Posts Tagged Medicaid
By Delly Parham, CPC
As of April 1, the deficit control measure known as sequestration mandated a 2 percent decrease on payments to fee-for-service healthcare providers for services to Medicare Part A and B beneficiaries. Although hardly good news, cuts to the Medicare program are lower than cuts made to other federal programs. Here is what you should know about how the 2 percent decrease affects your reimbursement.
Under sequestration, be aware that:
- The current allowed fees remain unchanged
- The 2 percent reduction will not apply to the deductible or coinsurance owed by the patient
- The 2 percent is calculated only on the amount actually paid to the provider or patient, and not to the amount allowed
- The effects of sequestration apply differently for participating and non-participating providers
The 2 percent reduction began with dates of service and dates of discharge after April 1, 2013 (The mandate is divided into two parts: Part one of this two-part mandate covers only the period through 12/31/13. Part two covers the period 2014 through 2021, but there could be many changes by 2014.)
Participating Providers
If you are a participating provider with Medicare (this means enrolled in the Medicare program for Part A or Part B beneficiaries), Medicare will apply the 2 percent reduction only to the amount paid to you. In other words, the 2 percent will be taken from only the calculated payment amount after the deductible is met, and it does not include the co-insurance. For example:
| Medicare approved amount |
$100.00 |
Medicare allowable before deductible & coinsurance |
| Deductible |
$50.00 |
Patient pays this amount |
| Amount after deductible |
$50.00 |
Medicare will pay 80 percent of this amount |
| Patient 20 percent coinsurance |
$10.00 |
Patient pays this amount |
| Medicare payment to provider |
$40.00 |
Before 2 percent reduction |
|
$00.80 |
2 percent reduction |
| Paid to provider after reduction |
$39.20 |
Provider is paid this amount |
The claim adjustment reason code 223 will be displayed next to the line item on the electronic or paper remittance advice for Part B providers, and at the end of the claim for Part A providers.
Non-Participating Providers
If you are a non-participating provider (not enrolled in the Medicare program), and you see Medicare Part A and Part B patients, you will not be affected by this reduction; however, you must take the following actions:
• You must notify Medicare patients of this mandate.
• Your Medicare patients will be liable for the full limiting charge (115 percent of Medicare allowable). For example, if the total limiting charge is $109.25, you may collect this amount from the patient.
• Medicare will apply the 2 percent reduction to the actual amount paid to your patients, for example:
| Medicare approved amount |
$95.00 |
Medicare allowable before deductible & coinsurance |
| Deductible |
$50.00 |
Patient is responsible for this (not reduced) |
| Amount after deductible |
$45.00 |
Medicare pays 80 percent of this amount |
| Amount to patient before2 percent reduction |
$36.00 |
Apply 2 percent reduction |
|
$00.72 |
2% Reduction |
| Reduced Payment |
$35.28 |
Patient will receive this amount |
If you have any questions specific to your practice, contact your Medicare carrier or Medicare Administrative Contractor (MAC) in your region.
Sources:
(http://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Downloads/2013-03-08-standalone.pdf
http://medicare.fcso.com/Fee_news/251772.asp, Federal Sequestration Payment Reductions
April 19th, 2013
By Delly Parham, CPC
Using locum tenens physicians to fill in for regular physicians may cost your practice instead of helping it if you don’t understand how to bill for their services. To ensure you get paid and stay in compliance, you must adhere to Medicare and commercial payer guidelines.
Practices usually use locum tenens (Latin for “lieutenant”) physicians when the regular physician is absent because of vacation, illness, childbirth, business, education, active duty, or having left the practice. The advantages of hiring a locum tenens physician versus using a physician in the same practice or in the same area are that it:
- Retains the regular physician’s existing patients
- Introduces new patients to the practice
- Maintains the patient level
- Keeps revenue with the regular physician
Most practices using the services of a locum tenens go through a recruiting agency, such as Comp Health. These companies handle the licensing requirements, professional liability insurance, and screening of the locum tenens, taking the liability and burden off practices. The practice or group pays the recruiting agency, and the agency pays the locum tenens physician. If your practice chooses to hire the locum tenens directly, you must:
- Check your state licensing laws for licensing requirements. Most – if not all – states require physicians be licensed in that state.
- Check with your professional liability insurance carrier.
- Make sure the locum tenens is in good standing and get his or her professional liability insurance certificate, verifying it covers the services the locum tenens will be performing for the regular physician.
Whether you use a recruiting agency or hire the locum tenens physician directly, the practice must:
- Train staff with information about locum tenens physician to retain patients with the regular physician and give them incentive to see locum tenens without fear, for example:
- The locum tenens is temporary and will only see them once or for a short period of time.
- The locum tenens’ experience and expertise as a physician.
The period for which a single locum tenens physician may substitute cannot be more than 60 continuous days. The 60-day period begins the first day the locum tenens physician provides services for Medicare patients of the regular physician. An exception to this 60-day rule is for regular physicians who are called to active duty in the armed forces. The time is unlimited. See Social Security Act at section 1842(b)(6)(D.)
The regular physician:
- Must schedule appointments under his or her schedule.
- Is the only physician who can break the locum tenens’ 60-day period.
- May re-set the 60-day period by returning to practice and see patients only one day after the initial 60-days and use the same locum tenens.
- Must bill for the services of the locum tenens.
- Must put his or her NPI number on all claims filed.
- May use more than one locum tenens to substitute for absences during the 60-day period.
- May reimburse the locum tenens a fixed amount per diem or similar fee for time.
- Must keep a record of each service furnished by the locum tenens physician and the NPI.
A locum tenens physician:
- Fills in for the regular physician for 60 continuous calendar days.
- Can substitute only if the regular physician is absent for any of the reasons above.
- Cannot substitute more than 60 continuous calendar days, unless there is a break in the 60-day by the regular physician.
- Cannot re-set the 60-day clock by taking a day off.
- Generally does not have a practice of his or her own and moves from area to area as needed.
- Is usually an independent contractor of the regular physician or group rather than an employee.
- Does not have to be enrolled in the Medicare program to see Medicare patients
- Cannot be a non-physician practitioner (e.g., NPs, CRNAs, PAs).
- Cannot bill Medicare for services within the 60-day continuous period in his or her name or NPI.
The regular physician bills and receives payment from Medicare and other payers who follow Medicare’s guidelines for the locum tenens physician’s services as though the regular physician performs the services. The regular physician must put the regular physician NPI in box 24J and his or her name in box 31 of CMS 1500 and the regular physician or group name and NPI in box 33 of the CMS 1500. Other Medicare rules include:
- Use the name and NPI of the regular physician or group.
- Use modifier Q6 after the procedure code (Q6 identifies services by locum tenens physician).
- If the only service a locum tenens physician performs is post-operative for an operation within a global period, it cannot be billed with Q6 modifier because the regular physician is paid a global fee, and it is not necessary to include the service on the claim.
- If a regular physician requires that the locum tenens physician provides services for longer than 60 continuous days without a break, the locum tenens physician must enroll with the practice.
Other payers have different rules. TRICARE requires that non-contracted locum tenens physicians complete a certificate or other document to be linked to the regular physician or group tax identification number. Some Medicaid programs (e.g., Florida Medicaid) require the locum tenens physician bill under his or her own name and NPI. Blue Cross Blue Shield adheres to the guidelines of Section 125b of the Social Security Act. (BCBS Manual for Physicians and Providers, May 2010).
Sources:
Medicare Claims Processing manual, Chapter 1, Section 30:2.11, www.cms.hhs.gov/manuals/downloads/clm104
www.cms.hhs.gov/transmittals/dowloads/R1486cp
By Robert A. Pelaia, Esq., CPC, CPCO
It’s foolish to ignore the signs that set off Office of Inspector (OIG) radar. Look around your work environment. If an OIG investigator walked into your office right now, what would he or she see (or not see) that shows compliance is not taken seriously in your practice?
Here are 10 telltale signs, in no particular order, to show investigators that they should take a second look at your compliance activities:
1. Patient Records are in Plain Sight: This is a big Health Insurance Portability and Accountability Act (HIPAA), red flag. It shows that you have no regards for confidentiality of patient information.
2. You Have No Compliance Contact: Your office should designate someone to be in charge of compliance activities. Whether you have an individual or group of individuals responsible for compliance, it’s important to have a “go-to” person for compliance issues.
3. Coding Books Are Outdated: Coders must keep on top of all the newest coding changes and if coders are using outdated coding books or software, that’s a compliance risk. It’s good to keep old coding books around as a historical reference; however, never code from outdated books.
4. Free Limousine Transportation Offered to Medicaid Patients: Section 1128A(a)(5) of the Social Security Act, enacted as part of HIPAA, imposes significant civil money penalties on providers who offer free gifts or services to Medicare or Medicaid beneficiaries that can influence the beneficiary to order items or services from the provider.
5. Coder “Cheat Sheets” Are Posted: It’s alright for coders to have code lists to help work more efficiently; however, an OIG investigator might have a significant problem if the “cheat sheet” only reflects high level codes. For example, if you are listing new patient evaluation and management (E/M) codes on your “cheat sheet,” make sure you list all five levels of new patient E/M codes, not just ones that pay the most money.
6. Memos Posted Instructing Coders to Change Diagnosis Codes: It’s okay to have a list of “covered” diagnoses, but it is not appropriate for the coder to change the diagnosis to one not supported in the medical record. Posted memos telling coders to use particular codes only when submitted with certain “covered” diagnoses and to change to another code if the “wrong” diagnosis is submitted is a red flag to OIG investigators.
7. Coders Get Bonuses when Revenue Increases: The government will closely scrutinize a bonus structure paid to a coder based on increases in revenue because the arrangement might be an incentive for an unscrupulous coder to “up-code.” Coding is complex enough without muddying the water with bonus structures tied to revenue. The less risky route is to base the incentive on productivity, timeliness, or accuracy, rather than revenue.
8. Dusty Compliance Manual: A compliance manual should not sit on the bookshelf, as it should be a useful and comprehensive reference tool used often and updated periodically.
9. Employee Complaints with No Follow-up: An organization that receives complaints or uncovers evidence of improper billing must demonstrate it responded appropriately to the situation, including taking necessary steps to prevent further similar offenses. If the organization’s management personnel fail to investigate employee complaints promptly, this questions the effectiveness of the program.
10. Not Employing “Certified” Coders: You can tell a lot about a health care employer by the company it keeps—it is true that you get what you pay for. Employers who hire certified coders are employers who maintain higher standards, value integrity, and understand that compliance activities are a requirement.
Disclaimer: Information published in this article is the personal views of the author and is not intended to be, nor should it be considered, legal advice. Readers should consult with an attorney to discuss specific situations in further detail.
April 16th, 2013
With so many Health Insurance Portability and Accountability Act (HIPAA) changes coming down the pike, it’s a great time to look at how privacy and security laws may impact your practice and compliance plan.
In a recent U.S. Department of Health & Human Services (HHS) press release, HIPAA expands the individual rights of patients to their health information. According to the press release, “The final omnibus rule greatly enhances a patient’s privacy protections, provides individuals new rights to their health information, and strengthens the government’s ability to enforce the law.”
This means patients can ask for copies of their electronic health records (EHRs). And when it comes to billing, it also means a patient who wants to pay cash can instruct the provider to not share treatment information with his or her health plan.
Keep Billers Compliant
According to Michael D. Miscoe, JD, CPC, CASCC, CUC, CCPC, CPCO, CHCC, here is why it is important to not bill insurance when a patient pays out-of-pocket:
“Although HITECH does not address billing directly, when a patient pays for a service out-of-pocket and instructs (through an appropriate ‘Restrictions on Uses and Disclosures Form’) that you may not disclose PHI associated with that service for payment or health care operations, you are prevented from submitting a claim since by doing so you would be disclosing PHI. If you chose to bill the service anyway, it would be an unauthorized disclosure constituting a breach. This may subject the provider to a penalty, which could be quite substantial if OCR determines the conduct was reckless (usually due to incomplete or non-compliant HIPAA privacy and security policies). Therefore, when the patient makes such a request, HITECH trumps any perceived contractual duty to file a claim because it can’t be done without violating a federal law. A contractual provision that requires you to violate a law is generally unenforceable.
Usually, the patient is paying cash because the service is non-covered. Most provider contracts as well as the Medicare statute do not require submission of claims for non-covered services on behalf of the beneficiary in any event.”
Under the pre-HITECH regulations, you could ignore the patient’s request not to file the claim. Under HITECH, you cannot.
Practical Advice
If a patient pays in full out-of-pocket and does not want to bill insurance, according to Miscoe, here are the best steps to take to stay compliant with HITECH:
- Have the patient sign a request that information relative to self-paid services not be disclosed (usually called a Restrictions on Uses and Disclosures Form). Note that self-paid services do not include circumstance where the patient ultimately pays the entire value of the service because of a deductible. The patient’s signed restriction on such disclosures absolutely precludes the provider from submitting a claim for those services. As noted above, the provider is protected from any allegation regarding provider contract breach for not billing by the patient or the carrier, even assuming such an obligation existed.
- Flag these records somehow so they are not disclosed to the health plan should the health plan make a request. The easiest way is to keep them in a separate file. If that’s not an option, clearly mark the record as “Not for Disclosure for Payment or Health Care Operations.”
- If you are sending the records to another provider (which is permissible), make sure the provider knows the records cannot be sent to the health plan due to the patient’s request. A big red stamp or other notation saying the records may not be disclosed in response to a carrier’s payment or health care operations request should suffice.
February 15th, 2013
Melissa Brown, CPC, CPC-I, CFPC, RHIA
As I watched the summer Olympics this past August, I couldn’t help but think about the correlation to the trend for “pay for performance,” or P4P, we face in health care. The Olympians used various approaches to prepare themselves for the Olympics, but they all had one goal in mind: Gold. In contrast, providers who take a “wait and see” approach toward P4P programs are sure to miss the starting gun.
P4P Is Here to Stay
Several years ago, the Centers for Medicare & Medicaid Services (CMS) introduced the concept of paying for quality services, with the promise of better reimbursement for physicians who reported certain quality measure indicators. The Physician Quality Reporting Initiative (PQRI), which has since become the Physician Quality Reporting System (PQRS), set the stage for a payment system based on quality performance. The goal from the onset has always been to improve patient care and provide better value (quality) for the money being spent on health care (a.k.a., value-based purchasing).
Anyone who has read the latest final rules for various Medicare payment systems can see that P4P is fast approaching (I would argue it’s already here). The proposed changes and overlapping goals of PQRS, the CMS Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs, and the Electronic Prescribing (eRx) Incentive Program make it clear that CMS is intent on rewarding providers who are on board and penalizing those who aren’t. And the trend is contagious: A scan of the headlines in health care journals reveals that many private payers are also implementing P4P-based incentive programs.
Patient-Centered Medical Home Is Within Range
Another concept you’re sure to hear more about in the coming years is the Patient Centered Medical Home (PCMH) designation, introduced by the National Committee for Quality Assurance (NCQA). The NCQA website describes the PCMH as “a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. Care is facilitated by registries, information technology, health information exchange, and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.” Such medical homes seek to improve patient outcomes by strengthening patient-clinician relationships so clinicians can efficiently deliver the right health care at the right time.
In this Game: Quality vs. Quantity
When looking at these emerging trends, some may claim we are recycling the concept of managed care. Although the basic concepts may be similar, the key difference for these new quality concepts is found in the incentives. The biggest argument against managed care was the perception that patients were denied care due to financial incentives for saving costs. The incentives being introduced now (and just as importantly, the penalties) are tied to the quality of the care, not the volume.
The gold medal winners in these games will be the enterprising providers who started training early, or who are training hard now. These providers are looking to maximize efficiencies among the available programs, and keeping their focus on the true goal: favorable patient outcomes.
Whatever your opinion of P4P programs, they are a reality in our industry, and only those who make the transition from simple data collection to ensuring quality outcomes will go home with the gold.
Melissa Brown, CPC, CPC-I, CFPC, RHIA, is manager of reimbursement and quality improvement, University of Florida Jacksonville Physicians, Inc. She has 20 years of experience in the health care industry. Ms. Brown’s areas of expertise include fee analysis, budgeting, and PQRS. She enjoys presenting on teamwork and communication skills. Toastmasters International awarded her its highest honor, Distinguished Toastmaster (DTM). Ms. Brown served as co-director of the annual “Coding on the River” conference in Jacksonville, Fla. for several years and is a past-chair of the AAPCCA board of directors.
November 1st, 2012
« Older Entries