Medicare Compliance & Reimbursement
CMS to Start Denying Claims That Don't Meet Ordering/Referring Edits 'Soon'
If a new CMS news release is any indication, the agency might soon follow through on its longstanding threat to deny claims that fail the ordering/referring provider edits. Although CMS has had this on the horizon for several years now, the agency has never actually formalized a date when the denials would start. However, a July 26 news release indicates that CMS "will soon begin denying Part B, DME, and Part A HHA claims that fail the ordering/referring provider edits." Although CMS has still not set a date, it warns providers that once it does, it will only offer a 60-day notice before the edits are turned on, so you should prepare now. Background: Part B reminder: Resource: CMS Grants 'CLIA-Waived' Status to 11 Additional Lab Tests Part B practices will benefit from 11 additional tests now classified as "CLIA-waived," thanks to a July 20 CMS article on this topic. According to MLN Matters article MM7868, CMS will consider the following tests CLIA-waived. You'll have to append modifier QW (CLIA-waived test) to these codes, which include the following, among others: To read the complete CMS transmittal on the new CLIA-waived tests, visit the CMS Web site at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7868.pdf. Cardio Office Visits Are on the OIG Radar Your office visits may be coming under increased scrutiny. A recent OIG study found that physicians increased their billing of higher-level E/M codes across all categories (inpatient, outpatient, etc.) between 2001 and 2010. According to the OIG report, when compared to other specialties, cardiology ranked near the top for billing higher-level E/M codes. Many reasons exist that could cause a practice to legitimately begin coding more high-level E/M services than in the past. For instance, the practice may have begun seeing a more complex patient population with more chronic problems that require intense management. But if you aren't sure how your physicians arrive at their E/M codes, it's time to offer a quick education session at your practice. The OIG recommends coding education as the number one priority following the results of this report, and also encouraged MACs to review physicians' E/M billing patterns to avoid improper payments. To read the complete report, "Coding Trends of Medicare Evaluation and Management Services," visit oig.hhs.gov/oei/reports/oei-04-10-00180.pdf. Affordable Care Act Already Having Effect In the wake of the U.S. Supreme Court's ruling upholding the Patient Protection and Affordable Care Act ("Obamacare"), the effects are already evident on the ground, says Maggie M. Mac, CPC, CEMC, CHC, CMM, ICCE, president of Maggie Mac-Medical Practice Consulting in Clearwater, Fla., and Brooklyn, N.Y. "I'm already starting to see a major transition of Medicaid services to mandatory plans that will provide greater benefits to the patient in an attempt to keep patients out of the hospital and/or long term care facilities," says Mac. "And there is a swing in New York to enroll dual eligibles (Medicare and Medicaid) who qualify for long-term care plans into Medicare Advantage programs. These initiatives will save billions of dollars in healthcare spending." More changes: Effects hitting home: Don't Count On ICD-11 Transition Despite endorsement of a direct move to ICD-11 from the American Medical Association and others, don't be surprised to see CMS ignore that advice. "It took the U.S. eight years to adapt the WHO version of ICD-10 and create ICD-10-CM for use in this country," the American Health Information Management Association (AHIMA) counters in a recent article. "Regardless of the benefits of ICD-11, the U.S. would need a national version to allow for the annual updating required by Congress and U.S. stakeholders. Assuming that the development timeline for a national version or clinical modification of ICD-11 could be cut in half down to four years, it would then take an additional two years to get through the HIPAA rulemaking process. As with ICD-10-CM/PCS, the industry would want at least a three-year period for converting systems to ICD-11," the AHIMA article says. End result: Private Payer Partnership Bolsters Government's Compliance Efforts You'll have more eyes looking over your claims for fraud, thanks to a new partnership between the Department of Health and Human Services and the insurance industry. The coalition includes 10 insurance plans (including Humana, some Blues plans, UnitedHealth, and more), industry groups, and government and law enforcement agencies, HHS says in a release. "The new partnership is designed to share information and best practices in order to improve detection and prevent payment of fraudulent health care billings," HHS says. "Its goal is to reveal and halt scams that cut across a number of public and private payers." Providers remain wary of the sharing of their billing data under this project, experts say.
Medicare Compliance & Reimbursement
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Watch Out: These New Alternative Sanctions Could Put You Out Of Business
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CMS to Start Denying Claims That Don't Meet Ordering/Referring Edits 'Soon'
If a new CMS news release is any indication, the agency might soon follow through [...]
