Medicare Presentation

Report
MPAA MEETING
WPS MEDICARE UPDATES
JANET MATEO
MEDICARE PART A OUTREACH ANALYST
01/02/2015
AGENDA
• Probe and Educate Process
• Probe 1 and 2 Results
• What’s New
• Review of Timely Filing Requirements
Exception Process
• Incarcerated Beneficiary Update
• WPS Medicare Updates
01/02/2015
PROBE AND EDUCATE PROCESS
PROBE 1 RESULTS
01/02/2015
PROBE 1
Part A Hospital
Provider Count
# of Providers
Sampled
# of Claims
Reviewed
J5
J8
800*
300*
412
151
3,625
*1,328
* Approximate Number
01/02/2015
OVERALL DENIAL RATE
J5
27%
01/02/2015
J8
26%
DENIALS BY TYPE
J8
01/02/2015
5PC01
Documentation does not support services
medically reasonable/necessary
5PC02
Insufficient documentation
5PC12
Order missing
5PC13
Order unsigned
5PC15
Certification not present
5PC17
No documentation of 2-midnight
expectation
PROBE 2 ESTIMATED TIMELINE
01/02/2015
PROBE 2 REVIEWS
• Prepay
• Reason code 5CR85
• For WPS Medicare providers
• Begins with admission dates 60 days from
date of final letter offering education
• Includes providers with
• Moderate or high levels of concern
• Incomplete or no claims in Probe 1
01/02/2015
PROBE 2
Part A Hospital
Provider Count
% of Claims
Completed
Top Denial Code
New in Probe 2
•
01/02/2015
J5
J8
736
253
32%
35%
5PC01
5PC01
5PC11 - Procedure not reasonable and
necessary
TIPS
• Verify your procedures for inclusion on the
inpatient-only list
• Include the signed admission order
• Compare physician notes to orders
• Document changes in expected patient
care
01/02/2015
REVIEW RESULTS
WH A T M A C S A R E C U R R E N T L Y S E E I N G
01/02/2015
MISSING OR FLAWED ORDER
• Error
• Physician order states “observation” but facility
billed as an inpatient
• Prevention
• Use specific language for inpatient orders
• Remember all care is outpatient care in the
absence of an inpatient order
01/02/2015
SHORT STAY PROCEDURES
• Error
• Patient presented for short stay procedure and
discharged the next day
• Prevention
• Procedures with typical expected length of stay of
less than two midnights are outpatient for payment
purposes
• Multiple short-stay procedures performed together ≠
an inpatient procedure
• In the absence of a two-midnight expectation
01/02/2015
UNCERTAIN COURSE
• Error
• Patient with complaints of dizziness
• Physician notes state intention to monitor overnight
but patient admitted and inpatient claim billed
• Prevention
• If clinical course uncertain, utilize outpatient
observation
• Keep as outpatient until clear the patient requires
two midnights of care
01/02/2015
ATTESTATION WITHOUT SUPPORT
• Error
• Checkbox stating “The beneficiary is expected to
require two or more midnights of hospital care”
• Physician notes state “plan to discharge in the
morning if stable” and patient discharged next day
• Prevention
• Certification statements not required or adequate to
support payment
• Expectation must be supported by entire medical
record
01/02/2015
INCOMPLETE DOCUMENTATION
• Error
• Incomplete medical record submitted
• Most common items missing include:
• Medication Administration Records (MARs)
• Nurses notes
• Prevention
• Verify the entire record is being submitted
• Review record to ensure it is legible
01/02/2015
WHAT’S NEW
2015 UPDATES
01/02/2015
IPPS UPDATES
CR 8900
• Provides FY 2015 updates to the Acute
Hospital IPPS and LTCH PPS
01/02/2015
OPPS UPDATES
CR 9014
• Describes changes to billing instructions for
various policies implemented in the January
2015, OPPS update
• Revision to certification requirements
01/02/2015
JANUARY 1, 2015, CHANGES
CMS currently requires a physician
certification, including an admission order and
certain additional elements, for all inpatient
admissions. CMS finalized its proposal to
require the physician certification only for
outlier cases and long-stay cases of 20 days or
more. The admission order will continue to be
required for all inpatient admissions when a
patient has been formally admitted as an
inpatient of the hospital.
01/02/2015
REVISION TO CERTIFICATION
REQUIREMENTS
• Inpatient certification requirements
eliminated
• For short stays < 20 days
• No changes for inpatient psychiatric hospital
or inpatient rehabilitation facility
01/02/2015
FURTHER CLARIFICATION
• Stays 20 days or greater and outlier cases
• Formal physician certification
• Reason for hospitalization
• Estimated time to remain in hospital
• Plan for post-hospital care
01/02/2015
REVISION TO CERTIFICATION
REQUIREMENTS - CAHS
• Effective for admissions on or after
October 1, 2014, certification required
• One day prior to the day the Part A bill is
submitted
01/02/2015
PAYMENT POLICIES RELATED TO PATIENT
STATUS – CMS-1599-F
• CR 8959
• Inpatient routine services in a hospital
include
• Room and board charges
•
•
•
•
01/02/2015
Regular room, dietary and nursing services
Minor medical and surgical supplies
Medical social services, psychiatric social services
Use of certain equipment and facilities
THERAPY CAPS
• Financial limitation for 2015
• $1,940 for OT
• $1,940 for PT/SLP combined
• Associated policies in effect until 3/31/15
• Exceptions process (KX modifier)
• Manual medical review ($3,700 threshold)
01/02/2015
UPDATE TO THERAPY CODE LIST
CR 8985
• Updates the 2015 therapy code list
• Added two “Sometimes Therapy” codes
• Deleted two “Sometimes Therapy” codes
01/02/2015
2015 UPDATES TO RHC AND FQHC
SERVICES
CR 8981
• Includes new and clarifying information on FQHC
PPS and RHC updates
01/02/2015
SPECIFIC MODIFIERS FOR DISTINCT
PROCEDURAL SERVICES
CR 8863
• Four new HCPCS modifiers established to
define subsets of the -59 modifier
• Modifier 59 is associated with considerable
high levels of abuse leading to:
• Reviews
• Appeals
• Civil fraud and abuse cases
01/02/2015
FOUR NEW HCPCS MODIFIERS
• Collectively referred to as –X {EPSU}
• Selectively identify subset of Distinct
Procedural Services
• 59 Modifier still accepted
• Should not be used when a more descriptive
modifier is available
• CMS may require more specific modifier for billing
certain codes at high risk for incorrect billing
01/02/2015
-X {EPSU}
• XE – Separate Encounter
• Service occurred during a separate encounter
• XS – Separate Structure
• Service performed on a separate organ or
structure
• XP – Separate Practitioner
• Service performed by a different practitioner
• XU – Unusual Non-Overlapping Service
• Does not overlap usual components of the main
service
01/02/2015
2015 AMOUNTS
CR 8982
•
•
•
•
•
Part A Deductible - $1,260
Part B Deductible - $147
Hospital Coinsurance - $304
Lifetime Reserve Days - $630
Skilled Coinsurance - $157.50
01/02/2015
REVIEW OF TIMELY FILING
REQUIREMENTS
01/02/2015
TIMELY FILING REGULATIONS
• Claims must be filed within one calendar year
after the Date of Service (DOS)
• Through date used to determine timely filing
deadline
• For institutional claims
• Claims in Return to Provider (RTP) status (T
B9997) are not considered properly submitted
claims
01/02/2015
FILING A CLAIM BEYOND THE TIMELY
FILING LIMIT
• Provider is responsible
• Claims should be processed
• Spell-of-illness implications and/or
• To record the days, visits, cash and blood
deductibles
01/02/2015
FILING A CLAIM BEYOND THE TIMELY
FILING LIMIT
• Beneficiary is charged utilization days,
Beneficiary may not be charged for the
services
• Except for applicable deductible and/or
coinsurance amounts
• Providers may not appeal a timely filing
rejection
01/02/2015
FILING A CLAIM BEYOND THE TIMELY
FILING LIMIT
• Provider believes the beneficiary is
responsible for late filing
• File claim
• Put “TIMELY-BENE” on the first line of remarks section
• Include a statement in the remarks field
• Usual appeal rights are available to the
beneficiary
01/02/2015
EXCEPTIONS TO TIMELY FILING
REQUIREMENT
Administrator Error
• Misrepresentation, delay, mistake or other
action by Medicare or its contractors
• Time limit will be extended through the last day of
the 6th calendar month
• Request for extension only accepted up to 4 years
from the DOS
01/02/2015
EXCEPTIONS TO TIMELY FILING
REQUIREMENT
Retroactive Entitlement
• Beneficiary was not entitled to Medicare at
the time the service was furnished
• Beneficiary subsequently received notification
of retroactive Medicare entitlement to or
before the DOS
01/02/2015
EXCEPTIONS TO TIMELY FILING
REQUIREMENT
Medicaid Agencies
• At the time the service was furnished the
beneficiary was not entitled to Medicare
• The beneficiary subsequently received
notification of Medicare entitlement effective
retroactively to or before the date of the
furnished service
01/02/2015
EXCEPTIONS TO TIMELY FILING
REQUIREMENT
Retroactive Disenrollment from Medicare
Advantage (MA) Plan
• At the time the service was furnished the
beneficiary was believed to be enrolled in a
MA plan
• The beneficiary was subsequently disenrolled
from the MA plan
• Effective retroactively to or before the date of the
furnished service
01/02/2015
EXCEPTIONS TO TIMELY FILING
REQUIREMENT
Retroactive Disenrollment from Medicare
Advantage (MA) Plan
• The MA plan recovered its payment for the
furnished service from a provider or supplier 6
months or more after the service was
furnished
01/02/2015
TIMELY FILING EXTENSION TIPS
• First line of the remarks page should include a
2 digit justification for timeliness reason code
• Additional remarks can be added to line 2
• Explanation of circumstances which led to late
filing/why party is responsible
• Request an extension to timely filing in writing
01/02/2015
TIMELY FILING EXTENSION TIPS
• Request for timely filing should be submitted
with:
• A copy of the claim describing the services
furnished
• Official SSA letter, if available
• Based on justification for timeliness reason code used
• Mail to General mailing address on the WPS
Medicare website
• http://www.wpsmedicare.com/j8macparta/contact_us/maili
ng-address-info.shtml
01/02/2015
REQUEST FOR REOPENING CLAIMS BEYOND
TIMELY FILING LIMITS
• CR 8581
• Standardizing the Process
• CMS recognized MACs lacked a standard process
for reopenings
• CMS petitioned NUBC for:
• Bill type frequency code to indicate a reopening
request
• Condition codes to identify type of reopening
• Effective for claims received on or after April 1,
2015
01/02/2015
WPS MEDICARE UPDATES
01/02/2015
CERT PROGRAM IDENTIFIED ERRORS
01/02/2015
CERT TASK FORCE
• MACs collaborate to educate
• Goal: reduce National payment error rate
• Departments>CERT>CERT A/B MAC
Outreach & Education Task Force
01/02/2015
C-SNAP ENHANCEMENTS
• Appeals status
• Discharge Status
• Submitting documentation through C-SNAP
• Coming Soon
01/02/2015
FUNCTIONALITY & BENEFITS
• Functionality
•
•
•
•
Upload your Medical Documentation
For all claims associated with a Probe
For an Additional Development Request (ADR)
For a returned to provider (RTP) claim requesting
Medical Documentation
• Verify Documentation Submitted
• View submitted documentation for up to 75 days
• Verify the status of the review
01/02/2015
FUNCTIONALITY & BENEFITS
• Benefits
• Free
• No printing costs
• No postage costs
• No esMD costs
• Time Saving
• Reduced records preparation time
• No paper forms to fill out
01/02/2015
FUNCTIONALITY & BENEFITS
• Benefits
• Instant Confirmation
•
•
•
•
Receive a confirmation number
Links directly to claim
No lost records
No fax issues
• No Shipping Delay
• Reduce days to payment
• Available 24/7
• For documentation submission
01/02/2015
COUNTDOWN TO ICD-10
• Compliance date is 10/01/2015
• Resources
• SE1410 - ICD-10
• CMS website
• www.cms.gov > Medicare > ICD-10
• WPS Medicare
• www.wpsmedicare.com > J8 MAC Part A > Claims > ICD10
01/02/2015
ICD-10 TESTING RESULTS
• Acknowledgement Testing in March
• Approximately 2,600 testers participated
• 50% were clearinghouses
• Over 127,000 claims submitted
• 89% of claims accepted by CMS
• Some intentionally submitted with errors
01/02/2015
END-TO-END TESTING
SE 1409
• Volunteer for upcoming ICD-10 End-to-End
Testing
• April 27 – May 1, 2015
• Additional opportunity for testing available
• July 20 – 24, 2015
01/02/2015
ACKNOWLEDGEMENT TESTING
• Upcoming testing weeks
• March 2-6, 2015
• June 1-5, 2015
• WPS Medicare will be appropriately staffed
to handle increased call volume via the EDI
Help Desk
01/02/2015
ACKNOWLEDGEMENT TESTING
• Acknowledgment test claims can be
submitted anytime up to the October 1,
2015, implementation date
• Registration is not required for these virtual events
01/02/2015
TOP 5 REASONS FOR REJECTS
• Invalid ICD-10 diagnosis code
• Some because they used dates of service that
were prior to the effective date of code on the
CEM reference file
• Invalid procedure code
• Caused by CEM issue
01/02/2015
TOP 5 REASONS FOR REJECTS
• Future dates of service used
• Must use current dates
• Missing Data
• Not necessarily related to ICD-10
• Other
• Invalid data not related to ICD-10
01/02/2015
CLAIM SUBMISSION ALTERNATIVES
• PC- ACE-PRO 32 Free Software
• Available to providers that do not complete the
necessary system changes to submit claims with
ICD-10 codes by October 1, 2015
• Software has been updated to support ICD-10
codes
• Does not provide coding assistance
• Allows providers to submit claims in ICD-10 claim
submission format
01/02/2015
MONITORING YOUR BUSINESS WITH
MEDICARE EDI
• All submitters of electronic claim files should use the
tools available to monitor your business
•
•
•
•
•
Read 999 responses
Read 277CA responses
Review the Medicare remittances
Monitor cash flow
Identify and correct any issues identified in a timely manner
01/02/2015
ELECTRONIC REMITTANCE ADVICE (ERA)
GO GREEN !
• Providers are encouraged to switch from
receiving standard paper remittance
advices to electronic remittance advice
• Using ERA saves time and
• Increases productivity
• Provides electronic payment adjustment
information that is portable, reusable, retrievable,
and storable
01/02/2015
MEDICARE SECONDARY PAYER (MSP)
UPDATE
• MSP hotlines consolidated to one toll free
number
• (866) 734-1521
• Effective November 17, 2014
• Will provide prompts for call routing to the
appropriate staff
• J5/J8, Part A/B
01/02/2015
MSP UPDATE
CR 8456
• Effective October 6, 2014, up to 25 iterations
of diagnosis codes associated with MSP nofault, liability, and workers’ compensation
records will be included on the HETS 271
response transaction
• Diagnosis codes will assist providers in better
determining when Medicare is the secondary
payer
01/02/2015
MSP GROUP HEALTH PLAN (GHP)
WORKING AGED POLICY UPDATE
CR 8875
• Under the MSP Working Aged provisions,
“spouse” applies to both opposite and
same sex marriages
• Effective January 2015
01/02/2015
BILLING MSP CLAIMS - 5010
• MSP claims must be sent electronically
• Not an Administrative Simplification Compliance
Act (ASCA) exception
• Avoid front end rejections, delays and
unprocessable rejections
• http://www.wpsic.com/edi/files/msp5010A1.pdf
01/02/2015
AVOID DELAYS AND UNPROCESSABLE
CLAIMS
• Important to determine the correct insurance
type code
• Always give the MSP insurance type code
• Give the complete primary payer’s name
and address
01/02/2015
AVOID DELAYS AND UNPROCESSABLE
CLAIMS
• Do not confuse the payers
• Medigap or Medicaid information should not be
reported in the primary insurance record
• Primary paid amount should not exceed the
billed amount
• Primary paid amounts at the claim level
should agree with line level
01/02/2015
REVALIDATION OF PROVIDER
ENROLLMENT INFORMATION
• All providers enrolled in Medicare prior to
March 25, 2011, must revalidate provider
enrollment information by March 2015
• Only after receiving notification from WPS
Medicare
01/02/2015
ENHANCED INTERNET-BASED PECOS
• Facilities are encouraged to utilize PECOS
to:
• Revalidate the CMS-855 Medicare enrollment
application
• Enroll in the Medicare Program
• Enhanced internet-based PECOS is easy,
fast and secure
01/02/2015
PROVIDER ENROLLMENT APPLICATIONS
• To ensure your application is not delayed, take a
second look
• Review your application for the following:
• Appropriate documentation
• Completion of all fields in all sections
• Signed and dated Authorization or Certification statement
01/02/2015
01/02/2015
PROVIDER ENROLLMENT NAVIGATOR
• Interactive tool to expedite processing
• Helps identify required information
• Asks a series of questions
• Guides you to correct forms
• Links provided
• Ensures submission to correct address
• Saves time and re-work
• Contact information
• Assistance with completion or submission
01/02/2015
ENROLLMENT STATUS
Status Dates:
Assigned
Initial Review
Development
In PECOS
Closed
Electronic Funds
Transfer (EFT) Initial
Letter Sent
• EFT Second Letter Sent
• EFT Approved
•
•
•
•
•
•
01/02/2015
Processing Statuses
• Processing
• Provider Enrollment
Chain and Ownership
System (PECOS) is
Approved
• Returned
• Denial
• Rejection
• Recommended
• Completed
ENROLLMENT APPLICATION STATUS
INQUIRY
• Web based system
• Confirms receipt of new applications via email
• Provides Application ID
• Link to EASI website
• Provides status during process
Current e-mail address in Section 13 will
ensure application ID and all other notifications are
received.
01/02/2015
APPEALS FORM SELECTOR
• Interactive tool to expedite processing
• Helps decide if appeal or not
• Asks a series of questions
• Guides you to correct form
• Links provided
• Ensures submission to correct address
• Saves time and re-work
01/02/2015
01/02/2015
INCARCERATED BENEFICIARY UPDATE
01/02/2015
INCARCERATED BENEFICIARY CLAIMS
• Some overpayments for incarcerated
beneficiaries were valid and were not
refunded
• If a claim was erroneously designated as a
overpayment, you may request a reopening
• Funds recovered and not subsequently refunded
01/02/2015
INCARCERATED BENEFICIARY CLAIM
• If the facility received a Remittance Advice
indicating a temporary allowance without
supporting documentation
• Contact WPS Medicare to request an explanation
01/02/2015
WEBSITE SATISFACTION
• Comments help enhance website
• Please be specific
01/02/2015
SELF SERVICE TOOLS
• No limits
• Available when you are
• No wait, or hold time
• Easy answers
• Multiple users at one time
• Most current information available
01/02/2015
01/02/2015
DISCLAIMER
This program is presented for
informational purposes only.
Current Medicare regulations
will always prevail.
01/02/2015

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