same.
The Globe says this process is usually kept under wraps because of confidentiality agreements between hospitals and payers. The newspaper called for more regulated healthcare policies to prevent reimbursement disparities from happening further.
Source: The Boston Globe
Cope with a new MAC
By Kimberly Anderwood Hoy, director of Medicare and compliance for HCPro
This week, CMS announced National Heritage Insurance Company (NHIC) as the A/B MAC for the New England jurisdiction (Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont). NHIC was primarily a Part B carrier prior to its selection as an A/B MAC for the northwest (Washington, Oregon, Idaho and Alaska), and now for New England. Many former students have discussed with me the difficulties they have experienced transitioning to a new contractor. This difficulty has been exaggerated in locations where the new contractor was formerly Part B carrier focused. This is presumably due to the very different coding, reimbursement, and even coverage environments of the services provided by suppliers (formerly billed to carriers) and those provided by institutional providers, such as hospitals.
I encourage everyone in these states, and anyone affected by a MAC transition, to review the Special Edition MLN Matters Article SE0837. It discusses steps providers can take to minimize problems during the transition, what to expect for process changes and possible disruptions to cash flow, and how to avoid them. I encourage everyone to pay particular attention to the possible changes to the local coverage determinations, including determinations of self-administered drugs. These may change under a new MAC, and the effective dates of changes can be confusing and have to be monitored closely to ensure you are notifying your patients appropriately of noncovered services.
2009 OPPS/ASC final rule published in Federal Register
On November 18, CMS published the CY 2009 OPPS/ASC final rule in the Federal Register. CMS had previously published a display copy of the final rule on its Web site.
View the CY 2009 OPPS final rule.
November 17-24: CMS and OIG Issuances
Frequently asked questions
On November 21, CMS issued 41 new/updated frequently asked questions related to Medicare fee-for-service payment.
View the frequently asked questions.
CMS selects A/B Medicare administrative contractor (MAC) for New England
On November 19, CMS announced its selection of National Heritage Insurance Corporation (NHIC) as the A/B MAC for Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont. As the A/B MAC contractor, NHIC will immediately begin implementation activities and will assume full responsibility for the claims processing work in its five-state jurisdiction no later than May 2009.
OIG issues report on Medicare billing for oxaliplatin at Franklin Memorial Hospital during calendar years (CY) 2004 and 2005
On November 19, the OIG issued a report in which it determined that Franklin Memorial billed Medicare incorrectly for oxaliplatin in CY 2004. These erroneous claims resulted in a net overbilling to Medicare of $97,968 for oxaliplatin furnished to hospital outpatients during CY 2004.
CMS issues proposed decision memo on surgery for diabetes
On November 17, CMS issued a proposed decision memo in which it proposed that type 2 diabetes mellitus is a comorbid condition related to obesity, as defined in NCD Manual 100.1 (Bariatric Surgery for Treatment of Morbid Obesity).
View the proposed decision memo.
CMS article discusses changes to deductibles, coinsurance rates
CMS has released a MLN Matters article related to changes in the deductible, coinsurance and premium rates for 2009.
To view the article, click here.
OIG issues report on allowable Medicare capital DSH payments for October 1, 2000 through September 30, 2006
On November 7, the OIG issued a report on disproportionate share hospital (DSH) capital payments for the period October 1, 2000, through September 30, 2006. The OIG found that a number of rural hospitals and hospitals with fewer than 100 beds claimed DSH capital payments during this period, even though those facilities were, according to federal requirements, ineligible for these payments.
To read the report, click here.
Patients don’t understand Medicare Part D coverage gap
Revenue cycle managers must continue to prepare their staff members to help confused patients with the Medicare Part D coverage gap.
More than 60% of patients who took a Medco Health Solutions survey do not fully understand the gap that forces patients to pay the entire cost of their prescription drugs, the Associated Press reports. And nearly 30% do not understand it at all, the survey says.
To read the full story in the Associated Press, click here.
Tip: Submission of claims for laboratory services
A hospital should ensure all claims for clinical and diagnostic laboratory testing services are accurate and correctly identify the services ordered by the physician (or other authorized requestor) and performed by the laboratory. The OIG recommends a hospital’s written policies and procedures require:
- The hospital bill for laboratory services only after they are performed
- The hospital bill only for medically necessary services
- The hospital bill only for tests actually ordered by a physician and provided by the hospital laboratory
- The CPT or HCPCS code used by the billing staff accurately describe the service ordered
- The coding staff only submit diagnostic information obtained from qualified personnel
- The coding staff contact the appropriate personnel to obtain diagnostic information when the individual who ordered the test has failed to provide such information
- The hospital document receipt of diagnostic information obtained from a physician or the physician’s staff after receiving the specimen and request for services
- The hospital conduct routine audits to assess billing compliance with the regulations
This tip was adapted from The Compliance Officer’s Handbook. For more information about the book or to order your copy, click here.
Tip: Understand the difference between a Medicare appeal and a Medicare reopening
By Deborah K. Hale, CCS
When facing a denied claim, organizations have two options if they believe the denial is wrong: file an appeal or ask for a reopening. A reopening can be used instead of an appeal if there is a minor clerical error on the claim. The basis of a reopening is to correct the minor clerical error or omission that resulted in the initial claim denial. If there were no clerical errors, and you disagree with a Medicare decision or policy, then an appeal must be made.
If you are unsure whether the issue on your claim is based on a minor error, it’s best to file initially for a reopening. You have the right to file for an appeal if your reopening request is denied. Do not file for both a reopening and an appeal at the same time; doing so will cause your request for a reopening to be considered null and void.
Valid reopening errors include:
- Mathematical or computational mistakes
- Transposed procedure or diagnostic codes
- Inaccurate data entry
- Misapplication of a fee schedule
- Computer error
- Denial of claims as duplicates, which the party believes were incorrectly identified as a duplicate
- Incorrect data items, such as provider number, use of a modifier, or date of service
Recent
Unapproved drugs still sold
December 1, 2008
by: Patient Access Weekly Advisor • Medicaid, e-Newsletters
Court approves Medicare freeze on payments to Miami home healthcare companies
December 1, 2008
by: Compliance Monitor • Billing and reimbursement, Medicare compliance, e-Newsletters
Hospitals receive different reimbursements for identical procedures
December 1, 2008
by: Case Management Weekly • Billing and reimbursement, e-Newsletters
Cope with a new MAC
December 1, 2008
by: Medicare Weekly Update • Billing and reimbursement, Coding, Medicare compliance, e-Newsletters
2009 OPPS/ASC final rule published in Federal Register
December 1, 2008
by: Medicare Weekly Update • Billing and reimbursement, Medicare compliance, e-Newsletters
Popular
Revenue Cycle Institute’s RAC Readiness Summit faculty announced
November 7, 2008
by: Andrea Kraynak, CPC-A • Billing and reimbursement, Medicare compliance, Popular, RACs
CMS delays RAC permanent program
November 5, 2008
by: Lori Levans • Auditing and assessment, Billing and reimbursement, Medicare compliance, Popular, RACs
News: Six Nevada doctors pay to settle Medicare fraud claims
October 23, 2008
by: Compliance Monitor • Billing and reimbursement, Medicare compliance, Popular, e-Newsletters
News: Louisiana Hospital pays $3.3 million to resolve Medicare fraud charges
October 23, 2008
by: Compliance Monitor • Billing and reimbursement, Medicare compliance, Popular, e-Newsletters
Hospitals absorb costs of treating uninsured immigrants
October 20, 2008
by: Case Management Weekly • Billing and reimbursement, ED, Popular, e-Newsletters
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