Medicare Compliance & Reimbursement

This holiday season, CMS has given several gifts that should keep on giving to your practice long into 2012 and beyond. Not only does Medicare plan to start covering annual cardiovascular disease prevention, depression screenings, and alcohol misuse screenings, but the agency also recently announced that it will cover obesity screening and counseling as well.

On Nov. 30, CMS said that Medicare "is adding coverage for preventive services to reduce obesity" in an effort to prevent 1 million heart attacks and strokes over the next five years.

"Obesity is a challenge faced by Americans of all ages, and prevention is crucial for the management and elimination of obesity in our country," CMS's Donald M. Berwick said in a statement.

Under the new decision, primary care providers who screen patients positive for obesity with a BMI of 30 kg/m2 or greater will be eligible for a face-to-face counseling visit each week for a month, followed by face-to-face counseling visits every other week for another five months. If the patient loses at least 6.6 pounds over the first six months, the patient can continue to see the physician for additional obesity counseling once a month for another six months, totaling 12 months of counseling.

To read CMS's coverage decision, visit www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?&NcaName=Intensive%20Behavioral%20Therapy%20for%20Obesity&bc=ACAAAAAAIAAA&NCAId=253&.

When it comes to looming Medicare pay cuts, the government sure likes taking things down to the wire.

Part B practices are facing a 27 percent cut to Medicare rates effective Jan. 1 unless Congress steps in and reverses that cut, which it has done in prior years. However, the recent failure of the country's deficit committee means that the government has not yet instituted any solutions to the issue.

"The AMA is deeply concerned that continued instability in the Medicare program, including the looming 27 percent cut scheduled for January 1, will force many physicians to limit the number of Medicare and TRICARE patients they can care for in their practices," said AMA president Peter W. Carmel, MD, in a Nov. 21 statement. "Congress has ignored the reality that short-term patches have grown the problem immensely. The cost of repealing the formula has grown 525 percent in the past five years and will double again in the next five years."

Keep an eye on this space as we move closer to the Jan. 1 deadline and determine whether cuts will go into effect as planned, or whether Congress will stave them off for another year.

Denials for claims that have ineligible physicians can have a big financial impact, warns consultant Judy Adams with Adams Home Care Consulting in Chapel Hill, N.C. That's because "agencies stand to have all reimbursement for episodes certified by a non-enrolled physician denied, since the MD was not qualified to certify a home health patient," Adams says.

HHAs have a longstanding requirement to check physicians' eligibility, reminds Chicago-based regulatory consultant Rebecca Friedman Zuber. For many years, "agencies have been responsible for ensuring that the physicians from whom they accept referrals and orders are appropriately licensed and have not been excluded from Medicare," Zuber says.

When agencies fail to make the checks or a physician slips through the cracks, HHAs have to eat the costs of the related episodes, says consultant Tom Boyd with Rohnert Park, Calif.-based Boyd & Nicholas.

Part B practices that report chiropractic manipulative treatment code 98941 shouldn't be too eager to collect their reimbursement, thanks to a new prepayment review that this code will trigger when submitted to National Government Services, a Part B payer in Connecticut and New York.

Thanks to a previous review of this code that yielded an alarming 80 percent denial rate, NGS is taking no chances on paying erroneous submissions of 98941. "Medical records will be requested to verify medical necessity of the services provided, and that services were billed according to Medicare Program guidelines," NGS says in its review notice. "If the submitted documentation does not support 98941, the services will either be correctly coded to an appropriate/lower level (98940) or denied," the directive notes.

To read the complete prepayment notice, visit www.ngsmedicare.com.

If you're lax about checking the credentials of your referring physicians, you may soon pay a big price. Sixty-nine home health agencies in the Houston area are already paying it, thanks to submitting claims that listed a physician who was ineligible to enroll in Medicare, according to the Centers for Medicare & Medicaid Services.

Under its new predictive modeling fraud data program, CMS identified claims with 86 such ineligible physicians, a CMS rep tells Eli. And in late August, CMS sent letters to 69 HHAs telling them claims from just one such ineligible physician would be denied starting Sept. 2. After starting with this one case, there are "about 85 similar circumstances that we will also be addressing," the CMS source pledges.

Since its initial run, CMS's Center for Program Integrity has also found more ineligible physicians, the rep adds. CMS can't release the names of the physicians due to HIPAA concerns. Watch for a "second batch" of letters on this topic to go out, the CMS rep says. But CMS will consult with the industry before sending them out.