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Navigate the New Medicare ID Transition in 9 Steps

Navigate the New Medicare ID Transition in 9 Steps

Due to a legislative mandate in MACRA passed in 2015, Medicare will no longer use social security numbers to identify individuals. Instead, a new randomly generated Medicare Beneficiary Identifier (MBI) will be assigned to all 58 million Medicare recipients. New Medicare ID cards containing the MBI are currently being sent to recipients.

“It is a big change,” said Phillip Allen, billing service manager with MediSYS. “MACRA requires that social security numbers be removed to protect beneficiaries from social security number theft, identity theft, and illegal use of benefits.” Which is why the gender and signature line will not be printed on the new Medicare cards either.

The MBI replaces the Health Insurance Claim Number (HICN) used for Medicare transactions like billing, eligibility status, and claim status. Whereas the HICN started with the 10-digit social security number and ended with a letter or two designating a policy type, the 11-digit MBI will contain both letters and numbers throughout.

The transition to these new cards is a big step for patients as well as providers. “All providers, vendors, and other stakeholders must be ready to accept, receive, and transmit the new MBI  … particularly for the new beneficiaries coming into the program,” said Monica Kay, acting director of the CMS division of program management.

Here are nine steps your practice should take to ease the transition and avoid payment delays:

  • Educate practice staff about the rollout of the new Medicare cards with the new MBIs.
  • Contact practice-management system vendors about what system changes need to be made to accommodate the MBIs.
  • Alert your Medicare patients that they will be receiving new Medicare cards with their new MBIs.
  • Remind Medicare patients to confirm that the Social Security Administration has their correct address on file to ensure that they receive their new Medicare cards.
  • Tell Medicare patients to bring their new Medicare cards to their next appointment after they receive it.
  • Begin using the new MBI in Medicare transactions as soon as it is available for the patient.
  • Monitor eligibility responses for messages that indicate the patient was mailed a new Medicare card.
  • Starting Oct. 1, 2018, monitor remittance advices for messages that provide the patient’s MBI.
  • Sign up for the MBI look-up tool via your regional MAC portal.

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CMS Reveals New Medicare Card Design; Strengthens Fraud Protections

CMS Reveals New Medicare Card Design; Strengthens Fraud Protections

The Centers for Medicare & Medicaid Services has redesigned its Medicare card to remove Social Security numbers and use a unique, randomly-assigned number in an effort to better protect users from identity theft and fraud.

CMS will begin mailing the new cards to people with Medicare benefits in April 2018 to meet the statutory deadline for replacing all existing Medicare cards by April 2019. People with Medicare will also be able to see the design of the new Medicare card in the 2018 Medicare & You Handbook. The handbooks are being mailed and will arrive throughout September.

“The goal of the initiative to remove Social Security numbers from Medicare cards is to help prevent fraud, combat identify theft, and safeguard taxpayer dollars,” said CMS Administrator Seema Verma. “We’re very excited to share the new design.”

CMS has assigned all people with Medicare benefits a new, unique Medicare number, which contains a combination of numbers and uppercase letters. People with Medicare will receive a new Medicare card in the mail, and will be instructed to safely and securely destroy their current Medicare card and keep their new Medicare number confidential. Issuance of the new number will not change benefits that people with Medicare receive.

Health care providers and people with Medicare will be able to use secure look-up tools that will allow quick access to the new Medicare numbers when needed. There will also be a 21-month transition period where doctors, health care providers, and suppliers will be able to use either their current SSN-based Medicare Number or their new, unique Medicare number, to ease the transition.

This initiative takes important steps towards protecting the identities of people with Medicare. CMS is also working with healthcare providers to answer their questions and ensure that they have the information they need to make a successful transition to the new Medicare number. For more information, please visit: www.cms.gov/newcard.

How can providers get ready for the changes?

  • Ask your billing and office staff if your system can accept the new 11-digit alphanumeric Medicare Beneficiary Identifier or
  • If your system cannot accept the new number, system changes should be made by April 2018
  • If providers use vendors to bill Medicare, ask them about their MBI practice management system changes and make sure they are ready for the change
  • Verify your patients’ addresses: If the address you have on file is different than the address you get in electronic eligibility transaction responses, ask your patients to contact Social Security and update their Medicare records. This may require coordination between your billing and office staff.

For more information go to https://www.cms.gov/Medicare/New-Medicare-Card/Providers/Providers.html

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A Refresher in the Medicare Claims Appeals Process…

A Refresher in the Medicare Claims Appeals Process…

With the increased audit activity we are seeing among the alphabet soup of Medicare contractors – RACs, ZPICs, SMRCs, CERTs, etc. – now appears to be a good time for a refresher on the Medicare claims appeals process. Due to this increased audit activity, more and more claims are being denied, both under pre-payment review and post-payment review. This article provides an overview on the Medicare claims appeals process, as well as some tips and pointers to keep in mind.

Request for Redetermination

A request for redetermination, the first level of appeal, must be filed within 120 days of receipt of a demand letter from the Medicare carrier (or, if no demand letter is received, within 120 days from the date a Medicare remittance advice shows a claim denial). If the request for redetermination is filed within the shorter time frame of 30 days, recoupment will not be initiated. If the request for redetermination is filed after the 30-day period, recoupment may be initiated, but will be stopped once the appeal has been filed. Interest begins to accrue on the 31st day and continues to accrue, even if an appeal is filed, until the overpayment is repaid or an entirely favorable decision is rendered. Thus, the only way to avoid the accrual of interest completely is to repay the overpayment before the 31st day. However, you still retain appeal rights even if the alleged overpayment has been repaid — you just have to go through the hassle of trying to get the money back from Medicare if a favorable decision is eventually rendered.
To ensure that all the relevant information is included, send a cover letter containing your arguments (with supporting documentation), as well as the request for redetermination form available at https://www.cahabagba.com/part-b/claims-2/appeals-2-2/.

The first level of appeal is reviewed by the applicable Medicare carrier, which for physicians practicing in Alabama is Cahaba GBA. The Medicare carrier has 60 days to render a decision.

Request for Reconsideration

A request for reconsideration, the second level of appeal, must be filed within 180 days of receipt of a decision by the Medicare carrier on
the request for redetermination filing. If the request for reconsideration is filed within the shorter time frame of 60 days, recoupment will not be initiated. If the request for reconsideration is filed after the 60-day period, recoupment may be initiated, but will be stopped once the appeal has been filed. Interest will continue to accrue, even if an appeal is filed, until the overpayment is repaid or an entirely favorable decision is rendered. Importantly, all information must be presented at the request for reconsideration level of appeal, as new information is generally not allowed to be presented at the following levels of appeal.

To ensure that all the relevant information is included, send a cover letter containing your arguments (with supporting documentation), as well as the request for reconsideration form available at https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS20033.pdf.

The second level of appeal is reviewed by the applicable Qualified Independent Contractor (“QIC”), an independent party hired by Medicare to review second level appeals. The QIC has 60 days to render a decision.

Administrative Law Judge

A request for a hearing before an Administrative Law Judge (“ALJ”), the third level of appeal, must be filed within 60 days of receipt of a decision by the QIC on the request for reconsideration, assuming the monetary thresholds are satisfied. Importantly, there is no opportunity to stop recoupment at this level of appeal. Thus, recoupment will begin and will continue until a favorable decision is rendered or until the full amount of the overpayment and accrued interest has been offset. Interest will continue to accrue at this level of appeal until the overpayment is repaid, offset through recoupment, or an entirely favorable decision is rendered.

To ensure that all the relevant information is included, utilize the ALJ hearing request form available at https://www.hhs.gov/about/agencies/omha/filing-an-appeal/coverage-and-claims-appeals/request-an-alj-hearing/index.html.

The ALJ hearing is usually conducted by telephone or video conference. By regulation, the hearing is supposed to take place and a decision rendered within 90 days of the appeal request. However, due to backlogs at the ALJ level, it is currently estimated that appeals will not be heard by ALJs for approximately 6-8 years, unless there is Congressional action to resolve the backlog. There is an option to escalate the appeal to the next level if a decision is not rendered timely in light of this delay. However, the success rate for providers at the ALJ level is relatively high, so bypassing this level of review is not always in the provider’s best interest. Nonetheless, despite the delay by the ALJ office, recoupment will continue.

Medicare Appeals Council

A request for review by the Medicare Appeals Council (“MAC”), the forth level of appeal, must be filed within 60 days of receipt of a decision from the ALJ, assuming the monetary threshold is satisfied. The MAC is supposed to render a decision within 90 days. However, due to backlogs, MAC decisions are also taking longer to be issued. There is an option to escalate the appeal to the next level if a decision is not rendered timely. However, such escalation is not always in the best interests of providers.

Judicial Review

A request for judicial review by the appropriate federal district court must be filed within 60 days from receipt of the MAC decision, assuming the monetary threshold is satisfied. From this point, the judicial system will oversee the proceeding.

A couple of points to keep in mind with respect to Medicare claims appeals. Be proactive – review the RAC website for approved audit issues, as well as the most-recent OIG Work Plan for target issues. Develop a formal intake and review process for records requests and demand letters. Always respond to records requests in a timely manner, as the failure to do so will result in an automatic claim denial. Keep track of denied claims and look for patterns. Determine corrective action to take, if applicable, and appeal as necessary and appropriate. If you appeal, file everything by a trackable delivery method and keep copies of all documents that are filed and received. Always ask for confirmation in writing when receiving advice or instruction from the applicable review body.

While the claims appeal process can be frustrating, time-consuming, and costly, providers tend to have a high degree of success. However, many providers simply pay the overpayment amount without challenging the finding due to the associated time and expense. Depending on the amount of the overpayment and the frequency with which you believe the pertinent issue has occurred within your practice, spending the time and effort to appeal may be beneficial.

Article contributed by Kelli Fleming, a partner at Burr & Forman LLP and practices exclusively in the Birmingham office within the Health Care Industry Group. Burr & Forman, LLP is a Bronze Partner with the Medical Association.

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Medicare Releases 2017 Physician Fee Schedule Final Rule

Medicare Releases 2017 Physician Fee Schedule Final Rule

The Centers for Medicare and Medicaid Services released its final rule for its 2017 physician fee schedule payment policies, which updates payment policies and payment rates for services provided under the Medicare Physician Fee Schedule (PFS) starting Jan 1, 2017.

The 1,400-page 2017 final rule discusses changes to a number of new policies that reflect a broader agencywide strategy to enhance quality, spend smarter and improve Americans’ health.

Here are eight changes to note:

CMS will begin gathering data on postoperative visits. The final rule requires reporting of postoperative visits for high-volume/high-cost procedures by a sample of practitioners in practices with 10 or more physicians. Reporting is required for services related to global procedures provided on or after July 1, 2017.

Changes were made to provider and supplier requirements for Medicare Part C. Providers and suppliers will be screened and enrolled in Medicare to contract with a Medicare Advantage organization to provide items and services to those enrolled in Medicare Advantage health plans.

CMS finalized its proposal to expand eligible telehealth services. The additional codes include those for end-stage renal disease-related dialysis, advanced care planning and critical care consultations. The critical care consultations provided via telehealth will use the new Medicare G-codes.

CMS will improve data transparency. Medicare Advantage organizations use a bidding process to apply to participate in the Medicare Advantage program, and the bidding process will reflect the organization’s estimated costs to provide benefits to enrollees. Under the final rule, Medicare Advantage organizations are required to release data associated with these bids on an annual basis. CMS will also require Medicare Advantage organizations and Part D sponsors to release medical loss ratio data on a yearly basis to help beneficiaries make enrollment decisions.

The agency revised the methodology used to calculate geographic practice cost indices. CMS adjusts payments under the physician fee schedule to reflect local differences in practice costs using geographic practice cost indices. The agency will revise the methodology used to calculate GPCIs to increase overall physician fee schedule payments in Puerto Rico. The updates will be phased in over 2017 and 2018.

CMS finalized expansion of the Medicare Diabetes Prevention Program. The 2017 rule finalizes some aspects of the expanded model, but future rulemaking will address payment policies, program safeguards and other issues. CMS expects to begin payment for MDPP services in 2018.

CMS revised the billing codes to more accurately pay for primary care, care management and other cognitive specialties. Among the changes are new codes to pay primary care practices that use interprofessional care management resources to treat patients with behavioral health conditions.

Physician payment rates will increase by 0.24 percent in 2017. CMS arrived at this increase after accounting for a 0.5 percent increase required by the Medicare Access and CHIP Reauthorization Act and mandated budget neutrality cuts, according to the American Hospital Association.

For more information, please see Final Policy, Payment, and Quality Provisions in the Medicare Physician Fee Schedule for Calendar Year (CY) 2017

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Death vs. Another Hospital Stay: Study Suggests Medicare Should Weigh Them Equally

Death vs. Another Hospital Stay: Study Suggests Medicare Should Weigh Them Equally

ANN ARBOR — In the last few years, American hospitals have focused like hawks on how to keep patients from coming back within a few weeks of getting out.

Driven by new Medicare penalties for such events, the effort has slowed a ‘revolving door’ of readmissions for heart attack, heart failure and pneumonia patients that costs the nation billions of dollars.

But, a new analysis suggests that Medicare should focus more on how well hospitals do at actually keeping such patients alive during the same time.

If hospitals got paid less when their patients died soon after a hospitalization, just like they get paid less when those patients end up back in the hospital, it would be a game-changer for one-third of hospitals, say researchers from the University of Michigan Medical School and VA Ann Arbor Healthcare System who published their findings in JAMA Cardiology.

According to the study, about 17 percent of hospitals are getting punished for excess readmissions, but are keeping patients alive more often than would be expected, and another 16 percent of hospitals essentially get rewarded for low readmission rates, but their patients are more likely to die in the first month after leaving their hospital beds.

In other words, some of the hospitals that get penalized for high readmissions are those that may actually do the best job at keeping patients alive – and vice versa.

Preventive incentives

If the penalties took both readmission and mortality into account, the Medicare system would save the same amount of money, but incentivize good outcomes more fairly, the researchers said.

“Under most circumstances, hospital patients would much rather avoid death than readmission,” said Scott Hummel, M.D., M.S., senior author of the new paper and a heart failure cardiologist. “But the incentive to prevent death in the first 30 days after a hospitalization is 10 times less than the incentive to prevent a return hospital visit.”

He and his colleagues hope their analysis will spark a conversation about how to fine-tune the Medicare system’s effort to encourage better performance by America’s hospitals.

Their work is based on data from 2014, the first year when hospitals could both be penalized for readmission rates that were higher than expected and earn a financial reward based on a mix of measures that include everything from 30-day death rates to how well patients rated the care they received and the hospital environment.

Under the current policy, hospitals can lose up to three percent of condition-related payments from Medicare for excess readmissions but can recoup only about 0.2 percent of such payments for having low mortality rates.

First author Ahmad Abdul-Aziz, M.D., an internal medicine resident at U-M, helped coordinate the data analysis using publicly available data from the Centers for Medicare and Medicaid Services, called CMS for short. Some of it was accessed via an online system created by Kaiser Health News, based on data from CMS. In all, data from 1,963 hospitals was included.

The authors, who also include senior team members Rodney Hayward, M.D., and Keith Aaronson, M.D., M.S., calculated a ratio for each hospital based on observed and expected readmissions and mortality in the first 30 days for heart attack, heart failure and pneumonia. Although other conditions were added to the readmission program in 2015 and 2016, they weren’t included because these diagnoses are not yet included in the reward program for low mortality rates.

All the data were adjusted for how sick each hospital’s patients were when they started, using standard methods that allow an apples-to-apples comparison. The socioeconomic status of each hospital’s patients, which can also affect patient outcomes but aren’t in a hospital’s control, wasn’t included because CMS hadn’t yet started taking it into account in 2014.

The authors don’t take issue with the idea of penalizing excess readmissions — though they do note that readmissions for any cause are included in the program, not just readmissions for the problem that sent the person to the hospital in the first place.

Admissions to any hospital within 30 days of discharge count against the hospital that the patient was discharged from, which may work against large hospitals that patients travel to for advanced care before returning to their home area.

Other researchers have shown there isn’t a tight link between a hospital’s 30-day readmission rate and the 30-day mortality rate for its patients with these conditions — suggesting that there’s more to the story when thinking about using them as measures of hospital quality.

The authors also call for continued improvement in risk models that will more precisely predict a patient’s risk of readmission, just like current, well-tested models to predict their risk of death.

Better tools would mean better ability to test a hospital’s actual performance against what might be expected based on their entire patient population. The researchers also plan to examine what kinds of hospitals are most likely to win or lose financially if the balance shifts between penalties for reducing readmissions and those for reducing early mortality.

“The misaligned incentives for preventing readmission and preventing death may help explain why some hospitals are doing really well on one, but not on the other,” said Hummel. “It’s important we continue to reduce preventable readmissions, but we need to watch out for unintended consequences too.

“Sometimes, a readmission might be a good thing — no one wants to see patients die because they should have been readmitted,” he added. “If financial penalties drive hospitals to figure out how to improve outcomes, increasing incentives to reduce early post-hospital deaths seems like a good place to start.”

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