Posts Tagged Part B
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!
Click here for the 2012 Medicare Part A and Part B Premiums and Deductibles.
Medicare Premiums for 2011:
Part A: (Hospital Insurance) Premium
Most people do not pay a monthly Part A premium because they or a spouse has 40 or more quarters of Medicare-covered employment.
The Part A premium is $248.00 per month for people having 30-39 quarters of Medicare-covered employment.
The Part A premium is $450.00 per month for people who are not otherwise eligible for premium-free hospital insurance and have less than 30 quarters of Medicare-covered employment.
Part B: (Medical Insurance) Premium
Most beneficiaries will continue to pay the same $96.40 or $110.50 premium amount in 2011. Beneficiaries who currently have the Social Security Administration (SSA) withhold their Part B premium and have incomes of $85,000 or less (or $170,000 or less for joint filers) will not have an increase in their Part B premium in 2011. For additional details, see the FAQ titled:
For all others, the standard Medicare Part B monthly premium will be $115.40 in 2011, which is a 4.4% increase over the 2010 premium. The Medicare Part B premium is increasing in 2011 due to possible increases in Part B costs. If their income is above $85,000 (single) or $170,000 (married couple), then the Medicare Part B premium may be higher than $115.40 per month.
Medicare Deductible and Coinsurance Amounts for 2011:
Part A: (pays for inpatient hospital, skilled nursing facility, and some home health care) For each benefit period Medicare pays all covered costs except the Medicare Part A deductible (2011 = $1,132) during the first 60 days and coinsurance amounts for hospital stays that last beyond 60 days and no more than 150 days.
For each benefit period you pay:
A total of $1,132 for a hospital stay of 1-60 days.
$283 per day for days 61-90 of a hospital stay.
$566 per day for days 91-150 of a hospital stay (Lifetime Reserve Days).
All costs for each day beyond 150 days
Skilled Nursing Facility Coinsurance
$141.50 per day for days 21 through 100 each benefit period.
Part B: (covers Medicare eligible physician services, outpatient hospital services, certain home health services, durable medical equipment)
$162.00 deductible for 2011. Patients pay 20% of the Medicare-approved amount for services after meetingthe the $162.00 deductible.
Check out the new services that Medicare will cover as of January 1, 2011 here.
More information on Medicare wellness visits in 2011 can be found here.
Information on the 2011 Medicare Part A and Part B deductibles and premiums can be found here.
The extensive changes coming for Medicare Part B coverage in 2011 should have primary care practices and some specialty practices thinking about their current processes. If you meet with your team now to educate them about the Medicare changes and explore process tweaking, you’ll be ready when January 1 rolls around.
Here are a few areas to think about:
- Advance Beneficiary Notices (ABNs) – Many practices struggle with the who and when of ABNs and the new coverage might not make it easier. There are lots of services now covered with new frequency limitations, so practices must be on their toes to recognize when a service is covered and when it isn’t. Sure, you can ignore ABNs and wait for Medicare to tell you a service is not covered, but then it’s too late to collect from the patient – not only too late, but also illegal to collect.
- The annual wellness visit is going to be a special challenge because the timing is precise. Medicare patients will hear “annual visit”, but won’t realize it will not be paid for if performed within 12 months of a previous wellness visit (Welcome to Medicare exam or annual visit). I’ve not seen any practice management software that handles this really well, but maybe it’s out there. I’d love to see Medicare patients scheduling their annual visits during their birthday month so staff would have a fighting chance of identifying the last annual visit and getting the date right. Of course, using your electronic recall will work too if you schedule the next year’s visit when the patient is checking out. (Do you proactively contact your Medicare patients to invite them to come in for their Welcome to Medicare exam?) Also encourage patients to keep up with the preventive services they are eligible to receive by registering with the My Medicare website (https://mymedicare.gov/). This is their personal Medicare website for tracking their Medicare services. It will send them e-mail reminders when they are eligible for Medicare coverage of preventive services. Great idea!
- Who will be doing the counseling about the “preventive services covered by Medicare” during the annual exam? Let’s hope Medicare puts out a really great handout!
- Most EMRs will let you load requirements for services based on diagnosis – for example, diabetes. Make sure you are taking advantage of the EMR’s ability to set up protocols for age, diagnosis and risk factors. If you are not on EMR yet, use your appointment schedule or recall system to set reminder appointments to contact patients for their services.
- Don’t forget your patients on Medicare who are not yet age 65. Run a report to find these patients and flag them to acknowledge that their Medicare services are at different times.
- Collections at time of service will change too, of course, as most services listed below will not be applied to the deductible. Exceptions are glaucoma screening, diabetes monitoring and education, medical nutritional, and smoking cessation. Patients understandably will be confused, so make sure your check-out staff are crystal clear.
Medicare Benefits Beginning January 1, 2011
- Medicare covers a one-time preventive physical exam within the first twelve months of having Part B. The exam will include a thorough review of health, education and counseling about the preventive services covered by Medicare and referrals for other care if needed. No Part B deductible and effective January 1, 2011 you pay nothing if the doctor accepts assignment.
- Abdominal Aortic Aneurysm Screening – People at risk for abdominal aortic aneurysms may get a referral for a one-time screening ultrasound at their “Welcome to Medicare” physical exam. Effective January 1, 2011 no deductible and no copayment.
- New Annual Wellness Visit – Effective January 1, 2011 Medicare will cover an Annual Wellness Visit that includes a thorough review of health, education and counseling about the preventive services covered by Medicare and referrals for other care if you need it. It is available every 12 months (after first 12 months of Part B coverage) but not within 12 months of receiving either a “Welcome to Medicare” physical exam or another Annual Wellness Visit. No Part B deductible ”“ Medicare pays 100% of the approved amount.
- Cardiovascular Screening Blood Tests – Medicare covers cardiovascular screening tests that check cholesterol and other blood fat (lipid) levels every 5 years. Includes:
- Total Cholesterol Test
- Cholesterol Test for High Density Lipoproteins; and
- Triglycerides Test
- No Part B deductible ”“ Medicare pays 100% of approved amount.
- Diabetes Screening Tests – Anyone enrolled in Medicare identified as “high risk” for diabetes will be able to receive screening tests to detect diabetes early. Covers up to two screenings each year. Includes:
- Fasting plasma glucose test
- Post-glucose challenge test
- No Part B deductible ”“ Medicare pays 100% of approved amount
- Glaucoma Screening – Must be done or supervised by an eye doctor (optometrist or ophthalmologist). Covered annually for:
- Those with diabetes
- Those with a family history of glaucoma
- African-Americans age 50 and older
- Hispanic-Americans age 65 and older
- Other high risk individuals
- Medicare pays 80% of the approved amount after you meet the yearly Part B deductible.
- Bone Mass Measurement – For those enrolled in Medicare at high risk for losing bone mass. Effective January 1, 2011 no Part B deductible ”“ Medicare pays 100% of approved amount.
- Screening Mammography (including new digital technologies) – For women age 40 and older enrolled in Medicare:
- Covered annually
- No Part B deductible ”“ Medicare pays 100% of approved amount beginning January 1, 2011.
- Screening Pap Test & Pelvic Examination (Includes clinical breast examination) – For all women enrolled in Medicare:
- Covered once every two years for most
- Covered annually for women at high risk
- No Part B deductible ”“ Medicare pays 100% of approved amount for Pap test and effective January 1, 2011 pays 100% of approved amount for pelvic and breast exam.
- Colorectal Cancer Screening – For all those enrolled in Medicare age 50 and older:
- Fecal-Occult blood test covered annually ”“ No Part B deductible & Medicare pays 100% of approved amount.
- Flexible sigmoidoscopy once every four years or 10 years after a previous screening colonoscopy”“ No Part B deductible or copayment starting January 1, 2011.
- Barium enema can be substituted for sigmoidoscopy or colonoscopy ”“ No Part B deductible – Medicare pays 80% of the approved amount. You will pay a higher coinsurance if the test is done in a hospital outpatient department.
- Colonoscopy for any age enrolled in Medicare
- Average risk – Once every ten years, but not within four years after a screening flexible sigmoidoscopy
- High-risk – Once every two years
- No Part B deductible and effective January 1, 2011 Medicare pays 100%.
- Prostate Cancer Screening Tests -For all men enrolled in Medicare age 50 and older:
- Covered annually
- Digital rectal exam ”“ Medicare pays 80% of the approved amount after the deductible
- Prostate Specific Antigen (PSA) test
- No Part B deductible – Medicare pays 100% of approved amount.
- Diabetes Monitoring and Education – Covers Type I and Type II diabetics enrolled in Medicare who must monitor blood sugar (Not paid for those in a nursing home) Covered services:
- Glucose-monitoring devices, lancets & strips
- Education & training to help control diabetes
- Foot care once every 6 months for those with peripheral neuropathy
- Medicare pays 80% of the approved amount after you meet the yearly Part B deductible.
- Medical Nutritional Therapy – Covered for those with diabetes or kidney disease. Includes diagnosis of special nutrition needs, therapy and counseling services to help you manage your disease. Medicare pays 80% of the approved amount after you meet the yearly Part B deductible.
- Smoking Cessation Services – Medicare will cover up to 8 counseling sessions per year for individuals who have an illness caused or complicated by tobacco use or you take medication affected by tobacco use. Medicare pays 80% of the approved amount after you meet the yearly Part B deductible.
- Flu Vaccination Annually (Medicare pays once per season. You do not have to wait 365 days since your last one.) No Part B deductible ”“ you pay nothing if your doctor accepts assignment. My post on billing for the flu shot is here.
- H1N1 Flu Vaccine Medicare covers the administration of the H1N1 flu shot. You cannot be charged for the vaccine. No Part B deductible or co-insurance.
- Pneumococcal Pneumonia Vaccination– Once per lifetime for all enrolled in Medicare. (A doctor may order additional ones for those with certain health problems.) No Part B deductible ”“ Medicare pays 100% of approved amount.
- Hepatitis B Shots – Covered for those who are at medium or high risk. Effective January 1, 2011, there will be no Part B deductible and Medicare pays 100%.
Today I was fortunate enough to attend an outreach session designed to educate hospitals, physicians and other providers about Recovery Audit Contractors (RAC), specifically Connolly Consulting, the RAC for North Carolina. Although I cannot vouch that the information I am sharing for Region C will be consistent for the other three RACs, the fact that there is a standard handout being used for all RAC outreach sessions makes me think there’s a very good chance that CMS is encouraging a high level of consistency.
If you read the recent Manage My Practice article here by Carla Hannibal, you already know that the RACs were established after CMS demonstration projects proved “to be successful in returning dollars to the Medicare Trust Funds and identifying monies that need to be returned to providers. It has provided CMS with a new mechanism for detecting improper payments made in the past, and has also given CMS a valuable new tool for preventing future payments.” (CMS website)
Each RAC bid for and won the jurisdiction as follows:
- Region A: CT, DE, DC, MD, ME, MA, NH, NJ, NY, PA, RI, VT Diversified Collection Services (DCS) -1-866-201-0580, website here
- Region B: MN, WI, IL, IN, OH, MI, KY CGI Technologies and Solutions -1-877-316-7222, website here
- Region C: AL, AR, CO, FL, GA, LA, MS, NC, NM, OK, SC, TN, TX, VA, WV and the territories of Puerto Rico and U.S. Virgin Islands. Connolly Consulting, Inc. -1-866-360-2507, website here
- Region D: WA, OR, ID, CA, NV, MT, WY, UT, AZ, ND, SD, NE, KS, IA, MO, AK, HI HealthDataInsights, Inc.-Part A: 866-590-5598, Part B: 866-376-2319, e-mail: website here
Each RAC is required to provide outreach education sessions in their region prior to sending out any letters. Any hospital or physician who bills fee-for-service programs (Part A and/or Part B) for Medicare beneficiaries is eligible for a RAC audit.
These are the important points that I took away from attending this outreach program:
- RACs may review claims as far back as October 1, 2007.
- RACs review claims after they have been paid using the same Medicare policies used to pay the claim initially.
- There are two types of reviews: Automated Reviews which do not request the medical record and Complex Reviews which will request the medical record.
- Automated Reviews are “done deals” and the claim will be adjudicated and a letter sent detailing the dollars requested.
- Providers may return the payment by writing a check, allowing a recoupment from future payments or may apply for an extended payment plan.
- Complex Reviews entail a request for medical records. Records can be mailed, faxed, or sent on a CD/DVD. Mailed records must be sent in a tamper-proof package, and should be sent via trackable carriers (FedEx, UPS, Registered USPS.) Multiple records may be sent in one package if each record set is in a separate envelope inside the package.
- Note: if faxing, fax the records to yourself to check for readability before you fax to the RAC.
- Email records are currently not acceptable due to HIPAA.
- Providers have 45 days plus 10 mailing days for a total of 55 days to send the records, but extensions are available if this is not abused. If you do not communicate with your RAC about any problems you are having sending the records (e.g. you can’t find the record!), you risk having the claim(s) automatically recouped. The Connolly representative even mentioned something to the effect that she wasn’t above calling the practice/entity CEO to let them know that their contact person wasn’t playing by the rules.
- Once a claim has been reviewed and a Complex Review is in play, the provider will receive a Demand Letter from the RAC and the provider will have a “discussion period” to contact the RAC and ask questions and/or provide additional information. The RAC representative emphasized to communicate, communicate, communicate and to call the RAC and speak to the reviewer of the claim. Once you have spoken to the reviewer, if you still disagree with the decision, you should ask to speak to the supervisor, and if there still is no agreement, you need to file an appeal.
- Appeals must be filed within 120 days of the receipt of the demand letter from the RAC.
Here is a suggested action plan for physician practices to prepare for the RAC process:
- Visit the CMS website here and click on Demonstration Projects to see what improper payments were found by the RAC demonstration projects.
- Visit the CMS and OIG websites to see what improper payments were found by reading the OIG (Office of Inspector General) reports here and CERT (Comprehensive Error Rate Testing) reports here.
- Conduct an internal assessment to see if you are in compliance with Medicare rules, and if not, identify corrective actions needed to bring your group into compliance. Corrective actions may include provider education and a periodic internal audit to rate the improvement.
- Provide your RAC (they will tell you how to do this) with a contact person who will receive RAC letters and who will be the point person for providing the RAC with additional documentation. The RAC will also ask for information about providers and their NPIs, including any providers who were with the group between October 1, 2007 and now, even if the provider is no longer with you. Connolly suggests copying the list of providers you supply to the RAC and placing it in the personnel file of the contact person to be reminded of this important responsibility if this person leaves the organization.
- Develop a basic tracking system for receipt of letters, and activity for each request.
- VISIT YOUR RAC WEBSITE AT LEAST WEEKLY.
I have received lots of questions about what a RAC letter will look like, and the speaker today provided a sliver of information saying that the Region C letters will have the CMS logo at the top of the letter and Connolly’s logo at the bottom of the letter. Because your practice/entity will be providing the RAC with a contact person’s name, unless things are in total chaos at your place of business, the letters will go to the person you’ve entrusted with this important responsibility.
Here are some other questions and answers from the program today:
Q: Does the RAC pay for the copying/mailing for records?
A: They will pay hospitals, but will not pay physicians for record expense.
Q: If a claim is refunded to Medicare, must the patient be refunded their portion?
Q:What determines which region the practice/entity belongs to for RAC?
A: The state that the practice/entity is located in.
Q: Are patients contacted if their claim is audited?
A: They receive a notice if the claim is adjusted in any way.
Q: I heard that there are consultants selling RAC insurance – is that a good idea?
A: There is no such thing as audit insurance, but there is such a thing as appeal insurance.
Q: Will a claim be audited if a practice/entity self-audits, finds an error and corrects it?
A: As long as an amended claim is filed by the provider, RAC will not audit the claim.
Q:Who sets the guidelines for medical necessity?
A: The medical director of the RAC.
Q: Are the number of claims that can be audited in each period counted by transaction lines (5 per CMS form) or by claim/single CMS form?
A: By transaction lines.
Q: Will the RACs extrapolate their findings?
A: The RACs are entitled to extrapolate their findings if they so choose.
Q: Are the RACs paid on a percentage of their findings?
A: Yes, RACs are paid a percentage of both overpayments and underpayments. The percentage ranges from 9% to 12.50% based on each RAC’s bid.
If this information is new to you, I suggest you click on some of the links provided in this article, start developing your RAC plan, and start educating your providers and staff. This topic is also a good one for sharing of best practices between local and regional groups. To get email updates on RAC from CMS, sign-up here. Remember to bookmark your RAC’s website and visit often!
Photo credit: © Milosluz | Dreamstime.com
With the Centers for Medicare and Medicaid Services (CMS) revealing yesterday what the Medicare premiums and deductibles will be for 2009, it seems like a good time to brush up on Medicare and what choices providers have in enrolling and participating in Medicare.
Medicare is a health insurance program created in 1965 for:
- people age 65 or older,
- people under age 65 with certain disabilities, and
- people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)
TRADITIONAL/ORIGINAL FEE-FOR-SERVICE MEDICARE
Medicare Part A – 99% of patients don’t pay a premium for Part A (hospital insurance) because they or a spouse already paid for it through their payroll taxes while working. The $1,068 deductible for 2009, paid by the beneficiary when admitted as a hospital inpatient, is an increase of $44 from $1024 in 2008. Part A helps cover:
- inpatient care in hospitals
- including critical access hospitals
- skilled nursing facilities (not custodial or long-term care)
- some hospice care
- some home health care
Medicare Part B – Part B (outpatient/doctor insurance) base premium for 2009: $96.40/month (no change from 2008.) Premiums are higher for single people over 65 making more than $85K per year and for couples making over $170K. Part B premiums cover approximately one-fourth of the average cost of Part B services incurred by beneficiaries aged 65 and over. The remaining Part B costs are financed by Federal general revenues. In 2009, the Part B deductible will be $135, the same as it was in 2008. Part B helps cover:
- doctors’ services and outpatient care
- some services of physical and occupational therapists
- some home health care
Medicare Part D – Starting January 1, 2006, Medicare prescription drug coverage became available to everyone with Medicare. In 2008, the deductible is $275, in 2009 it will be $295.
MEDICARE HEALTH PLANS (MEDICARE ADVANTAGE)
Medicare Part C – Medicare now offers beneficiaries the option to have care paid for through private insurance plans. These private insurance options are part of Medicare Part C, which was previously known as Medicare+Choice, and is now called Medicare Advantage. Medicare Advantage expands options for receiving Medicare coverage through a variety of private insurance plans, including private fee-for-service (PFFS) plans, health maintenance organizations (HMOs) and preferred provider organizations (PPOs), and through new mechanisms such as medical savings accounts (MSAs), as well as adding payment for additional services not covered under Part A or B.
COMPARISON OF MEDICARE PLANS
Original Medicare Plan
WHAT? The traditional pay-per-visit (also called fee-for-service) arrangement available nationwide.
HOW? Providers can choose to participate (“par”) or not participate (“non-par”.) Participating providers accept the Medicare allowable and collect co-insurance (20% of the allowable.) Reimbursement comes to the providers. Non-participating providers may charge 15% more (called the “limiting” charge) than the Medicare allowable schedule, but the patient will receive the check, which is why some non-par practices require payment at time of service for Medicare patients. To charge patients for non-covered services, patients must sign an ABN before the service is provided.
Original Medicare Plan With Supplemental Medigap Policy
WHAT? The Original Medicare Plan plus one of up to ten standardized Medicare supplemental insurance policies (also called Medigap insurance) available through private companies.
HOW? Medigap plans may cover Medicare deductibles and co-insurance, but typically will not cover anything Medicare will not. Medicare primary claims will “cross-over” to many Medigap secondary claims so the practice does not have to file the secondary Medigap claim. Patients may still have a small balance that is cost-prohibitive to bill for.
Medicare Coordinated Care Plan
WHAT? A Medicare approved network of doctors, hospitals, and other health care providers that agrees to give care in return for a set monthly payment from Medicare. A coordinated care plan may be any of the following: a Health Maintenance Organization (HMO), Provider Sponsored Organization (PSO), local or regional Preferred Provider Organ. (PPO), or a Health Maintenance Organization with a Point of Service Option (POS).
HOW? You have to have signed a contract or be grandfathered in (called an “all-products” clause) under an existing contract to see patients and get paid. Primary care providers may have to provide referrals and/or authorization for specialty services and providers. A PPO or a POS plan usually provides out of network benefits for patients for an extra out-of pocket cost.
Private Fee-For-Service Plan (PFFS)
WHAT? A Medicare-approved private insurance plan. Medicare pays the plan a premium for Medicare-covered services. A PFFS Plan provides all Medicare benefits. Note: This is not the same as Medigap.
HOW? Most PFFS plans allow patients to be seen by any provider who will see them. PFFS plans do not have to pay providers according to the Medicare fee schedules or pay in 15 days for clean claims. Providers may bill patients more than the plan pays, up to a limit. It would be a good thing to notify patients if your practice intends to bill above the plan payment.