The Centers for Medicare and Medicaid Services (CMS) Placed 10 day Hold on All Medicare Claims

On July 2^nd all Medicare Contractors were instructed to hold all Medicare claims for services dates July 1, 2008 or later, for 10 business days. This hold was placed to allow Congress more time to consider legislation related to the Medicare payment cuts that were scheduled to take effect July 1, 2008.

In December 2007 Congress had passed a law to postpone the cuts scheduled for January 1, 2008 for six months which went thru June 30, 2008. The new law contained a formula which reflected an increase of about 0.5 percent from the 2007 reimbursement rates.

This new halt will only last until July 15^th. If Congress fails to come up with a new law before July 15^th health care providers will see about a 10.6 percent cut from the 2007 rates.

There is a law pending called The Medicare Improvements for Patients and Providers Act which would postpone the steep payment cuts for an additional 18 months. This Act includes a 1.1 percent increase for 2009. However the law hasn’t made it out of the House of Representatives yet.

In the meantime there is nothing that we providers/billers can do but sit and wait to see what Congress ends up doing. It is such a huge cut that it greatly affects all health care providers. Rumors are that up to 60 percent of Participating Medicare Providers plan on dropping out of the program if the cuts are put into place.

It is understandable why they would want to drop out. However the problem is that by dropping out they are really only hurting the Medicare patients and the providers who stay in the program. There is no good outcome if the cuts are put into place.

Hopefully Congress will do the right thing for Medicare and come up with an alternative to the 10.6 percent cut in reimbursement rates.

Medicare “Cleaning Up” Providers with Tax ID vs. SS Numbers

Medicare is cracking down on providers who do not have their information recorded properly with Medicare. For example, if a provider signed up with Medicare under his/her social security number, but now uses a tax ID# for claims, his/her claims are being rejected by Medicare stating “NPI/Tax ID number not on crosswalk.” Medicare is requiring that your NPI number, your EIN or Tax ID number, and your LBN (Legal Business Name as registered with the IRS) all match up. If you tax id number is registered to John Smith MD but you call your practice Centertown Medical Office, Medicare must have you on file as John Smith MD. Their name for you must match what is on file with the IRS. Also, your NPI number must also match up with the IRS information. So if you are receiving strange rejections from Medicare, or if you have received a letter from CMS stating that your information doesn’t match, you need to straighten it out.

If you don’t have any idea what part is not matching, your best bet is to call your Medicare carrier and verify your information with them. They usually can direct you as to what information is not matching up.

Congress passes law to halt the 10.6% Provider Reimbursement Cuts in Medicare

Congress voted today, July 15^th, and passed a law that not only stops the 10.6% Medicare cuts, but it also includes a 1.1% increase for 2009. Today also ends the 10 day hold CMS had instructed Medicare carriers to impose on all claims with dates of service after July 1^st. This means that Medicare health care providers will not have to take a substantial pay cut for servicing Medicare providers.

New ABN (Advance Beneficiary Notice) for Medicare

CMS released a revised ABN or Advance Beneficiary Notice of Noncoverage (CMS-R-131) on March 3,2008 but providers and suppliers will be required to begin using it by September 1, 2008. This new form replaces the General Use ABN (CMS-R-131-G) and the Lab ABN (CMS-R-131-1) that were previously available. The new form and the instructions can be found on the cms web site at the following: www.cms.hhs.gov\bni

The ABN is a notice given to Medicare beneficiaries to advise them that Medicare is not likely to pay for a service or supply. Providers and suppliers must complete this form before providing services or products that are subject to this notice to the patient. The ABN must be explained to the patient or the patient’s representative and then the patient must sign the form.

One of the key features of the new form is that the title of the form, “Advance Beneficiary Notice of Noncoverage” more clearly conveys the purpose of the form. The new form replaces the need for two separate forms needed in the past. Also, this new ABN can be used for voluntary notifications instead of having the use the old separate form, the Notice of Exclusion from Medicare Benefits (NEMB).

The new ABN has a mandatory field for cost estimates. The provider or supplier must complete this field with the estimate of the cost of the service or good which may not be covered under Medicare. There is also a new beneficiary option on the new ABN form that allows a patient to choose to receive an item or service, pay for it out of pocket, and not have the claim filed with Medicare.

If you are providing services or supplies to patients that may not be covered by Medicare and are subject to the ABN you must make sure you are using the new ABN form before September 1^st. Make sure that the ABN is explained to the patient and have the patient sign the ABN. The patient should receive a copy of the ABN and a copy should be kept in the patient’s file. It is important that you have followed these steps when providing non covered services to Medicare patients.

NPI # Only Causes Claim Denials By Medicare

On May 23, 2008 insurance carriers were suppose to accept NPI only on all paper & electronic claims. Not only were you required to include the NPI number, but you were required to EXCLUDE the legacy numbers. Some insurance carriers were not ready for the deadline and applied for an extension (like NYS Medicaid). But Medicare was ready and if you include your PTAN (legacy) number on your claims they are being rejected.

For the insurance carriers who were ready for this deadline, you must make sure you do not have the legacy number in the shaded area of box 24J or box 32A & 33A. If your software is set up to automatically print the legacy number in this box you need to remove it. If you submit claims electronically, make sure your vendor has it set up to exclude the legacy number.

For the insurance carriers who were not ready and applied for an extension, you will need to continue including the legacy number until they have complied. This makes things a little messy. You need to make sure you are submitting the claims that require the legacy number with it, and the ones that don’t allow it, without. Crazy, but it’s what we billing people have to do to make sure the money keeps coming in.

Another little crazy thing to worry about is the NPI number entered in 24J. If you are set up with Medicare as an individual provider (not a group) and you only have a type I NPI, you must leave the NPI part of box 24J blank. You cannot include the individual NPI number here. If you are an individual provider and you put your NPI number in 24J, Medicare may reject your claims.

If you are a group with Medicare then you need to continue putting the rendering provider’s individual NPI in box 24J and the group NPI (type II) in box 33A. If you are not sure if you are an individual or a group you can tell by your PTAN number. If you only have one PTAN number then you are an individual. If you have a PTAN for the individual provider and a separate PTAN for the practice name then you are a group. Just when you thought it couldn’t get much more confusing!

If you want to keep your cash flow steady it is important to make sure you are submitting the claims correctly. If you have any question as to what a particular insurance carrier requires, give them a call. Better to have it right the first time than to have to resubmit!

Insurance Companies Downcoding Your Claims

Ever wonder why sometimes when you get reimbursed for a claim, the insurance company has ‘changed the code to a more appropriate code for payment’? You submitted the claim as a 99214 but they paid you for a 99213 or even worse, a 99212. This practice is called downcoding.

Do you have to accept it? Well in some cases you do. A lot will depend on the contract that you have with the insurance carrier. Some contracts will only allow providers to bill certain cpt codes. In that case, they can change a billed code to one of the allowed codes. Or the contract may specify that you can only bill a certain number, or percentage of claims at the higher codes.

But sometimes an insurance carrier will just downcode your claim and it is not due to contract specifications. In that case you can appeal it. We recently had a claim that the insurance carrier downcoded a 99214 to a 99213 and told us that they only allow a provider to bill a 99214 every 6 weeks for a patient. That is ludicrous. How can that guideline apply to any patient?

Sometimes we just have to remind the insurance carriers that the doctors are the ones who determine the patient’s needs. In this case we sent in office notes and a letter advising them that we were appealing the processing of the claim. The doctor had met the requirements to justify the billing of a 99214 and their ‘guidelines’ were inappropriate. We received payment for the difference about 10 days later.

So if you are having problems with your claims being downcoded, and they are not due to contract specifications, you should appeal. Don’t just accept what the insurance carrier does. That is what they are counting on. Just think of how much money they save on the providers that don’t do anything about it.

Mental Health Billing Made Easy

We're just putting the final touches on our newest e-book "Mental Health Billing Made Easy" A Complete Guide to everything you need to know to submit your claims and get reimbursed properly for your services. Whether you are a psychologist, psychiatrist, social worker, or a psychoanalyst, this book will walk you through the entire billing process and more. We cover everything from participating with insurance companies, credentialing, authorizations, referrals, copays, deductibles, coinsurance,codes, completing insurance forms, insurance denials, insurance appeals, practice management systems, and more. This e-book also contains our entire e-book "How To Complete A CMS 1500 Form Completely and Correctly - Line By Line, Box By Box".