Effective May 14, 2012, CMS has updated its enrollment process for Medicare providers. Providers and suppliers can now submit their enrollment applications 30 days sooner. CMS-855 enrollment applications and Internet-based PECOS applications may now be submitted 60 days prior to the effective date.

This new policy does NOT apply to the following groups:

1. Providers and suppliers submitting a Form CMS-855A application

2. Ambulatory Surgical Centers (ASCs)

3. Portable X-ray Suppliers (PXRSs)

On May 9, 2012, a bipartisan bill was introduced to the U.S. House of Representatives that would permanently repeal the Sustainable Growth Rate (SGR) formula. The SGR formula was adopted by Congress in 1997 with the intention of preventing Medicare spending on physicians from exceeding the overall growth of the economy. Every year by March 1, the SGR is calculated and presented to the Medicare Payment Advisory Commission (MedPAC) for evaluation of cuts that need to be made to the Medicare Physician Fee Schedule. In turn, every year physicians push back against Congress, demanding that the drastic cuts be postponed. This back-and-forth proposal and push back escalated this year to the drastic threat of a 27% reduction in physician reimbursements. Fortunately, the “doc fix” went into effect in the eleventh hour, relieving physicians of this reduction – at least for this year. However, unless further legislation passes between now and then, the proposed reimbursement cut for January 1, 2013 looms above 30%.

The May 9th “Medicare Physician Payment Innovation Act,” proposed by U.S. Reps. Allyson Schwartz (D-PA) and Joe Heck, D.O. (R-NV), would permanently repeal the SGR formula and end the annual battle against drastic cuts. In lieu of the SGR formula, the bill proposes alternate reimbursement models that provide more predictable updates to the yearly reimbursement schedule.

The proposed bipartisan bill has garnered support from leaders in the medical community, including David L. Bronson, MD, FACP, President of the American College of Physicians: “We enthusiastically support this legislation. It not only addresses the continued threat of the SGR formula, it also addresses moving us beyond the fee-for-service payment model toward new models that better align payment with value.”

The full press release from the office of U.S. Representative Allyson Y. Schwartz can be viewed here.

Today, May 9, 2012, the Department of Health and Human Services announced its proposed rule to implement the Affordable Care Act requirement that Medicaid reimburse primary care providers at the same as Medicare. As providers and their medical billing companies already know, Medicaid currently reimburses at a lower rate than Medicare in the majority of states, including Maryland. According to DHHS Secretary Sebelius, the proposed rule for increased payment will be entirely federally-funded, and over $11 billion will go to the States to reimburse the providers that render primary care services in the fields of internal medicine, family medicine, pediatric medicine and the like. This proposal will benefit those who are patient, as it will be applied to primary care services that are rendered in 2013 and CY 2014.

Visit the Office of the Federal Register to review the full-text of the proposed rule.

On April 24, 2012, Aetna updated Clinical Policy Bulletin (CPB) #0106 for fetal echocardiograms. If you render any maternal-fetal services, or likewise do the medical billing for any speciality that accepts commercial insurance, you should make yourself familiar with Aetna’s Clinical Policy Bulletins. These CPB’s clearly define Aetna’s standards regarding medical necessity and services that fall within the category of experimental and/or investigational billing. The CPB’s outline the medical literature that supports the status determinations, and offers a complete table of CPT’s and ICD-9′s that are covered. Prior to rendering any services, a medical billing and coding expert should consult with the provider to discuss the medical conditions and diagnoses that warrant medically necessary procedures, per Aetna’s policies. In the absence of a supporting diagnosis, the provider should be made aware that claims can deny for experimental/investigational billing. To ease this process, providers should familiarize themselves with the lists of ICD-9′s that specifically support the billing of particular CPT’s. At the present, we draw your attention to Aetna’s CPB on fetal echocardiography. This CPB was recently updated to expand the indications of medical necessity for fetal echocardiograms. These new indications include: autoimmune antibodies associated with congenital heart disease, familial inherited disorders (e.g. Marfan syndrome) associated with congenital heart disease, monochorionic twins, multiple gestation and suspicion of twin-twin transfusion syndrome, or teratogen exposure; and indications of fetal extra-cardiac anomaly, hydrous, or unexplained severe polyhydramnios. CPT’s affected by this revision include 76825, 76826, 76827, and 76828. For the complete list of supported ICD-9′s, please view the complete CPB on Aetna’s website.

Again, each of Aetna’s CPB’s are publicly-accessibe on their website. The CPB’s cover medical procedures that span across all specialities. As always, the provider should use his or her own professional judgment when determining the appropriateness of medical procedures and the treatment of each patient.

(Source: Aetna Clinical Policy Bulletin: Fetal Echocardiograms #0106, Last Review 04/24/2012).

Every provider and billing company knows that there will always be instances in which it is necessary to file a corrected claim. Perhaps a more appropriate CPT needs to be billed, a modifier appended, or diagnosis revised. In any case, the process of correcting and resubmitting claims can be both time-consuming and frustrating when reimbursement is delayed. If your medical billing team is still submitting corrected claims by paper, then this delay will only be worsened! It used to be thought that corrected claims needed to be sent via paper so that the insurance carriers would not deny the resubmission as a duplicate of the original. Printing and snail-mailing claims increases days in AR, and likewise increases the chance of the claim being lost or reported as not received by the insurance carrier. Meanwhile, submitting electronically not only increases turn-around between resubmission and reimbursement, but also provides a traceable record of claim submission and carrier receipt. Fortunately, most major carriers now have the capacity to accept electronically-submitted corrected claims. Even CareFirst BlueCross BlueShield published in its recent April 25, 2012 Provider Newsletter that all providers who are able to submit electronically should do so for both original and corrected claims.

In order to prevent the electronic resubmission from rejecting as a duplicate by your clearinghouse or insurance carrier, two fields need to be populated in the HIPAA 837P claims transaction. A value of ‘7’ should be listed in Loop 2300, Segment CLM05-3. The ‘7’ is the “claim frequency type code” that indicates that the claim is a replacement of the original. In Loop 2300 (Ref*F8), the original claim # should be listed. (Note: If you were mailing the corrected claim, these two segments correspond to HCFA Box 22a and 22b). Now, while many of us do not know the exact meaning of the various segments and loops of the electronic claim transaction, most Practice Management systems should have readily-available fields where this information can be added to the claim. If you can’t find the appropriate fields, give Healthcare Data Management a call! We constantly strive to find ways of increasing providers’ efficiency and reimbursement speed.

The Centers for Medicaid & Medicare (CMS) recently released an MLN Matters Article that highlights the Medicare Secondary Payer (MSP) rules. These rules delineate the circumstances in which Medicare will only make payment after another insurance carrier issues the primary payment. All too frequently, physicians and their billing companies will receive denials from Medicare due to a coordination of benefits (COB) issue. As examples, Medicare will not make primary payment on a claim if there is any open workers’ compensation case on file for the patient, or if the patient or patient’s spouse is currently employed. In order to alleviate denials and delays in payment receipt, physicians, healthcare providers, and billing services should help to educate patients about coordination of benefits issues. It may be helpful to post signs or remind patients that they must contact their insurance companies (both Medicare AND the other payer) to coordinate benefits in any of the following situations:

• If there is a change in patient’s employment status, including retirement and changes in health insurance companies.
• If there is a change in the PATIENT’S SPOUSE has a change in employment status.
• If an attorney has taken legal action on patient’s behalf for any claim.
• If the patient has been involved in an automobile accident or a workers’ compensation case.

It is then the provider’s responsibility (and the responsibility of the billing service) to submit secondary claims to Medicare with all available information on the primary payment (including the Explanation of Benefits received from the primary payer). Medicare uses this information to determine the appropriate secondary payment amount.

For the complete Medicare Secondary Payer (MSP) manual, including all of the detailed circumstances in which Medicare is the secondary payer, visit the CMS website for a downloadable PDF.

According to Michigan State University, the occurrence of twin births has increased dramatically in the past several decades. Consider this remarkable statistic: in 1980, one in every 53 babies was a twin; in 2009, that number rose to one in every 30 births. These findings were presented in early April 2012 at the 14th Congress of the International Society for Twin Studies in Florence, Italy. Barbara Luke of the MSU College of Human Medicine’s Department of Obstetrics, Gynecology and Reproductive Biology presented these findings, and also noted that the rise can be attributed to an increase in maternal age and the increase use of fertility treatments.

As perinatologists and other providers of Maternal-Fetal medicine are well aware, multiple pregnancies are accompanied with greater health risks than single gestation pregnancies. Attentive care and ongoing research seek to mitigate these risks and deliver the healthiest possible outcomes for mothers and babies alike. For more information on MSU’s research, their news publication can be viewed here.

In a press release issued today, HHS Secretary Kathleen Sebilius announced a proposed rule that will delay the compliance date for ICD-10 from October 1, 2013 to October 1, 2014. In February, the Secretary stated that the compliance date would be delayed; however, no firm date on the extension was provided until today’s announcement. This update provides valuable planning information for all HIPAA covered entities, from insurance plans and health care clearinghouses to health care providers and medical billing companies. Full press release can be read here.

Effective January 1, 2012, Highmark Medicare Services (HMS)was acquired by Diversified Service Options, Inc. (DSO). Consequently, the HMS name has changed to Novitas Solutions, Inc. Novitas (pronounced NO-vih-tas) will now be the Medicare Administrative Contractor (MAC) for Jurisdiction 12 (J12) and Section 1011. The states included in J12 include Delaware, District of Columbia, Maryland, New Jersey, and Pennsylvania.

Physicians and medical billing companies should not face many disruptions as a result of this transition. According to Novitas Solutions, the current Highmark Medicare website will be fully transitioned to the new Novitas site by March 30, 2012. During the transition, visitors to the old website (https://www.highmarkmedicareservices.com) will be automatically re-directed to the new Novitas Solutions website (https://www.novitas-solutions.com), where a new header and page logo can be seen. Bookmarks that users may already have for the Highmark website will purportedly still work with the new page. The Electronic Payer ID has not appeared to change, so claims submission and processing should remain unaffected by the transition. For more information, see the Informational Alert here: https://www.novitas-solutions.com/partb/info-alerts.html.