Medicare Compliance & Reimbursement

The check is in the mail -- really. That's the word from an April 5 CMS Open Door Forum, where CMS's Stewart Streimer said that CMS is in the process of reprocessing claims that were paid incorrectly over the past year.

"I'm hoping that you are starting to see your claims getting reprocessed, and that is those claims that were affected by the Affordable Care Act, or 2010 corrections to the Medicare Physician Fee Schedule, and many of those claims would be for the period of Jan. 1, 2010 through the end of May, 2010," Streimer said. "I'm hoping you're seeing that."

However, if you haven't seen those adjustments come through, don't lose heart. "I hope you understand that we are trying to do this in a deliberate fashion so that all new claims coming into the Medicare program are not delayed or affected by the reprocessing workload," Streimer added. "Clearly, the volume of claims being reprocessed is enormous, and we want to make sure that while we're reprocessing claims, we're not in any way adversely affecting the timeliness of our payments for those new claims coming into the program."

How you'll see the adjustments: The MACs will process the adjustments on a "first in, first out basis," Streimer said, so the oldest claims from 2010 will be processed first, followed by the more recent claim adjustments.

When you'll see the adjustments: Once the reprocessing system identifies you as a practice that should get more money based on the readjustments, it will wait until you are scheduled to collect a regular claims payment, and it will add the readjustment to that regularly-scheduled payment.

During a previous open door forum held on Feb. 22, CMS's William Rogers, MD, told callers that RNs and LPNs can perform annual wellness visits (AWVs), which surprised several people who were on that forum. However, during the most recent April 5 call, Mark Hartstein acting director of CMS's hospital and ambulatory policy group did not confirm this advice. When asked who could perform an AWV, Hartstein read from the original transmittal, which does not specifically identify RNs and LPNs as being eligible, but is more open-ended regarding who qualifies as a "health professional."

When challenged about which advice was accurate, Hartstein said, "I think whatever guidance that you get on whether there are any components of it that need to be provided by a physician should be through the law and the regulations that created the benefit, as well as the change request that implemented the benefit," he said. "Whoever answered the question at the prior open-door forum was probably the subject matter expert and probably gave you more precise, accurate advice." However, he cautioned, until CMS comes out with the advice that RNs and LPNs can perform AWVs in writing, practices should use caution.

One payer, WPS Medicare, already indicates in FAQs on its Web site that "an RN or LPN can perform the visit" under "the direct supervision of a physician" as long as their state license allows it (http://www.wpsmedicare.com/part_b/education/awv-faq.shtml).

One caller to the April 5 forum asked about the Affordable Care Act's mandate that practices must not collect deductibles or coinsurance for annual wellness visits. She indicated that she didn't receive a CMS transmittal warning against collecting these coinsurance and deductibles until March, so her practice had collected copays between January and the March transmittal issue date. She asked whether her practice must repay those copays to the Medicare program, and was disappointed to hear that she has to issue refunds to the affected MACs.

"Yes, we experienced some difficulties with implementing the claims processing aspects of that new benefit," Streimer said. "Claims will be adjusted, and if you did incorrectly collect coinsurance, you need to pay that back."