Articles Posted in Medicare

On June 18 the U.S. Senate passed a six-month plan to prevent the Medicare physician 21 percent payment cut. The measure, which will cost $6.4 billion, was pushed through with the concern that the steep payment cut would raise the possibility that medical providers would turn away patients covered by Medicare. It will delay the cuts until November 30, 2010 while Congress tries to create a long-term plan. The plan was passed unanimously and lawmakers attribute its passage to the efforts to offset its attributed costs.

Almost immediately after the U.S. Senate announced the passage of the plan, Medicare announced that it would process Medicare claims received for June at the lower rate. This is because the U.S. House of Representatives will not be able to consider the plan until next week. However, there are indications that the bill’s success in the House may be complicated. House Speaker Nancy Pelosi announced that the House will not pass the Senate bill until the Senate agrees to act on job-creation legislation. If the bill does pass in the House, Medicare providers will have the burden to resubmit their claims to be made whole.

For more information on Medicare payments or the physician fee cut, please visit www.wachler.com or contact a Wachler & Associates attorney at 248-544-0888.

On May 14, 2010, the Centers for Medicare and Medicaid Services (CMS) released an MLN Matters article explaining Change Request (CR) 6954. CR 6954 adds Section 3.14 to the Medicare Program Integrity Manual. This section clarifies language regarding clinical review judgments. It requires Medicare claim review contractors to instruct their clinical review staffs to use the clinical review judgment process when making complex review determinations about a claim. The clinical review judgment involves two steps:

(1) The synthesis of all medical record information to create a longitudinal clinical picture of the patient; and

(2) The application of the clinical picture to the review criterial to determine whether the clinical requirements in the relevant policy are met.

The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 6698 to clarify how Medicare claim review contractors review claims and medical documentation submitted by providers. This clarification included an outline of new rules for signatures and added language for e-prescribing.

The previous language in the Program Integrity Manual (PIM) required a “legible identifier” in the form of a handwritten or electronic signature for every service provided or ordered. CR 6698 updates these requirements to require that every service provided or ordered be “authenticated by the author” by handwritten or electronic signature; stamp signatures are generally unacceptable.

CR 6698 also provides some exceptions to the signature requirement. First, facsimiles of original written or electronic signatures are acceptable for certifications of terminal illness for hospice. Second, there are other circumstances for which an order does not need to be signed. For example, orders for clinical diagnostic tests are not required to be signed, but there must be medical documentation by the treating physician that s/he intended the clinical diagnostic test to be performed. The documentation showing intent must be authenticated by the author with a handwritten or electronic signature. Finally, other regulations and CMS instructions regarding signatures take precedence. For example, if the NCD, LCD, and CMS manuals have specific signature requirements, those signature requirements take precedence. However, if these are silent as to signature requirements, the reviewer should follow the guidelines set forth in CR 6698.

Last month the Centers for Medicare and Medicaid Services (CMS) published an MLN Matters Article regarding changes to remittance advice coding. The article is directed towards Home Health Agencies that submit claims to a Regional Home Health Intermediary (RHHI) or to the Home Health Medicare Administrative Contractor (HH MAC – National Heritage Insurance Corporation (J14 only)) for services provided to Medicare beneficiaries.

The article explains that CMS released Change Request (CR) 6897 to instruct Medicare RHHIs and the J14 HH MAC to use a new Remittance Advice Remark Code (RARC) and a changed Claims Adjustment Reason Code (CARC) for home health agencies (HHAs) that are subject to the Home Health Prospective Payment System (HH PPS) outlier limitation. Up to CR 6897, the code “CARC 45” had been used to alert HHAs that an outlier payment, which would be eligible for payment, was not eligible because the HHA’s outlier limitation had been met. CMS found that CARC 45 did not adequately explain the reasoning for the denial of the payment, and therefore created a new remittance advice remark code (RARC) to be used in situations where the outlier limitation has been met. Then new RARC is N523. In addition to N523, HHAs can expect to see the claim adjustment reason code B5 (CARC B5).

The new RARC and updated CARC are effective for claims with dates of service on or after March 1, 2010. Therefore, if a calculated outlier amount is not paid because the HHA has reached the outlier limitation, HHAs can expect to see the following on their remittance advice: (1) Group Code CO: “Contractual Obligation,” (2) Claim adjustment reason code B5 (CARC B5); (3) RARC N523.

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) Home Health Care Survey is designed to measure the experiences of individuals receiving home health care from Medicare-certified home health care providers. The CAHPS has three broad goals: (1) to produce comparable data on the patient’s perspective that allows objective and meaningful comparisons between home health agencies on domains that are important to consumers; (2) public reporting of survey results so as to create incentives for agencies to improve their quality of care; and (3) public reporting to enhance public accountability in health care by increasing the transparency of the quality of care provided in return for public investment.

The home health care CAHPS (HHCAHPS) survey began in October 2009 with agencies that wished to implement the survey on a voluntary basis. The data collected during the voluntary period will be posted in Spring 2011. Agencies will have the option to suppress the reporting of their data collected during the voluntary period.

However, the Home Health Prospective Payment System (HHPPS) Final Rule (November 10, 2009) stated that HHCAHPS will be linked to the quality reporting requirement for the CY 2012 annual payment update (APU). The Centers for Medicare & Medicaid Services (CMS) strongly encourages that the designated quality staff in all Medicare-certified home health agencies (HHAs) read the Final Rule.

The Patient Protection and Affordable Care Act (PPACA), also referred to as the Healthcare Reform Legislation, made significant changes for Medicare providers. One change found in Section 6404 of the PPACA reduces the Medicare Parts A and B claims filing deadline to one (1) calendar year after the date of service furnished on or after January 1, 2010. The Section also gives the Secretary of the Department of Health and Human Services discretion to specify “exceptions” to the filing deadline. However, the PPACA did not specify the exceptions and it will be necessary to wait until the Centers for Medicare and Medicaid Services (CMS) begins the rulemaking process to implement the new filing deadlines. Regardless of the lack of specification of the exceptions to the filing deadlines, the new timely filing deadlines are self-executing.

It is also important to note that Section 6404 of the PPACA alters the timely filing deadline for claims under Medicare Parts A and B with dates of service prior to January 1, 2010. Claims with dates of service prior to January 1, 2010 must be filed by December 31, 2010.

For more information on health law issues, please visit www.wachler.com or contact a Wachler & Associates attorney at 248-544-0888.

On April 15 President Obama signed H.R. 4851 into law, blocking the 21% reduction in Medicare physician payments through May 31. The original Senate bill delayed the cuts until April 30, but was passed with an amendment that pushed the date to May 31. Although the 21% cuts toMedicare reimbursement technically took effect on April 1, the Centers for Medicare and Medicaid Services (CMS) has withheld processing claims.

The American Medical Association (AMA) continues to react against the repeated delays and uncertainty behind the congressional action. The AMA urges Congress to find a permanent fix to the currently used sustainable growth rate (SGR) formula. “Congress must now turn toward solving this problem once and for all through repeal of the broken payment formula…Fixing the Medicare physician payment problem is essential to the security and stability of Medicare.”

For more information, please visit www.wachler.com or contact a Wachler & Associates attorney at 248-544-0888.

A proposed bill, the Medicare Fraud Enforcement and Prevention Act, introduced in the House on Tuesday would double penalties for Medicare fraud. Sentences for Medicare fraud would be increased from 5 to 10 years and fines from $25,000 to $50,000. In addition, it would create a new crime for distributing patients’ Medicare or Medicaid IDs or billing information. That new crime would carry a maximum 3-year sentence.

The bill was introduced by two representatives from Florida, Ileana Ros-Lehtinen (R-Miami) and Ron Klein (D-Boca Raton). The bill, one of the first bipartisan efforts since the passage of the federal healthcare reform is a rebuttal to the increase in fraud despite the efforts of a federal health care fraud task force that prosecuted more than 800 people and identified more than $2.5 billion in fraudulent claims since 2006. According to law enforcement officials, Medicare fraud is an estimated $60 billion annual crime and is now more lucrative than drug dealing.

For more information on health law issues, please visit www.wachler.com or contact a Wachler & Associates attorney at 248-544-0888.

On Monday March 1st, a 21% Medicare physician payment cut went into legal effect. However, the Obama administration directed Medicare billing companies to stop processing claims for 10 business days in order to provide lawmakers with extra time to create a solution. On March 2, 2010, Kathleen Sebelius, Secretary of the Department of Health and Human Services, addressed the American Medical Association (AMA) and assured members that she was committed to developing a permanent fix to the sustainable growth rate (SGR) that controls Medicare payments to physicians.

For more information, please visit www.wachler.com or contact a Wachler & Associates attorney at 248-544-0888.

February 2010: In November 2009, the Centers for Medicare and Medicaid Services (CMS) announced changes to Medicare’s 2010 home health prospective payment system rates and modifications to the home health outlier policy. The rule became effective January 1, 2010.

In recent years, CMS has become more attuned to the growth in outlier payments, specifically very high outlier payments in certain areas of the country. An outlier payment is made for an episode that has a cost which exceeds a threshold amount. A Home Health Agency must bear a fixed dollar loss (FDL) before an episode becomes eligible for outlier payments. In 2009 CMS did not raise the FDL ratio due to the extremely high outlier payments in designated areas.

For CY 2010, CMS underwent an analysis of all providers who received outlier payments, focusing on total HH PPS payments, total outlier payments, number of episodes, number of outlier episodes, and location of provider. This analysis prompted CMS to propose an agency level outlier cap: in any given calendar year, an individual HHA will receive a maximum of 10 percent of its total HH PPS payments in outlier payments. In addition, CMS proposed to reduce the FDL ratio to .67 for CY 2010 (from .89 in CY 2009).