JK: Medicare Hot Topics

Transcription

1 JK: Medicare Hot Topics HFMA - September 29, 2016

2 Today s Presenter Andrea Freibauer Provider Outreach & Education Consultant 2

3 Disclaimer National Government Services, Inc. has produced this material as an informational reference for providers furnishing services in our contract jurisdiction. National Government Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare Program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare Program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the CMS website at 3

4 No Recording Attendees/providers are never permitted to record (tape record or any other method) our educational events This applies to our webinars, teleconferences, live events and any other type of National Government Services educational events 4

5 Acronyms Acronyms used in this presentation can be viewed on the NGSMedicare.com website. On the Welcome page, click on Provider Resources > Acronyms. 5

6 Agenda Production Alerts Provider Enrollment Revalidation Electronic Data Interchange LCDs and SIAs Data Analysis Education NGSConnex CERT NGS Website 6

7 Production Alerts 7

8 FISS Mass Adjustments for Claims Processed After the August 5, 2013 Implementation An issue with reason codes and identified when a HCPCS G-code billed with noncovered charges CMS issued instructions to all MACs on 8/8/2016 to process mass adjustments to claims processed after 8/5/2013 per the following conditions: Outpatient claims, TOBs: 12X, 13X, 22X, 23X, 32X, 33X, 34X, 74X, 75X, 82X, 85X or 77X and; Claims processed from 8/5/2013 and up to 7/25/2016 and; HCPCS codes: G8978-G8999 or G9158-G9186 (with RC present on line) VA claims/providers are excluded from this logic OBs can be limited based on how your revenue code and HCPCS file is set up for the G HCPCS codes 8

9 FISS Mass Adjustments for Claims Processed After the August 5, 2013 Implementation NGS began releasing claims on 8/29/2016 with claims being suspended for reason code U6000 (claim purged from CWF) However, NGS discovered numerous claims rejected because adjustments applied to beneficiary's therapy cap, placing them over legislative limit and rejecting in error, and affecting provider payment NGS stopped releasing claims as of 9/1/2016 and requesting further direction from CMS Impacted claims have the following information on Remarks page in FISS DDE: CQ adjusting reimbursement Current Status Please do not attempt to correct or appeal these claims NGS will issue an update via Production Alerts section of our website and Updates when further instruction provided by CMS 9

10 Provider Enrollment Revalidation 10

11 Provider Enrollment Revalidation Who All providers five years after initial enrollment or last revalidation When Only when notified and before due date Notices are mailed 2-3 months prior to due date Unsolicited revalidation applications returned if received more than 6 months prior due date What Verify entire Medicare enrollment record Why Avoid payment hold or deactivation of Medicare billing privileges by responding promptly 11

12 Provider Enrollment Revalidation Check PECOS Check CMS website (Medicare Revalidation Look Up Tool) Due date will display or TBD (To Be Determined) if not currently due MLN Matters article SE1211 MLN Matters article SE1605 MLN Matters article SE

13 Electronic Data Interchange 13

14 New EDI Guided Enrollment Process Began 8/1/16 New process to eliminate need to manually complete multiple forms individually for electronic billing Guides you through required steps in easy to complete format Eliminates need to print, sign and fax any forms to NGS by allowing electronic signature within online submissions EDI will be able to begin processing your enrollment request once it is submitted online You will also receive an with your packet ID number (PID), which identifies your request to NGS Guided Enrollment application and detailed instructions found at Claims & Appeals > Electronic Data Interchange 14

15 LCDs and SIAs 15

16 September 2016 Revised Local Coverage Determinations (LCDs) and Articles Filgrastim, Pegfilgrastim, Tbo-filgrastim, Filgrastimsndz (e.g., Neupogen, Neulasta, Granix Zarxio ) - Related to LCD L33394 (A52408) Investigational Device Exemption Requests - Medical Policy Article (A52841) Nivolumab (Opdivo ) - Related to LCD L33394 (A54862) Paclitaxel (e.g., Taxol /Abraxane ) - Related to LCD L33394 (A52450) 16

17 Retired LCDs and Supplemental Instruction Articles (SIAs) Retired effective 9/1/2016: Incision and Drainage (I & D) of Abscess of Skin, Subcutaneous and Accessory Structures SIA (A52858) Psychiatric Inpatient Hospitalization SIA (A52823) Psychiatric Partial Hospitalization Programs SIA (A52824) Vertebroplasty and Vertebral Augmentation (Percutaneous) SIA (A52871) Biologic Products for Wound Treatment and Surgical Interventions LCD (L33391) and Related Articles (A52389, A52401, A52387, A52847, A52388, A54057, A52410, A54707, A52418, A52392, A52396, and A52411) 17

18 Data Analysis Education 18

19 Provider Outreach and Education Reason Code Reduction Initiative Initiative to assist providers with reducing claim denials, rejections and RTPs Data on top 10 reason codes compiled and top providers identified for each on ongoing basis Monthly Compliance officers contacted with information about reason code(s) Every six months Individual education offered for providers with high occurrences of identified reason code(s) 19

20 Benefits of Preventing Claim RTPs, Rejections and Denials Increase Medicare cash flow Ensure claims are Medicare-compliant upon first claim submission Ensure claims are filed timely with Medicare Avoid being investigated for Medicare program integrity (fraud & abuse) Use staff time better 20

21 Top Claim Submission Errors Part A > Claims & Appeals > Top Claim Errors Denials RTPs Rejections 21

22 Top Denial Reasons - July 7WEXC Unacceptable diagnosis Provider failed to submit documentation requested by the intermediary within 45 days 55B31 Documentation needed to make payment missing/incomplete (ex. Therapy units billed) 54NCD None of the diagnoses on claim support medical necessity of service 52MUE All line items on claim have units of service in excess of medically reasonable daily allowable frequency 22

23 Top Rejection Reasons - July U5233 Services on claim fall within or overlap Medicare advantage HMO enrollment period Exact duplicate of a previously submitted claim U5200 Beneficiary not entitled to Medicare coverage for type of services billed on claim Outpatient claim contains service dates that equal or overlap previously submitted outpatient claim from your facility and at least one revenue code or HCPCS code matches U5210 Beneficiary's entitlement for Medicare coverage terminated prior to first date for services provided on claim 23

24 Top Return to Provider (RTP) Reasons - July Claim immediately preceding DOS on this bill not received (inpatient SNF and non- PPS bills must be processed in sequence) Outpatient OPPS types of bills cannot have overlapping DOS when provider numbers are equal unless condition code G0' or '20' or '21' present on claim HCPCS code reported on claim not billed with valid revenue code for DOS Therapy evaluation/re-evaluation code not submitted with appropriate G-code and modifier Revenue code non-billable for this TOB and covered charges are greater than zero 24

25 NGSConnex 25

26 NGSConnex Portal Did You Know? Secure Internet portal offered at no charge to NGS providers Access and submit information in a secure, protected environment: Check claim status and line-level detail, including appeal status Review beneficiary eligibility and entitlement Review financial data, including offset information and claims included on specific checks Submit online questions to our Contact Center Upload supporting documentation References: NGSConnex User Guide NGSConnex Job Aids NGSConnex Recertification Instructions (annual) 26

27 NGSConnex Portal Did You Know? Additional Development Requests (ADRs) Electronically submit documentation - no need to mail or fax response! Benefits: Instant acceptance of your documentation Confirmation that your documentation was submitted Acknowledgement sent Date stamped for easy tracking Reduces time factor for responding to your facility s ADR Secure portal for sending PHI and eliminates the need to utilize the postal services Review ADR history Reminder: Ensure medical records are complete and be sure to follow signature requirements as described in CMS MLN article MM

28 NGSConnex Portal Did You Know? Credit Balance Reports Directly submit CMS-838 Detail Report including certification page Benefits: No need to fax or mail anything to complete process Confirmation that credit balance report successfully submitted Certification page can be signed electronically 838 detail report submitted either manually or by attaching CMS-838 file Acknowledgement sent Date stamped for easy tracking 28

29 NGSConnex Portal Did You Know? Cost Reports Submit cost report/desk audit review documentation electronically to National Government Services Audit and Reimbursement (A&R) department Includes ability to submit bad debt listings or data in support of disproportionate share claims Benefits: Secure Internet portal accepts any type of document such as Microsoft Word, Microsoft Excel,.txt, ASCII, or.jpegs. Can even attach cost report files from HFS, CompuMax or any other reporting system No need to fax anything to complete process Note: Hard copy signed certification (signature) page with encryptions must continue to be mailed to NGS Confirmation that cost report successfully submitted and acknowledgement sent More efficient and cost effective 29

30 NGSConnex Portal Did You Know? Appeals Electronically submit redetermination or reopening requests securely Benefits: Easily locate status of appeal Submit one redetermination request for each claim; no need to submit separate request for each line within claim Secure portal for sending PHI eliminates need to utilize postal services and no need to fax or mail anything to complete process! No file size limitations to attachments Most file types accepted; file types not accepted:.xml,.log, and.cfg Instant acceptance of documentation - date stamped for easy tracking Confirmation that documentation submitted and acknowledgement sent Reduces time factor for requesting reopening or redetermination 30

31 Comprehensive Error Rate Testing (CERT) 31

32 CERT Documentation Request Listings Now available on CERT Provider Website Documentation reference lists based on provider and billing types Listed alphabetically Available in English and Spanish Can view and print listings Lists include medical record documentation that may be needed to support services billed to Medicare If submitting documentation via CD, send password via to and use CID number in subject line (no encryption needed for ) 32

33 CERT A/B MAC Outreach & Education Task Force 33

34 CERT A/B MAC Outreach & Education Task Force The goal of the A/B MAC Outreach & Education Task Force is to ensure consistent communication and education to reduce the Medicare Part A and Part B error rates. A joint collaboration of the A/B MACs to communicate national issues of concern regarding improper payments to the Medicare Program. Partnership to educate Medicare providers on widespread topics affecting most providers and complement ongoing efforts of CMS, the MLN and the MACs individual error-reduction activities within its jurisdictions Disclaimer: The CERT A/B MAC Outreach & Education Task Force is independent from the CMS CERT team and CERT contractors, which are responsible for calculation of the Medicare fee-for-service improper payment rate. 34

35 CERT A/B MAC Outreach & Education Task Force CMS works closely with the CERT A/B MAC Task Force and the CERT DME MAC Outreach & Education Task Force CMS has a web page dedicated to education developed by the CERT A/B MAC Outreach & Education Task Force Contracting/FFSProvCustSvcGen/CERT-Outreach-and-Education-Task- Force.html NGS CERT Task Force Web Page Go to our website, in the About Me drop down box, select your provider type and applicable state, click on Next, accept the Attestation. Choose the Medical Policy & Review tab, then choose CERT, the CERT Task Force link is located to the right of the web page. 35

36 National Government Services Website 36

37 Personalized Provider Website New voluntary option for providers to use website more efficiently by creating free account Options to save frequently-used bookmarks, forms, and job aids/manuals for easy access (up to 10 each) Automatically saves recent searches Customizes your News based on your provider type Easy to sign up! NGSConnex users log in using NGSConnex User ID and password 4-step process if not currently a NGSConnex user 37

38 Updates Subscribe to receive the latest Medicare information. 38

39 Website Survey This is your chance to have your voice heard click on Yes, I ll give feedback when you see this pop-up so NGS can make your job easier! 39

40 Medicare University Interactive online system available 24/7 Educational opportunities available Computer-based training courses Teleconferences, webinars, live seminars/face-to-face training Self-report attendance Website 40

41 Thank You! Questions? 41