Medicare Compliance & Reimbursement

If you enrolled in Medicare before March 25, 2011, the Affordable Care Act requires you to revalidate your enrollment information — but practices that haven’t yet done that are probably hearing from their MACs by now.

The various MACs have been sending out revalidation requests for the past few years, and will continue to do so through March 23, 2015. Some practices, however, are confused about how to handle these requests, and Part B MAC National Government Services (NGS) recently sent out an instructional note about what to do if you receive one of its “yellow envelopes,” which contain the revalidation information.

As long as you respond within 60 days of the postmark date on the letter, you won’t hold up your payments (or deactivate your billing privileges), but you should complete the application as soon as possible. The fastest way, NGS says, is to log into the Provider Enrollment Chain and Ownership System (PECOS) and submit your revalidation that way. It will require you to electronically verify your information, make any changes or updates, sign the application online, and upload any supporting documents.

If you aren’t able to access the information via PECOS, you can submit the paper CMS-855 form. Make sure your legal name on the form exactly matches the name on record with Medicare, and double check your NPI and PTAN to ensure that the revalidation goes smoothly. For more on revalidation, visit your MAC’s website or call its provider relations phone number.

Ever Feel Like Auditors Are on A Witch Hunt? CMS Responds

If you get frustrated over auditors’ reviews of your claims, you aren’t alone. A caller to CMS’s Jan. 7 Open Door Forum questioned whether the Centers for Medicare & Medicaid Services (CMS) is just performing fishing expeditions, finding practices guilty until proven innocent — and one CMS official explained why.

“Observation management codes, if they’re less than eight hours, they don’t count,” the caller said. Auditors, however, have no idea about whether submitted observation care codes reflect services performed for less than eight hours or not until they receive the practices’ paperwork. “We always give the information and it’s always legitimate and they keep asking for it, and it’s a real hassle to keep getting this information,” the caller said. “They just keep fishing for it… is that okay? Is that why we’re doing that? I thought we were just looking for the bad actors.”

“We are looking for the bad actors,” responded CMS’s William Rogers, MD, who acknowledged that as a physician he always wishes it were easier to submit information when auditors request it, but as a CMS official, “to see the amount of erroneous and fraudulent billing going on, it’s just unbelievable.”

“We can use the types of technique that credit card companies use to look for aberrant patterns, and that’s helpful,” Rogers said. “But to a certain extent some of it just has to be brute force asking for information and looking for problems that don’t pop up when we look at billing aberrancies and it is a huge hassle for you, but like all rules, if everyone was honest we wouldn’t need these rules and our lives would be much simpler.”

“Unfortunately,” Rogers added, “there are a whole lot of people who are either not reading the instructions or are intentionally defrauding the taxpayer and we are held responsible for those payments,” he said. “Of course there is a cost to the taxpayer so we don’t want to do it excessively.” So CMS must strike to a balance, which can be frustrating for practices but is a necessary evil.

Meet New Home Health RAC

If you get hit by Recovery Audit Contractor review, it may go more smoothly. CMS has granted a new contract to have one RAC for home health, hospice and DME issues, it says on its website. “CMS has awarded the Region 5 Recovery Audit contract to Connolly, LLC,” CMS said Dec. 30. “The purpose of this contract will be to support [CMS] in completing this mission through the identification and correction of improper payments for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), and home health/hospice (HH/H) claims.”

The RAC will review claims and work with CMS and the MACs to adjust claims to recoup overpayments and pay underpayments, CMS explains.

Plus: “This award marks the beginning of the new Recovery Audit contracts and is the start date of the implementation of many improvements to reduce provider burden and increase transparency in the program,” CMS adds.

Pro: Those changes include requiring RACs to have a 10 percent or less overturn rate on appeal, CMS says on its site.

Con: CMS also pledges that RACs will focus on more than just hospital inpatient claims. That could mean more review of home health and hospice claims.

These changes, plus the appointment of a RAC provider relations coordinator which CMS announced last summer, should help home care providers with their RAC-related issues, expects financial consultant Tom Boyd with Simione Consulting in Rohnert Park, Calif.

MAC Puts Expanded F2F Review On Hold

You’ve got one less face-to-face headache to deal with — for the moment.

Then: In a Dec. 8, 2014 message to providers, Home Health & Hospice MAC CGS said, “For home health claims reviewed on or after January 1, 2015, CGS will begin reviewing the face-to-face (FTF) encounter documentation for all home health episodes, including the initial (Start of Care) and subsequent episodes for appropriateness. Previously, CGS only reviewed the FTF documentation when reviewing initial (Start of Care) claims. However, because the FTF documentation is a requirement for Medicare payment, all additional development requests (ADRs) for home health claims must include the FTF documentation.”

Now: “Plans for this future process change have been suspended as of December 11, 2014, pending further clarification,” CGS says in a new message to providers