Compliance Update: Go Electronic With Medicare Claims

Handle the electronic filing final rule with confidence
CMS recently offered some wiggle room on its rule mandating electronic claims by Oct. 16 - but only for providers making good-faith efforts to comply with HIPAA. The agency will allow noncompliant transactions after the Oct. 16 deadline to allow for a transition period, but it did not specify how long the period will last.
The interim final rule, which appeared in the Federal Register Aug. 15, formally requires all providers to submit Medicare claims electronically, with only a handful of exceptions.
The biggest exception is for small providers and suppliers. CMS defines a "small" entity as either a) a provider of services with fewer than 25 full-time equivalent employees, or b) a physician, practitioner, facility or supplier with fewer than 10 full-time employees. The rest of the exceptions, as a rule, are pretty arcane. They include:
Circumstances in which there is no method available for the submission of an electronic claim - claims submitted directly by beneficiaries, for example, would fall into this category, as would roster billing of vaccinations, claims submitted under Medicare demonstration projects, and claims in which more than one plan is responsible for payment prior to Medicare; and
Claims submitted during a service interruption that's beyond the control of the organization submitting
the claim.
CMS states that facilities can appeal to their fiscal intermediaries (FIs) for special waivers that would excuse them from electronic billing. But FIs will likely grant these waivers only in "extraordinary circumstances," says an alert from attorneys William Sarraille, Laura Cole and Susie Squier with Sidley Austin Brown & Wood in Washington. The agency also points out in the rule that it applies to initial Medicare claims - not changes, adjustments
or appeals.

Even if you meet the small-provider exception or receive a special waiver, says consultant L. Michael Fleischman with Gates Moore & Co. in Atlanta, don't hold your breath waiting for payment from paper claims. Once everyone moves to electronic billing, those few paper claims remaining will fall to the very bottom of the FI's pile, Fleischman predicts.
Tip: Work with your payers and business partners in advance to ensure that your claims submission process goes smoothly this fall. If your facility isn't yet billing electronically, your best bet will be to contact a clearinghouse to start handling your billing for you, Fleischman says.
To see the full text of the rule, go to http://a257.g.akamaitech.net/7/257/2422/14mar20010800/edocket.access.gpo.gov/2003/03-20955.htm.
 

- Published on 2003-10-06