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  • No COLA (Cost of Living Adjustment) 2010 Social Security checks will not increase
  • Simply applying a cardiac monitor does not qualify the transport for ALS payment. Ex- a patient tripped and fell. The monitor read NSR. A cardiac monitor is not indicated . Would downcode to BLS. Routine blood draws do not qualify as justification for ALS if it is part of protocol. With breathing treatment, would expect to see monitoring of breath sounds and POX checks When reviewing an ALS claim, check that the level is ALS then determine if it is R+n.Look for crew credentials..need to see EMT intermediate, advance, or paramedic
  • The three doses may be the same or different medications, but they must be three separate doses. If three separate medication doses were not administered, the provider may still receive payment at the ALSII level if one of the ALSII services were performed. The provider may also receive payment at the ALSII level if one of these procedures is attempted but unsuccessful, as long as the service was reasonable and necessary ie. Intubation attempt is unsuccessful during a cardiac arrest/ CPR in progress.
  • Limitations of Internet-based PECOS for Provider and Supplier Organizations There are some scenarios that Internet-based PECOS cannot accommodate at this time; they will be available at a future date. These scenarios are: Changes in Taxpayer Identification Number (TIN). These must be done using the paper enrollment application (CMS-855). • Changes in Legal Business Name (LBN). These must be done using the paper enrollment application (CMS-855). • An enrolled Medicare Part A provider or supplier organization wants to enroll with a Medicare carrier or A/B MAC to bill for Part B services. This must be done using the paper enrollment application (CMS-855). • Initial applications submitted by Federal Qualified Health Centers, Rural Health Clinics,and End-Stage Renal Disease Facilities.
  • Slide 60 provides the Enrollment Processing timeframes when you utilize the PECOS system. 90 % of the Internet Based applications are processed within 45 days of receipt. CMS requires that Medicare contractors process 80 percent of initial paper enrollment applications within 60 days, and 80 percent of paper changes and reassignments within 45 days. Also, for both paper and Internet Based Applications, there is a thirty day retrospective billing guideline meaning: The Providers effective date for billing is 30 days prior to the receipt of the application, or, the date the Provider begins practicing at the location. CR 6310 – IOM 100-08, Chapter 10, Section 6.1.4 In accordance with 42 CFR §424.520(d), the effective date for the individuals and organizations identified above is the later of the date of filing or the date they first began furnishing services at a new practice location. Note that the date of filing for Internet-based PECOS applications for these individuals and organizations is the date that the contractor received an electronic version of the enrollment application and a signed certification statement. In accordance with 42 CFR §424.521(a), the individuals and organizations identified above may, however, retrospectively bill for services when: • The supplier has met all program requirements, including State licensure requirements, and • The services were provided at the enrolled practice location for up to— 30 days prior to their effective date if circumstances precluded enrollment in advance of providing services to Medicare beneficiaries, or 90 days prior to their effective date if a Presidentially-declared disaster under the Robert T. Stafford Disaster Relief and Emergency Assistance Act, 42 U.S.C. §§5121-5206 (Stafford Act) precluded enrollment in advance of providing services to Medicare beneficiaries. The effective date of billing for a physician/non-physician practitioner and physician/non-physician practitioner’s organization is the later of the date of filing or the date the physician or non-physician practitioner began furnishing services at the practice location. Example 1: Dr. Joe is establishing a new practice location on July 1, 2009, and submits his enrollment application on June 10, 2009. The effective date is July 1, 2009. Obviously, there is no period of retrospective payment, since Dr. Joe submitted his CMS-855 application prior to the start date. Example 2: Dr. Joe started working at his new practice location on August 15, 2009 and filed his enrollment application on September 1, 2009. While September 1, 2009 is the later of these two dates and is therefore the effective date of filing, the effective date for billing purposes (and for retrospective payment) is August 15, 2009. EXAMPLE: Dr. Joe started working on January 2, 2009 and submits his enrollment application on March 1, 2009. Dr. Joe’s effective date of filing is March 1, 2009, but his effective date for billing purposes is limited to the 30 days prior to March 1, 2009. In this case, Dr. Joe’s effective billing date is January 31, 2009. NOTE: This calculation includes 28 days for February. EXAMPLE 4: Dr. Joe’s Medicare billing privileges were deactivated due to 12 consecutive months of non-billing on October 1, 2009. Dr. Joe submits an enrollment application on December 15, 2009 to reactivate his billing privileges. In this case, Dr. Joe’s enrollment application indicates that he started seeing patients at this location on January 1, 1998. Dr. Joe’s effective date of filing is December 15, 2009, while his effective date of billing is November 16, 2009. Dr. Joe is precluded from receiving payment for services rendered between October 1, 2009 and November 15, 2009. In each scenario described above, the contractor shall enter the effective date of billing into sections 1 and 4 of PECOS. Note that for purposes of 42 CFR §424.520(d) and §424.521(a), a CMS-855 reactivation application is treated as an initial enrollment application. This means that a reactivated provider will have a new effective date (i.e., the later of the date of filing or the date it first began furnishing services at a new practice location) and, per §424.521(a), limited ability to bill retrospectively.
  • New diagnosis coding system to replace ICD 9. This is being implemented October 1, 2013.
  • Why ICD 10? ICD 10 offers more detailed information and the ability to expand specificity and clinical information in order to capture advancements in clinical medicine. CMS has sponsored many calls on this and will continue to have information regarding the implementation of ICD 10.
  • Time Limitation on Filing Part B Reasonable Charge and Fee Schedule Claims The time limit on filing claims for service furnished in the last 3 months of a year is the same as if the services had been furnished in the subsequent year. Thus, the time limit on filing claims for services furnished in the last 3 months of the year is December 31 of the second year following the year in which the services were rendered. Whenever the last day for timely filing of a claim falls on a Saturday, Sunday, Federal nonworkday or legal holiday, the claim will be considered filed timely if is filed on the next workday.(NOTE – THIS HAS CHANGED) Example: an enrollee received surgery in August 2001. He must file a claim for payment for such services on or before December 31, 2002. MCM 3004.1 Extension of Time Limit Due to Administrative Error If the failure to submit the claim within the timeframes specified in 3004.A was due to “administrative error” (I.e. misrepresentation, delay, mistake or other action) of an officer Exceptions for filing claims late: Unusual or exceptional situations determined by the Medicare carrier; MSP claims when the primary payment sheet is sent to the beneficiary);and foreign claim. Add islided Jim sending on CPt Icd-9
  • What is a RAC? The RACS detect and correct past improper payments so that CMS, Carriers, FI and MACS can implement actions that will prevent future improper payments.
  • For the RAC review process claims are reviewed on a post payment basis and they use the same Medicare policies as the claims processing contractors. Such as LCD’s and NCD’s.
  • The RAc contractor for your region is Diversified Collection Services Inc. Be sure to respond to nay requests coming from this company. On this slide we have given you further information on how to contact the RAC.
  • There are 2 types of reviews: Automated and complex When an overpayment is identified a demand letter is issued by the RAC.
  • Your a/B MAC receives a demand letter from the RAC and uses the same process they have in place for overpayments.

Transcript

  • 1. 2010 MEDICARE PART B United New York Ambulance Network March 17, 2010
  • 2. Update Agenda
    • 2010 Medicare program changes
    • NY Medicare / Medicaid Crossovers
    • Medicare Fee Schedule
    • Ambulance coverage – the basics
    • Provider Enrollment / PECOS
    • ICD-10-CM/PCS
  • 3. 2010 Medicare Part B Amounts
    • 2009
    • Part B Premium
      • $96.40
    • Higher Part B Premium
      • $85,000/$170,000
    • Part B Deductible
      • $135.00
    • 2010
    • Part B Premium
      • $110.50
    • Higher Part B Premium
      • $85,000/$170,000
    • Part B Deductible
      • $155.00
  • 4. 2010 Medicare Part A Amounts
    • Part A Premium
      • < 30 quarters $461
      • 30-40 quarters $254
    • Part A Deductible
      • $1,100
    • Part A Coinsurance
      • $275 (Days 61-90)
      • $550 (Lifetime Reserve Days)
      • $137.50 (SNF Coinsurance)
  • 5. 2010 Part B Premium
    • Medicare Part B premium will remain the same as 2009 for most beneficiaries
      • $96.40 if annual income is below $85,000 (individual) / $170,000 (couple)
    • Exceptions
      • $110.50 if Enroll in Medicare in 2010
      • Beneficiaries with high incomes are subject to higher Part B premium
  • 6. Medicare Trends
    • Medicare Advantage enrollment is above 25% of beneficiaries with potential for changes coming in the marketplace.
    • 47 million beneficiaries enrolled in 2010; growing to over 62 million by 2020
    • $507 billion in expenditures growing to $898 billion in 2020
  • 7. Ambulance Update
    • National fee schedule in place
    • Updates are based on the % increase of the CPI-Urban Consumers
    • CPI-U for 2010 is -1.4% which is 0% update.
    • Use the Ambulance Service Center at
    • www.cms.hhs.gov
    • 2010 Deductible and coinsurance apply
  • 8.  
  • 9.  
  • 10. Ambulance Coverage The Basics
  • 11. Emergency Ambulance Transport
    • Place the patient’s health in serious jeopardy;
    • Result in serious impairment of bodily functions; or
    • Result in serious dysfunction of any bodily organ.
    • Symptoms or Conditions that May Warrant an Emergency Ambulance Transport Include, But are Not Limited To:
    • Severe pain or hemorrhage;
    • Unconsciousness or shock;
    • Injuries requiring immobilization of the patient;
    • Patient needs to be restrained to keep from hurting himself or others;
    • Patient requires oxygen or other skilled medical treatment during transportation; and Suspicion that the patient is experiencing a stroke or myocardial infarction.
  • 12. Non - Emergency Ambulance Transports
    • Appropriate with a patient who is bed -confined AND his/her condition is such that other methods of transportation are contraindicated; OR
    • The patient’s condition, regardless of bed-confinement, is such that transportation by ambulance is medically required (patient poses a danger to him or herself or to others).
    • Bed-confinement alone is neither sufficient nor necessary to determine the coverage for Medicare benefits.
    • To be considered bed-confined, the patient must be unable to do all three of the following :
    • Get up from bed without assistance;
    • Ambulate; and
    • Sit in a chair or wheelchair.
  • 13. Advanced Beneficiary Notice- new form in place
    • When to use an ABN?
    • Patient does not require an ambulance to be transported.
    • Air Transport when ground ambulance would suffice
    • ALS to BLS
    • When it is not needed!
    • Partial mileage denial
    • ( Beneficiary is liable)
    • Patient is under duress- critically ill circumstance
  • 14. Ground Ambulance Scenarios: Beneficiary Death -Medically necessary level of service furnished -After pickup, prior to or upon arrival at the receiving facility -The provider’s BLS base rate, no mileage or rural adjustment; use the QL modifier when submitting the claim -After dispatch, before beneficiary is loaded onboard ambulance (before or after arrival at the point-of-pickup) -None -Before dispatch Medicare Payment Determination Time of Death Pronouncement
  • 15. Documentation Requirements
    • Ambulance suppliers are not required to submit documentation
    • Ambulance suppliers are required to retain documentation that
    • contains information about the personnel involved in the transport and the patient’s condition and to be made available to Medicare
    • Ambulance suppliers are also required to obtain a Physician Certification Statement (PCS) for non-emergency transports which states the reason(s) a patient requires non-emergency transportation by ambulance.
  • 16. How to Avoid Improper Billing
    • Be sure that coverage criteria and level of service criteria for ambulance transport are met and that it is backed up with the appropriate documentation
    • Communicate the patient’s condition as reported by the dispatch center and as observed by the ambulance crew
    • Maintain documentation that will help to determine whether ambulance transports meet program requirements
  • 17. How to Avoid Improper Billing
    • Generally, coverage errors for ambulance transports were due to documentation discrepancies between the ambulance supplier and the third-party provider
    • (e.g., emergency room records)
    • Be sure to include the origin and destination modifiers when billing. Medicare needs to determine whether the coverage and/or level of service is correct
  • 18. Levels of Service
    • Basic Life Support , non-emergency transport (BLS)- A0428
    • Basic Life Support, emergency transport (BLS-emergency)- A0429
    • Advanced Life Support, non-emergency transport, level 1 (ALS1)- A0426
    • Advanced Life Support, emergency transport, level 1 (ALS1-emergency)- A0427
  • 19. Levels of Service
    • Advanced Life Support, level 2 (ALS2)- A0433
    • Specialty care transport (SCT)- A0434
  • 20. Advanced Life Support (ALS) Ambulance
    • ALS vehicles must be staffed by at least two people, at least one of whom must be certified as an EMT-Intermediate or an EMT-Paramedic
      • EMT-Intermediate is qualified as an EMT-basic who is also certified to perform essential advanced techniques and to administer a limited number of medications
      • EMT-Paramedic is qualified as an EMT-Intermediate and possesses skills to administer additional interventions and medications
  • 21. Advanced Life Support, non-emergency transport, level 1 (ALS1)
    • Only an ALS crew was qualified to perform the assessment
    • An ALS assessment does not necessarily result in a determination that the patient requires an ALS level of service
    • An ALS intervention is a procedure that is required to be done by an emergency medical technician-intermediate (EMT-intermediate) or EMT-Paramedic
  • 22. Examples of ALSI Services
    • The ALS vehicle must have specialized life sustaining equipment and specialized staff. Typical of this type of ambulance are mobile coronary care units staffed by personnel trained and authorized to administer intravenous therapy (IVs), provide anti-shock trousers, establish and maintain a patient's airway, defibrillate the heart, provide EKG monitoring, and perform other advanced life support procedures or services.
  • 23. Advance Life Support II (ALSII)
    • Transportation by ground ambulance vehicle, medically necessary supplies and services, and the administration of at least 3 medications by intravenous push/bolus or by continuous infusion excluding crystalloid, hypotonic, isotonic, and hypertonic solutions (Dextrose, Normal Saline, Ringer’s Lactate);
            • OR
  • 24. Advance Life Support II (ALSII)
    • Transportation by ground ambulance vehicle, medically necessary supplies and services, and the administration of at least 3 medications by intravenous push/bolus or by continuous infusion excluding crystalloid, hypotonic, isotonic, and hypertonic solutions (Dextrose, Normal Saline, Ringer’s Lactate);
            • OR
  • 25. Advance Life Support II (ALSII)
    • Transportation, medically necessary supplies and services, and the provision of at least one of the following ALS procedures:
        • Manual defibrillation/cardioversion
        • Endotracheal intubation
        • Central venous line
        • Cardiac pacing
        • Chest decompression
        • Surgical airway
        • Intraosseous line
  • 26. Provider Enrollment PECOS
  • 27. Enrollment Revalidation for Providers not in PECOS System
    • Providers who have not made changes to enrollment record since 2003 will not be in PECOS
      • May need to revalidate enrollment
    • NGS is currently sending out revalidation letters
    • Providers who receive a letter must respond or billing privileges will be revoked
  • 28. Reminder PECOS Limitations
    • Internet-based PECOS cannot be used for:
      • Changes in Taxpayer Identification Number (TIN)
      • Changes in Legal Business Name (LBN)
      • Enrolling an existing Medicare Part A provider/supplier with Medicare carrier or A/B MAC to bill for Part B services
      • Initial applications submitted by Federal Qualified Health Centers, Rural Health Clinics, and End-Stage Renal Disease Facilities
  • 29. Completing Online Enrollment
    • Three Basic Steps
      • Must have active NPPES User ID and Password
        • Additional security clearances needed for groups
          • PECOS Identification and Authentication system (PECOS I&A) clearances for Authorized Official
      • Complete online enrollment and submit
      • Print, sign and date, and mail Certification Statement to National Government Services along with all supporting paper documentation within seven (7) days of electronic submission
        • Signed by AO for groups
    • Wait at least 15 days before checking status of online application
  • 30. Medicare Enrollment Timeframes
    • Effective date of enrollment is later of:
      • Date of filing (receipt date)
      • Date began furnishing services at practice location (if within 30 days)
    • Date of filing for online applications based on contractor receipt of Certification Statement
    • 30-day retrospective billing guideline as of April 1, 2009
    • Reactivation application treated as initial enrollment application
  • 31. Deactivation of Medicare Provider Numbers
    • Medicare PTAN becomes inactive if no valid Medicare claim submitted in 12-month period
    • To reactivate, provider must:
      • Be ready to submit valid claim
      • Submit appropriate CMS-855 form online or on paper
    • Upon reactivation, new PTAN is assigned and new effective date applied
    • Providers who received paper checks prior to deactivation are required to complete CMS-588 (EFT Authorization Agreement) to reactivate
  • 32. National Provider Identifier (NPI) Reminders
    • Apply for NPI online
      • https://nppes.cms.hhs.gov
    • Contact NPI Enumerator for assistance with applying for NPI or updating data in NPPES records
      • 1-800-465-3203
      • CustomerService@NPIEnumerator.com
    • FREE NPI Registry
      • https:// nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do
    • CMS' dedicated NPI web page
      • www.cms.hhs.gov/NationalProvIdentStand
  • 33. Enhancements/Updates to NPPES
    • MLN Special Edition Article SE0914
    • Effective On/After September 13, 2009
    • Security enhancements:
      • Users required to select five secret questions and answers for verification purposes in order to reset own passwords
      • Users prevented form changing passwords more than once within 24 hours from last password change
    • Revised Electronic File Interchange (EFI) User Manual and Technical Companion Guide
  • 34. JSM 10158 - Dark Days for Provider Enrollment, Chain and Ownership System (PECOS )
    • CMS is implementing “Dark Days” for the implementation of PECOS R7.0
    • The CMS will be disabling the PECOS Provider Interface (PI), AKA Internet-based PECOS, on March 29, 2010
    • Internet Based PECOS will be enabled on April 5, 2010
    • PECOS Dark Days should have minimum impact on your Internet Based PECOS submissions
  • 35. Listing of all providers in PECOS
    • As of January 28, 2010, CMS has made available a file that contains the National Provider Identifier (NPI) and the name (last name, first name) of all physicians and non-physician practitioners who are of a type/specialty that is eligible to order and refer in the Medicare program and who have current enrollment records in Medicare (i.e., they have enrollment records in PECOS that contain an NPI).  This file is downloadable from the Medicare provider/supplier enrollment web site:  www.cms.hhs.gov/MedicareProviderSupEnroll :  click on “Ordering/Referring File” on the left-hand side. 
  • 36. The Top Reasons for the Return of Enrollment/PECOS in Ranking Order  
    • 2008 Version of the Application
    • No signature & No date
    • Authorized Official is Not Correct
    • Tracking I.D. not found in PECOS
  • 37. The Top Reasons for the Return of Enrollment/PECOS in Ranking Order  
    • Signature with no date
    • Wrong Contractor
    • Individual Rendering Provider & Authorized Official Signatures do not Match
    • Dates are more than 6 Months Apart
  • 38. All changes will also require EFT – 588 form
  • 39.  
  • 40.  
  • 41.  
  • 42.  
  • 43. Complete per agreement
  • 44. Notify us with 60 days of a change! D
  • 45. Billing & Claims Processing Reminders & Updates
  • 46. ICD-10-CM/PCS
    • New diagnosis coding system
      • ICD-10-CM
        • Replacement for ICD-9-CM, Volumes 1 & 2
      • ICD-10-PCS
        • Replacement for ICD-9-CM, Volume 3 (hospitals)
    • Implementation date – October 1, 2013
  • 47. ICD-10-CM/PCS
    • MLN Matters Special Edition Article SE0832
    • CMS web site - www.cms.hhs.gov/icd10
      • Questions and answers
      • General Equivalence Mappings (crosswalks)
      • Educational resources
      • Information on upcoming CMS-sponsored calls and transcripts from completed calls
    • ICD-10-CM/PCS Fact Sheet
      • General information about the benefits of adopting the new coding system
      • Structural differences between ICD-9-CM and ICD-10-CM/PCS
      • Implementation planning recommendations
    • Available for download from CMS Medicare Learning Network
  • 48. New York Medicare / Medicaid Crossovers Effective December 3, 2009
    • http://www.ngsmedicare.com/Content.aspx?CatID=2&DOCID=21493
    • Posted 01/29/2010 - NGS will be sending letters to providers whose claims did not crossover to Medicaid
    • Revised 02/01/2010 – NGS has suspend sending letters advising providers claims did not crossover to NYS Medicaid due to the large volume of claims not being accepted by NYS Medicaid for crossover benefits
    •  
    • If you received a letter previously, contact NYS Medicaid to have your provider information set up with Medicaid
    • We recommend you contact the NYS Medicaid Enrollment Unit at 800-343-9000 and ask about enrolling the NPI
  • 49. Medicare Claims Crossover to Supplemental Payer Problem
    • JSM 10139 for additional Information http://www.ngsmedicare.com/Content.aspx?CatID=2&DOCID=21648
    • NGS has informed providers, physicians, and suppliers to an issue that occurred starting on or about January 1, 2010 having a negative impact on their patients’ crossover claims
    • Due to a system issue with the Common Working File (CWF), some claims are not crossing over to the supplemental insurance carrier for benefits
    • CMS and the CWF System Maintainer are working towards a system solution and recommend:
      • Examine your Remittance Advice to determine if your patients' claims are identified as having been crossed over to their supplemental insurers
      • Remittance Remark Code MA 18 will indicate a claim has crossed over a supplemental insurer 
      • If a claim did not crossed over, you are within your rights to submit claims to your patients' insurers for supplemental payment using methodologies acceptable to those entities
  • 50. Medicare Crossover Reminders
    • Allow sufficient time for the Medicare crossover process to work - approximately 15 work days after Medicare’s reimbursement is made, before attempting to balance bill your patients’ supplemental insurers as stated in MLN Matters Article SE0909. http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0909.pdf
    • Do not balance bill until written confirmation from Medicare that your patients’ claims will not be crossed over is received, or you’ve received a special notification letter explaining why specified claims cannot be crossed over.  
  • 51. Medicare Crossover Reminders
    • January 2010 Issue:
    • Claims that crossed over to NYS Medicaid are being rejected by Medicaid because they are unable to identify the provider or does not have a provider agreement on file. 
    • Providers will need to contact NYS Medicaid to have their provider information setup with Medicaid. NYS Medicaid Provider Enrollment: 800-343-9000
  • 52. Attention Paper Claims Submitters Posted January 29, 2010
    • http://www.ngsmedicare.com/Content.aspx?CatID=2&DOCID=21489
    • Prior to February 26, 2010, paper claims received where the health insurance claim number and the beneficiary name did not match were returned to the provider with a development letter advising the provider to correct the problem and submit as a new claim
    • CMS has directed contractors to follow the current electronic rejection process with all claims, electronic and paper 
    • Effective February 26, 2010, paper claims are rejected and returned to the provider with a rejection letter specifying the reason the claims were returned
  • 53.  
  • 54. Stay Informed of Medicare Changes!
    • Sign-up for www.ngsmedicare.com list serv
    • Attend National Government Services trainings:
      • Teleconferences
      • Webinars
      • In-person seminars
    • Complete free computer-based trainings (CBTs) in Medicare University
    • Participate in CMS calls
      • Special topic calls (PQRI, ePrescribing, ICD-10)
      • Monthly Open Door Forum calls
  • 55. J13 Medicare Part B News Flash Teleconferences
    • Free monthly seminar for CT and NY Part B providers (J13)
      • Current claims processing issues
      • New and revised Medicare regulations, materials & LCDs
      • Tips on how to avoid common claim denials
    • For more information and to register for next session:
      • Events Calendar on www.ngsmedicare.com
    • Handout available for download from Events Calendar at least one day prior to teleconference
  • 56. Ask-the-Contractor Teleconferences (ACTs)
    • Free quarterly teleconference for J13 Part B providers
    • Similar to Open Door Forums offered by CMS
      • Providers can ask questions on any topic (no PHI)
    • Information / registration for next session:
      • Events Calendar on www.ngsmedicare.com
  • 57. Provider Authentication Requirements for Telephone and Written Inquiries
    • For calls to IVR or Provider Contact Center
    • Three data elements required for provider authentication:
      • Your National Provider Identifier (NPI)
      • Your Provider Transaction Access Number (PTAN)
      • Last five digits of your tax identification number (TIN)
    • Only allowed three attempts to successfully authenticate identity
  • 58. Effective 12/15/09 J13 Contact Information NY & CT 877-273-4334 EDI: National Government Services Part B Provider General Written Inquiries P.O. Box 7052 Indianapolis, IN 43207-7052 Correspondence: 866-709-1905 Fax on Demand: 866-837-0241 Provider Contact Center: 1-877-869-6504 Interactive Voice Response unit (IVR)
  • 59. Contacting the Telephone Reopening Unit (TRU Line)
    • TRU Line – 888-812-8905 - follow prompt
    • Part B TRU line hours of operation : Monday - Friday, 8:00 AM to 3:00 PM (Eastern)
    • Faxes are accepted and representatives are permitted to accept more than 3 claims per call
    • When calling TRU Line, provide the following information:
      • Beneficiary’s Name
      • Medicare Health Insurance Claim Number
      • Your Full Name (first and last name)
      • Your Phone Number
      • Provider’s Name
      • Provider’s Number
      • Date(s) of Service in Question
      • Reason for Request
  • 60. Claim Filing Rules & Limits
    • 10 % late filing fee assessed for assigned claims not submitted within one year from date of service
    • Claims not submitted by time limit are provider-liable
      • Beneficiary cannot be charged for provider-liable charges
    10/01/08 – 09/30/09 10/01/07 – 09/30/08 Services Rendered: 12/31/10 12/31/09 Claim Filing Date
  • 61. Duplicate Claim Submissions
    • Definition –
      • Claims submitted more than once for services provided by same provider to same beneficiary for same item(s) or service(s) for same date(s) of service.
    • Denials identified on remittance advice with “CO18”
    • Inappropriate billing practice with Medicare
      • Claim payment delays
      • Investigated as abusive or fraudulent billing
    • POE contacting and educating highest duplicate billers
  • 62. Submitting Duplicate Claims:
    • May delay payment
      • Resubmitting your claim prior to receiving a determination not only increases administrative costs to the Medicare program but to you as well.
    • Could cause you to be identified as an abusive biller; or may result in an investigation for fraud if a pattern of duplicate billing is identified
      • Although NGS does not believe providers are trying to deliberately receive duplicate payment by submitting duplicate claims for one service we must remind providers that this is an inappropriate billing practice.
  • 63. Avoid Duplicate Claims
    • Allow 29 days for paper claims and 14 days for electronic claims to be processed
    • Electronic Claims Submitters should :
      • Check your EDI validation report to verify claims were received and accepted
      • Check your software system to verify claims’ software system is not set up for automatic rebill every 30 days or at any other set time intervals
      • Ensure that your claims batching process is functioning properly
  • 64. Avoid Duplicate Claims
    • Electronic and Paper Submitters should:
      • Access the Interactive Voice Response (IVR) System to determine if a claim has been denied as a duplicate (CO-18)
      • Pay close attention to your remittance advice to determine if the denied claim(s) should be resubmitted or appealed
      • Make sure that your billing staff or third party billing service knows the Medicare payment floors and claims filing rules
  • 65. Ambulance Claim Denials
  • 66. Recovery Audit Contractor (RAC)
  • 67. RAC Review Process
    • Detect and correct past improper payments
    • Issues reviewed by RAC will be approved by CMS prior to widespread review
    • Approved issues will be posted to RAC website before widespread review
    • Claims reviewed on post-payment basis
      • Use same Medicare policies as claim processing contractors (NCDs, LCDs, and CMS Manuals)
  • 68. RAC Contractor
    • Region A –
    • Diversified Collection Services, Inc. (DCS)
      • CT, DE, ME, MD, MA, RI, NH, NJ, NY, PA & Washington DC
      • www.dcsrac.com
      • 333 North Canyons Parkway, Suite 100, Livermore, CA 94551-7661
    • CMS RAC Web site: www.cms.hhs.gov/RAC
    • CMS RAC e-mail: [email_address]
  • 69. Know Where Previous Improper Payments Have Been Found
    • Look to see what improper payments were found by the RACs
      • Demonstration findings : www.cms.hhs.gov/rac
      • Permanent RAC findings: Listed on the RACs’ Web sites
    • Look to see what improper payments have been found in
      • Office of Inspector General (OIG) reports
        • www.oig.hhs.gov/reports.asp
      • Comprehensive Error Rate Testing (CERT) reports
        • www.cms.hhs.gov/cert
  • 70. Diversified Collection Services www.dcsrac.com [email_address] (866) 201-0580
  • 71. RAC Review Process
    • RAC’s are able to look back three years from claim paid date (will not review claims paid prior to October 1, 2007)
    • Two types of review:
      • Automated (no medical record needed)
      • Complex (medical record required)
    • When overpayment identified, a demand letter issued by RAC
  • 72. When an Overpayment is Identified
    • The same process as overpayments identified by A/B MAC (except the demand letter comes from RAC)
    • “RAC Discussion Period”
      • Opportunity for provider to discuss improper payment determination with RAC outside normal appeal process
  • 73. Know If You Are Submitting Claims With Improper Payments
    • Conduct an internal assessment to identify if you are in compliance with Medicare rules
    • Identify corrective actions to implement for compliance
    • Keep track of denied claims
    • Look for patterns
    • Determine what corrective actions you need to take to avoid improper payments
  • 74. CMS’ 5 th Annual Medicare Contractor Provider Satisfaction Survey (MCPSS) http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE1005.pdf The 2010 survey is administered by a new contractor, SciMetrika, LLC (public health consulting firm) and will be distributed to a random sample of approximately 30,000 Medicare Fee-for-Service providers nationwide For specific questions about the MCPSS, call the MCPSS Provider Helpline at 800-835-7012 to speak to a SciMetrika study representative or visit www.cms.hhs.gov/mcpss and www.mcpsstudy.org Questions will focus on seven business Provider / Contractor functions
      • Provider Outreach & Education
      • Provider Inquiries
      • Claims Processing
      • Appeals
      • Provider Enrollment
      • Medical Review
      • Provider Audit & Reimbursement
  • 75. Thank you
    • Your questions