Medicare Compliance & Reimbursement

Plus: Prepare to fight a powerful insurance lobby to stop 10 percent pay cut

You can count on one more requirement to make the new year even crazier than usual.

The Centers for Medicare & Medicaid Services (CMS) has set a deadline for Medicare providers to begin using National Provider Identifiers (NPIs). "Effective January 1, 2008, your Medicare fee-for-service claims received must include an NPI in the primary fields on the claim (i.e., the billing and pay-to fields)," CMS says in a message to providers.

You can submit NPI/legacy pairs in those fields or submit only your NPI, CMS explains. If you submit claims with only a legacy provider number in the primary fields, the carrier will return them as unprocessable, CMS says.

Providers can continue to include legacy numbers only for the secondary fields, such as referring physicians, CMS adds.

Tip: If your claims with legacy pairs are processing fine, now's a good time to try submitting a test batch of NPI-only claims, CMS suggests. "This test will serve to assure your claims will successfully process when only the NPI is mandated on all claims."

You May Have To Fight The Managed Care

Lobby To Avoid Massive Cuts

Now's the time to call your Senator. The Senate Finance Committee is working on legislation that would put a stop to your 10-percent pay cut, slated for Jan. 1. The draft bill would pay for the cuts entirely through cuts to payments for Medicare Advantage plans--which means the bill could run into some pretty stiff opposition from powerful lobbying groups, say Capitol Hill insiders.

MA plans are a favorite target amongst lawmakers after the controversy over unethical marketing by so-called private fee-for-service plans (see below). But "this is not a slash-and-burn exercise here on Medicare Advantage," Democratic committee aide Shawn Bishop said in a statement.

Congress is currently working under continuing resolutions (CRs) that allow the government to operate past the Sept. 30 fiscal year end, although no appropriations bills have been passed. More CRs are likely forthcoming, observers note.

In other news...

• You may notice the number of your patients enrolled in private fee-for-service (PFFS) managed care plans on the rise again.

CMS told the seven health plans that halted marketing of PFFS products this summer that they could resume the marketing. "CMS conducted a comprehensive review of these seven sponsors and found vast improvements to their internal controls and oversight processes consistent with regulations and guidance," acting CMS Administrator Kerry Weems said.

Lawmakers aren't so sure. "Talk is cheap and I look forward to action when PFFS plans are again caught misleading Medicare beneficiaries," House Ways & Means Health Subcommittee Chair Pete Stark (D-CA) said.

• He's old enough to be a Medicare recipient, but 80-year-old physician Orestes Alvarez-Jacinto took part in a scam that bilked $7 million from Medicare for HIV medications, say prosecutors. Alvarez-Jacinto will serve 18 months in prison for prescribing medications that the HIV patients didn't need and which he knew could harm them.

• Some clearinghouses are still stripping the National Provider Identifiers (NPIs) from claims, and some billing services aren't adding the NPIs even when providers ask them to, CMS warns. This could have a drastic effect on your cash flow, especially as carriers turn on edits to validate NPI/legacy pairs against the NPI crosswalk.