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ED Coding and Reimbursement Alert

Go Electronic With Your Medicare Claims

Published on Sat Sep 20, 2003

Final rule from CMS mandates e-claims this fall

If you don't submit your claims electronically by Oct. 16, in virtually every circumstance you won't get paid - and you won't be compliant with HIPAA's transaction rule.
 
CMS made that clear in an interim final rule published in the Federal Register Aug. 15. The rule formally requires that Medicare claims be submitted electronically starting Oct. 16, with only a handful of exceptions.
 
CMS makes the biggest exception for small providers and suppliers. CMS defines "small" entities 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
     
  • claims submitted during a service interruption that's beyond the control of the organization submitting the claim.

    CMS notes that practices can appeal to their carriers for special waivers that would excuse them from electronic billing. But carriers will likely grant these waivers only in "extraordinary circumstances," states an alert from attorneys William Sarraille, Laura Cole and Susie Squier with Sidley Austin Brown & Wood in Washington. The agency also says in the rule that it applies to initial Medicare claims - not changes, adjustments or appeals.
     
    Failing to bill electronically by Oct. 16 could saddle you with severe consequences. "The Secretary may audit entities that continue to bill Medicare non-electronically, and those in violation may be subject to claim denials, overpayment recoveries, and applicable interest on overpayments," the Sidley Austin attorneys say.
     
    "If you're not filing electronically, you might as well hang it up," says consultant L. Michael Fleischman, with Gates Moore & Co. in Atlanta. Even if you meet the small-provider exception or receive a special waiver, don't hold your breath waiting for payment from paper claims, he says. Once everyone moves to electronic billing, those few paper claims remaining will fall to the very bottom of the carrier's pile, Fleischman predicts.
     
    Tip: Work with your payers and business partners in advance to ensure that your claims-submission process goes smoothly come Oct. 16. If your practice isn't yet billing electronically, your best bet will be to contact a clearinghouse to start handling your billing for you, Fleischman says. Of course, you must make sure that clearinghouse is HIPAA-ready. Otherwise, you'll be no better off than if you had buried your head in the sand and taken no action at all.

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