The Centers for Medicare & Medicaid Services’ Office of E-Health Standards and Services (OESS) is announcing that it will not initiate enforcement action for an additional three (3) months, through June 30, 2012, against any covered entity that is required to comply with the updated transactions standards adopted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA): ASC X12 Version 5010 and NCPDP Versions D.0 and 3.0.
Posts Tagged Centers for Medicare & Medicaid Services
Stark, False Claims and Anti-Kickback Laws: Easy Ways to Stay Compliant with the Big Three in Healthcare
In health care, we are “blessed” with an abundance of rules, policies, standards and laws. In Health Care Regulation in America: Complexity, Confrontation, and Compromise, Robert I. Field, professor of health management and policy at Drexel University School of Public Health, observes the following:
“Regulation shapes all aspects of America’s fragmented health care industry, from the flow of dollars to the communication between physicians and patients. It is the engine that translates public policy into action. While the health and lives of patients, as well as almost one-sixth of the national economy depend on its effectiveness, health care regulation in America is bewilderingly complex.”
Here are some of the most important regulations in health care that you should not only know about, but should be actively managing with a robust compliance plan.
As we finish off another month here at MMP, we wanted to go back over some of our most popular posts from the month and get ready for another busy, productive, and meaningful month. Presenting, The Best of Manage My Practice, October 2011!
- Are you ready for the holidays? How about the New Year? Even though it’s still a few months off, make sure you don’t see an interruption in your practice’s cashflow by getting ready for the January 1st 5010 deadline!
- CMS has released the Premiums and Deductibles for Medicare patients for 2012, so you can start informing staff and patients now. More importantly, will 2012 be the year that you get serious about collecting deductibles at the time of service?
- Mary Pat’s “Collection Basics”series about the fundamentals of Revenue Cycle Management in Physician offices is now at part three! Check out Patient Collections Basics: Developing a Financial Assistance Program.
- One of Healthcare’s most misunderstood and underutilized documents– the Medicare Advance Beneficiary Notice- is changing for 2012. Make sure you’re ready.
- And finally, the Office of the Inspector General (OIG) of he department of Health and Human services has released its 2012 Work Plan for areas it will concentrate on investigating. Better safe than sorry! Mary Pat goes over the highlights here.
We’ve started this monthly wrap-up to make sure you don’t miss any of the great stuff we post throughout the month on Manage My Practice, but we also want to hear from you! What were your favorite posts and discussions this month? Did we skip over your favorite from October? Let us know in the comments!
Announcement from CMS:
All providers and suppliers who enrolled in the Medicare program prior to Friday, March 25, 2011, will be required to revalidate their enrollment under new risk screening criteria required by the Affordable Care Act (section 6401a). Providers/suppliers who enrolled on or after Friday, March 25, 2011 have already been subject to this screening, and need not revalidate at this time.
New Screening Criteria
In the continued effort to reduce fraud, waste, and abuse, CMS implemented new screening criteria to the Medicare provider/supplier enrollment process beginning in March 2011. Newly-enrolling and revalidating providers and suppliers are placed in one of three screening categories – limited, moderate, or high – each representing the level of risk to the Medicare program for the particular category of provider/supplier, and determining the degree of screening to be performed by the Medicare Administrative Contractor (MAC) processing the enrollment application. More information on the screening categories is here.
Notices Will Be Sent to Providers/Suppliers
Between now and March 2013, MACs will be sending notices to individual providers/suppliers; please begin the revalidation process as soon as you hear from your MAC. Upon receipt of the revalidation request, providers and suppliers have 60 days from the date of the letter to submit complete enrollment forms. Failure to submit the enrollment forms as requested may result in the deactivation of your Medicare billing privileges. The easiest and quickest way to revalidate your enrollment information is by using Internet-based PECOS (Provider Enrollment, Chain, and Ownership System), at https://pecos.CMS.hhs.gov.
Section 6401a of the Affordable Care Act requires institutional providers and suppliers to pay an application fee when enrolling or revalidating (“institutional provider” includes any provider or supplier that submits a paper Medicare enrollment application using the CMS-855A; CMS-855B, not including physician and non-physician practitioner organizations; CMS-855S; or associated Internet-based PECOS enrollment applications); these fees may be paid via www.Pay.gov.
In order to reduce the burden on the provider, CMS is working to develop innovative technologies and streamlined enrollment processes – including Internet-based PECOS. Updates will continue to be shared with the provider community as these efforts progress.
For more information about provider revalidation, review the Medicare Learning Network’s Special Edition Article #SE1126, titled “Further Details on the Revalidation of Provider Enrollment Information.”
NOTE April 2011: CMS recently announced that July 5, 2011 will not be the date that claim editing will begin.
If you read my post on November 29th, you already know that CMS delayed pulling the trigger on January 1, 2011 to require PECOS enrollment for ordering and referring providers and enforcing nonpayment of claims that fail the ordering/referring provider edits.
CMS has just announced a new implementation date (calling it “a placeholder future implementation”) of
July 5, 2011 – unknown.
As a refresher, the only providers who can order/refer Medicare beneficiary services are:
doctor of medicine or osteopathy;
certified clinical nurse specialist;
certified nurse midwife;
clinical social worker
Claims that are the result of an order or a referral must contain the National Provider Identifier (NPI) and the name of the ordering/referring provider and the ordering/referring provider must be in PECOS or in the Medicare carrier’s or Part B MAC’s claims system with one of the above types/specialties.
The claim editing that will begin on
July 5, 2011 date not known will verify the ordering/referring provider on a claim is eligible to order/refer and is enrolled in Medicare.
The process to be used to determine if the ordering/referring provider on the claim matches the provider in the national PECOS file or in the contractor’s master provider file is as follows:
- MCS (Multi-Carrier System) will verify the National Provider Identifier (NPI) of the ordering/referring provider reported on the claim against the national PECOS file.
- If a match is not found, the MCS will verify the NPI of the ordering/referring provider on the claim against the MCS master provider file.
- If a match is found, the MCS will then compare the first letter of the first name and the first 4 letters of the last name of the matched record.
- If the names match, the ordering/referring provider on the claim is considered verified.
If you’ve not verified that your providers are properly enrolled in PECOS, you have yet another chance to get it figured out.
Here’s the Cheat Sheet:
- Check to see if your provider is enrolled by reviewing the Ordering and Referring file found in the download section of the “OrderingReferringReport” tab (click here) on the Medicare Provider and Supplier Web Site. The report is currently more than 15,000 pages but you can view it on the screen.
- If not enrolled, you can get your provider enrolled by paper or electronically. The Internet-based PECOS application is here.
- After submitting an enrollment application via Internet-based PECOS, you must:
- Print, sign and date (blue ink recommend) the Certification Statement(s), and
- Mail the Certification Statement(s) and applicable supporting documentation to the designated Medicare contractor (no later than 7 days after you complete the online portion.)
NOTE: The Medicare contractor will not be able to begin to process your enrollment application until it receives a signed and dated Certification Statement.
For more detailed information on PECOS, click on the PECOS category on the right-hand side of this web page.
A updated post on record retention with a simple record retention schedule can be found here.
State laws generally govern how long medical records are to be retained.
However, the Health Insurance Portability and Accountability Act (HIPAA) of 1996 administrative simplification rules require a covered entity, such as a physician billing Medicare, to retain required documentation for six years from the date of its creation or the date when it last was in effect, whichever is later. HIPAA requirements preempt State laws if they require shorter periods. Your State may require a longer retention period.
While the HIPAA Privacy Rule does not include medical record retention requirements, it does require that covered entities apply appropriate administrative, technical, and physical safeguards to protect the privacy of medical records and other protected health information (PHI) for whatever period such information is maintained by a covered entity, including through disposal.
The Centers for Medicare & Medicaid Services (CMS) requires records of providers submitting cost reports to be retained in their original or legally reproduced form for a period of at least 5 years after the closure of the cost report.
CMS requires Medicare managed care program providers to retain records for 10 years.
- Providers/suppliers should maintain a medical record for each Medicare beneficiary that is their patient.
- Medical records must be accurately written, promptly completed, accessible, properly filed and retained.
- Using a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries is a good practice.
- The Medicare program does not have requirements for the media formats for medical records. However, the medical record needs to be in its original form or in a legally reproduced form, which may be electronic, so that medical records may be reviewed and audited by authorized entities.
- Providers must have a medical record system that ensures that the record may be accessed and retrieved promptly.
- Providers may want to obtain legal advice concerning record retention after CMS-required time periods.
Independent Diagnostic Testing Facilities (IDTFs) Can Expect Quarterly Letters From Medicare A/B MACs About January 2012 Accreditation Requirement
For more information on the Medicare accreditation requirement for entities billing the technical component for advanced diagnostic imaging (CT, MRI, PET/Nuclear Medicine) effective January 1, 2012, read my post here.
Medicare Learning Network (MLN) just released MM6912, effective August 2, 2010: Mailing To All Individual Practitioners, Medical Groups and Clinics and Independent Diagnostic Testing Facilities (IDTF) Who Are Billing or Have Billed For The Technical Component of Advanced Diagnostic Imaging Services
What exactly is an IDTF?
Some suppliers that perform diagnostic tests, other than clinical laboratory or pathology tests, are required to enroll with Medicare as an Independent Diagnostic Testing Facility (IDTF). Not all suppliers that perform these diagnostic tests are required to enroll as an IDTF. Generally, entities can bill for the technical component of the diagnostic tests without an IDTF enrollment if it has the following characteristics:
- A physician practice that is owned, directly or indirectly, by one or more physicians or by a hospital
- A facility that primarily bills for physician services and not for diagnostic tests
- A facility that furnishes diagnostic tests primarily to patients whose medical conditions are being treated or managed on an ongoing basis by one or more physicians in the practice
- The diagnostic tests are performed and interpreted at the same location where the practice physicians also treat patients for their medical conditions
- If a substantial portion of the facility’s business involves the performance of diagnostic tests, the diagnostic testing services may be a sufficient separate business to require enrollment as an IDTF. In that case, the physician or physician group practice can continue to be enrolled as a physician or physician group practice but are also required to enroll as an IDTF. The physician or group can bill for professional fees and the diagnostic tests they perform on their patients using their billing number. Therefore, the practice must bill as an IDTF for diagnostic tests furnished to Medicare beneficiaries who are not regular patients of the physician or group practice.
Who will receive a mailing?
Enrolled physicians, non-physician practitioners, including single and multi- specialty clinics, and IDTFs who have billed the Medicare program for the technical component of advanced diagnostic testing services within the preceding six month period and who continue to have Medicare billing privileges with Medicare contractors (carriers and Part A/B Medicare Administrative Contractors (A/B MACs)) are affected.
If you have billed the Medicare program for the technical component of advanced diagnostic testing services within the preceding six month period and continue to have Medicare billing privileges with Medicare contractors, you will receive a letter from your Medicare contractor advising you of the need to become accredited by January 1, 2012, in order to continue to provide these services and bill Medicare.
When more than one physician or non-physician practitioner is operating within a group, such as a single specialty or multispecialty clinic, only the group will receive the letter, not each of the individual physicians or non-physician practitioners working for the group.
What will the mailing say?
You must be accredited by one of the three Centers for Medicare & Medicaid
Services (CMS) approved national accreditation organizations by January 1, 2012,
in order to be eligible to continue to furnish the technical component of advanced
diagnostic testing services to Medicare beneficiaries and submit claims for those
services to your Medicare contractor.
Your contractor will be mailing the letter quarterly beginning with July 2010 through July 2011. If necessary, follow the instructions in the letter to become accredited by January 1, 2012, in order to continue billing for the technical component of advance diagnostic imaging services. Make sure that your office staffs are aware of these new accreditation requirements and begin the accreditation process as soon as possible to protect your Medicare billing rights for these services.
Why do IDTFs have to become accredited now?
Section 135(a) of the Medicare Improvements for Patients and Providers Act of
2008 (MIPPA) amended section 1834(e) of the Social Security Act and required
the Secretary, Health and Human Services, to designate organizations to accredit
suppliers, including but not limited to physicians, non-physician practitioners and
Independent Diagnostic Testing Facilities, that furnish the technical component
(TC) of advanced diagnostic imaging services.
What qualifies as an advanced diagnostic imaging procedure?
MIPPA specifically defines advanced diagnostic imaging procedures as including:
”¢ Diagnostic magnetic resonance imaging (MRI),
”¢ Computed tomography (CT), and
”¢ Nuclear medicine imaging, such as positron emission tomography (PET).
MIPPA expressly excludes from the accreditation requirement x-ray, ultrasound,
and fluoroscopy procedures. The law also excludes from the CMS accreditation
requirement diagnostic and screening mammography, which are subject to quality oversight by the Food and Drug Administration under the Mammography Quality Standards Act.
How long does it take to become accredited?
Since CMS expects that it may take as much as nine months from the time you initiate the accreditation process to completion, you should begin the accreditation process for advanced diagnostic imaging services as soon as possible, but not later than March 2011.
Who are the accrediting organizations?
CMS approved three national accreditation organizations — the American College
of Radiology, the Intersocietal Accreditation Commission, and The Joint
Commission — to provide accreditation services for suppliers of the TC of advanced diagnostic imaging procedures. The accreditation will apply only to
the suppliers of the images themselves, and not to the physician interpreting
the image. All accreditation organizations have quality standards that address the safety of the equipment as well as the safety of the patients and staff.
If you have questions, contact your Medicare carrier and/or A/B MAC at
their toll-free number, which may be found here (zip file.)
The letter will look like this:
[Supplier Name and Address]
Dear Physician/Non-Physician Practitioner/IDTF owner:
In accordance with Section 135(a) of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), suppliers, including but not limited to physicians, non-physician practitioners and Independent Diagnostic Testing Facilities that furnish the technical component (TC) of advanced diagnostic imaging services must be accredited by January 1, 2012 in order to continue to furnish these services to Medicare beneficiaries.
Our records indicate that you have furnished advanced diagnostic imaging procedures such as diagnostic magnetic resonance imaging (MRI), computed tomography (CT), and nuclear medicine imaging such as positron emission tomography (PET) within the last six months. If you are not accredited by one of the organizations shown below by January 1, 2012, you will not be eligible to bill the Medicare program for advanced diagnostic imaging services. This letter requests that you take the necessary action to become accredited by the January 1, 2012 deadline. Since we expect it can take up to nine months from the time you initiate the accreditation process to completion, we urge you to begin the accreditation process for advanced diagnostic imaging services as soon as possible.
MIPPA expressly excludes from the accreditation requirement x-ray, ultrasound, and fluoroscopy procedures. The law also excludes from the CMS accreditation requirement diagnostic and screening mammography which are already subject to quality oversight by the Food and Drug Administration under the Mammography Quality Standards Act.
The Centers for Medicare & Medicaid Services (CMS) approved three national accreditation organizations ”“ the American College of Radiology, the Intersocietal Accreditation Commission, and The Joint Commission – to provide accreditation services for suppliers of the TC of advanced diagnostic imaging procedures. The accreditation will apply only to the suppliers of the images themselves, and not to the physician interpreting the image. All accreditation organizations have quality standards that address the safety of the equipment as well as the safety of the patients and staff. The accrediting organization that issues your accreditation will notify Medicare once your accreditation is complete and approved.
To obtain additional information about the accreditation process, please contact the accreditation organizations shown below.
American College of Radiology (ACR)
1891 Preston White Drive
Reston, VA 20191-4326
Intersocietal Accreditation Commission (IAC)
6021 University Boulevard, Suite 500
Ellicott City, MD 21043
The Joint Commission (TJC)
Ambulatory Care Accreditation Program
One Renaissance Boulevard
Oakbrook Terrace, IL 60181
If you have questions about this letter, contact [carrier or A/B MAC phone number/contact person].
[Name of carrier or A/B MAC]
Supplier Billed Advanced Medical Imaging CPT codes for Section 135 (a) of the MIPPA to Receive Accreditation Requirement Notification Letter
70336 70540 71250 72125 73200 74150
70450 70542 71260 72126 73201 74160
70460 70543 71270 72127 73202 74170
70470 70544 71275 72128 73206 74175
70480 70545 71550 72129 73218 74181
70481 70546 71551 72130 73219 74182
70482 70547 71552 72131 73220 74183
70486 70548 71555 72132 73221 74185
70487 70549 72133 73222
70488 70551 72141 73223
70490 70552 72142 73225
70491 70553 72146 73700
70492 70554 72147 73701
70496 70555 72148 73702
70498 70557 72149 73706
70558 72156 73718
70559 72157 7371972158 73720
75557 76360 77011 78000 78811
75559 76376 77012 78001 78812
75561 76377 77021 78003 78813
75563 76380 77058 78006 78814
76390 77059 78007 78815
76497 77078 78010 78816
76498 77079 78011 78891
Providers have the opportunity to participate with Medicare once annually. This period called “Open Enrollment” is usually from mid-November to the end of the calendar year. Providers who may have declined to participate with Medicare for the 2010 calendar year due to the anticipated deep cuts in the physician Medicare fee schedule now have a special opportunity to jump on board between now and July 16, 2010. Here is the announcement:
Dear Medicare Part A and Part B Providers,
Opportunity for Nonparticipating Physicians/Practitioners to Become Participating
In consideration of the recent enactment of the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010, which established a 2.2 percent update to the Medicare Physician Fee Schedule (MPFS), the Centers for Medicare & Medicare Services (CMS) is offering physicians and other practitioners, whose current participation status is non-participating, the opportunity to become participating (PAR). This opportunity is being offered only to those physicians/practitioners whose current PAR status is non-participating. This opportunity is available through July 16, 2010.
Non-participating physicians/practitioners who would like to become a participating physician/practitioner should download and complete the Medicare Participating Physician or Supplier Agreement (Form CMS-460). The form can be obtained by using the following CMS web site link: http://www.cms.gov/cmsforms/downloads/cms460.pdf.
Any new CMS-460 form received during this limited enrollment period will be retroactive for claims with dates of service of January 1, 2010, and later. However, the change in participation status will only apply to new MPFS claims submitted after your new status as a participating physician/practitioner is processed. Claims previously submitted and processed will not be adjusted for only a change in participation status.
Medicare claims administration contractors (Medicare Administrative Contractors and carriers) will accept and process requests to become a participating physician/practitioner that are submitted on the CMS-460 form and are post-marked on or before July 16, 2010.