Presentation is loading. Please wait.

Presentation is loading. Please wait.


Similar presentations

Presentation on theme: "JANET MATEO MEDICARE PART A OUTREACH ANALYST MPAA MEETING WPS MEDICARE UPDATES 01/02/2015."— Presentation transcript:


2 AGENDA Probe and Educate Process Probe 1 and 2 Results What’s New Review of Timely Filing Requirements Exception Process Incarcerated Beneficiary Update WPS Medicare Updates 01/02/2015


4 PROBE 1 J5J8 Part A Hospital Provider Count 800*300* # of Providers Sampled 412151 # of Claims Reviewed 3,625*1,328 * Approximate Number 01/02/2015

5 OVERALL DENIAL RATE J5 27% J8 26% J8 26% 01/02/2015

6 DENIALS BY TYPE 5PC01Documentation does not support services medically reasonable/necessary 5PC02Insufficient documentation 5PC12Order missing 5PC13Order unsigned 5PC15Certification not present 5PC17No documentation of 2-midnight expectation J8 01/02/2015


8 PROBE 2 REVIEWS Prepay Reason code 5CR85 For WPS Medicare providers Begins with admission dates 60 days from date of final letter offering education Includes providers with Moderate or high levels of concern Incomplete or no claims in Probe 1 01/02/2015

9 PROBE 2 J5J8 Part A Hospital Provider Count 736253 % of Claims Completed 32%35% Top Denial Code 5PC01 New in Probe 2 5PC11 - Procedure not reasonable and necessary 01/02/2015

10 TIPS Verify your procedures for inclusion on the inpatient-only list Include the signed admission order Compare physician notes to orders Document changes in expected patient care 01/02/2015


12 MISSING OR FLAWED ORDER Error Physician order states “observation” but facility billed as an inpatient Prevention Use specific language for inpatient orders Remember all care is outpatient care in the absence of an inpatient order 01/02/2015

13 SHORT STAY PROCEDURES Error Patient presented for short stay procedure and discharged the next day Prevention Procedures with typical expected length of stay of less than two midnights are outpatient for payment purposes Multiple short-stay procedures performed together ≠ an inpatient procedure In the absence of a two-midnight expectation 01/02/2015

14 UNCERTAIN COURSE Error Patient with complaints of dizziness Physician notes state intention to monitor overnight but patient admitted and inpatient claim billed Prevention If clinical course uncertain, utilize outpatient observation Keep as outpatient until clear the patient requires two midnights of care 01/02/2015

15 ATTESTATION WITHOUT SUPPORT Error Checkbox stating “The beneficiary is expected to require two or more midnights of hospital care” Physician notes state “plan to discharge in the morning if stable” and patient discharged next day Prevention Certification statements not required or adequate to support payment Expectation must be supported by entire medical record 01/02/2015

16 INCOMPLETE DOCUMENTATION Error Incomplete medical record submitted Most common items missing include: Medication Administration Records (MARs) Nurses notes Prevention Verify the entire record is being submitted Review record to ensure it is legible 01/02/2015

17 WHAT’S NEW 2015 UPDATES 01/02/2015

18 IPPS UPDATES CR 8900 Provides FY 2015 updates to the Acute Hospital IPPS and LTCH PPS 01/02/2015

19 OPPS UPDATES CR 9014 Describes changes to billing instructions for various policies implemented in the January 2015, OPPS update Revision to certification requirements 01/02/2015

20 JANUARY 1, 2015, CHANGES CMS currently requires a physician certification, including an admission order and certain additional elements, for all inpatient admissions. CMS finalized its proposal to require the physician certification only for outlier cases and long-stay cases of 20 days or more. The admission order will continue to be required for all inpatient admissions when a patient has been formally admitted as an inpatient of the hospital. 01/02/2015

21 REVISION TO CERTIFICATION REQUIREMENTS Inpatient certification requirements eliminated For short stays < 20 days No changes for inpatient psychiatric hospital or inpatient rehabilitation facility 01/02/2015

22 FURTHER CLARIFICATION Stays 20 days or greater and outlier cases Formal physician certification Reason for hospitalization Estimated time to remain in hospital Plan for post-hospital care 01/02/2015

23 REVISION TO CERTIFICATION REQUIREMENTS - CAHS Effective for admissions on or after October 1, 2014, certification required One day prior to the day the Part A bill is submitted 01/02/2015

24 PAYMENT POLICIES RELATED TO PATIENT STATUS – CMS-1599-F CR 8959 Inpatient routine services in a hospital include Room and board charges Regular room, dietary and nursing services Minor medical and surgical supplies Medical social services, psychiatric social services Use of certain equipment and facilities 01/02/2015

25 THERAPY CAPS Financial limitation for 2015 $1,940 for OT $1,940 for PT/SLP combined Associated policies in effect until 3/31/15 Exceptions process (KX modifier) Manual medical review ($3,700 threshold) 01/02/2015

26 UPDATE TO THERAPY CODE LIST CR 8985 Updates the 2015 therapy code list Added two “Sometimes Therapy” codes Deleted two “Sometimes Therapy” codes 01/02/2015

27 2015 UPDATES TO RHC AND FQHC SERVICES CR 8981 Includes new and clarifying information on FQHC PPS and RHC updates 01/02/2015

28 SPECIFIC MODIFIERS FOR DISTINCT PROCEDURAL SERVICES CR 8863 Four new HCPCS modifiers established to define subsets of the -59 modifier Modifier 59 is associated with considerable high levels of abuse leading to: Reviews Appeals Civil fraud and abuse cases 01/02/2015

29 FOUR NEW HCPCS MODIFIERS Collectively referred to as –X {EPSU} Selectively identify subset of Distinct Procedural Services 59 Modifier still accepted Should not be used when a more descriptive modifier is available CMS may require more specific modifier for billing certain codes at high risk for incorrect billing 01/02/2015

30 -X {EPSU} XE – Separate Encounter Service occurred during a separate encounter XS – Separate Structure Service performed on a separate organ or structure XP – Separate Practitioner Service performed by a different practitioner XU – Unusual Non-Overlapping Service Does not overlap usual components of the main service 01/02/2015

31 2015 AMOUNTS CR 8982 Part A Deductible - $1,260 Part B Deductible - $147 Hospital Coinsurance - $304 Lifetime Reserve Days - $630 Skilled Coinsurance - $157.50 01/02/2015


33 TIMELY FILING REGULATIONS Claims must be filed within one calendar year after the Date of Service (DOS ) Through date used to determine timely filing deadline For institutional claims Claims in Return to Provider (RTP) status (T B9997) are not considered properly submitted claims 01/02/2015

34 FILING A CLAIM BEYOND THE TIMELY FILING LIMIT Provider is responsible Claims should be processed Spell-of-illness implications and/or To record the days, visits, cash and blood deductibles 01/02/2015

35 FILING A CLAIM BEYOND THE TIMELY FILING LIMIT Beneficiary is charged utilization days, Beneficiary may not be charged for the services Except for applicable deductible and/or coinsurance amounts Providers may not appeal a timely filing rejection 01/02/2015

36 FILING A CLAIM BEYOND THE TIMELY FILING LIMIT Provider believes the beneficiary is responsible for late filing File claim Put “TIMELY-BENE” on the first line of remarks section Include a statement in the remarks field Usual appeal rights are available to the beneficiary 01/02/2015

37 EXCEPTIONS TO TIMELY FILING REQUIREMENT Administrator Error Misrepresentation, delay, mistake or other action by Medicare or its contractors Time limit will be extended through the last day of the 6 th calendar month Request for extension only accepted up to 4 years from the DOS 01/02/2015

38 EXCEPTIONS TO TIMELY FILING REQUIREMENT Retroactive Entitlement Beneficiary was not entitled to Medicare at the time the service was furnished Beneficiary subsequently received notification of retroactive Medicare entitlement to or before the DOS 01/02/2015

39 EXCEPTIONS TO TIMELY FILING REQUIREMENT Medicaid Agencies At the time the service was furnished the beneficiary was not entitled to Medicare The beneficiary subsequently received notification of Medicare entitlement effective retroactively to or before the date of the furnished service 01/02/2015

40 EXCEPTIONS TO TIMELY FILING REQUIREMENT Retroactive Disenrollment from Medicare Advantage (MA) Plan At the time the service was furnished the beneficiary was believed to be enrolled in a MA plan The beneficiary was subsequently disenrolled from the MA plan Effective retroactively to or before the date of the furnished service 01/02/2015

41 EXCEPTIONS TO TIMELY FILING REQUIREMENT Retroactive Disenrollment from Medicare Advantage (MA) Plan The MA plan recovered its payment for the furnished service from a provider or supplier 6 months or more after the service was furnished 01/02/2015

42 TIMELY FILING EXTENSION TIPS First line of the remarks page should include a 2 digit justification for timeliness reason code Additional remarks can be added to line 2 Explanation of circumstances which led to late filing/why party is responsible Request an extension to timely filing in writing 01/02/2015

43 TIMELY FILING EXTENSION TIPS Request for timely filing should be submitted with: A copy of the claim describing the services furnished Official SSA letter, if available Based on justification for timeliness reason code used Mail to General mailing address on the WPS Medicare website ng-address-info.shtml ng-address-info.shtml 01/02/2015

44 REQUEST FOR REOPENING CLAIMS BEYOND TIMELY FILING LIMITS CR 8581 Standardizing the Process CMS recognized MACs lacked a standard process for reopenings CMS petitioned NUBC for: Bill type frequency code to indicate a reopening request Condition codes to identify type of reopening Effective for claims received on or after April 1, 2015 01/02/2015



47 CERT TASK FORCE MACs collaborate to educate Goal: reduce National payment error rate Departments>CERT>CERT A/B MAC Outreach & Education Task Force 01/02/2015

48 C-SNAP ENHANCEMENTS Appeals status Discharge Status Submitting documentation through C-SNAP Coming Soon 01/02/2015

49 FUNCTIONALITY & BENEFITS Functionality Upload your Medical Documentation For all claims associated with a Probe For an Additional Development Request (ADR) For a returned to provider (RTP) claim requesting Medical Documentation Verify Documentation Submitted View submitted documentation for up to 75 days Verify the status of the review 01/02/2015

50 FUNCTIONALITY & BENEFITS Benefits Free No printing costs No postage costs No esMD costs Time Saving Reduced records preparation time No paper forms to fill out 01/02/2015

51 FUNCTIONALITY & BENEFITS Benefits Instant Confirmation Receive a confirmation number Links directly to claim No lost records No fax issues No Shipping Delay Reduce days to payment Available 24/7 For documentation submission 01/02/2015

52 COUNTDOWN TO ICD-10 Compliance date is 10/01/2015 Resources SE1410 - ICD-10 CMS website > Medicare > ICD-10 WPS Medicare > J8 MAC Part A > Claims > ICD- 10 01/02/2015

53 ICD-10 TESTING RESULTS Acknowledgement Testing in March Approximately 2,600 testers participated 50% were clearinghouses Over 127,000 claims submitted 89% of claims accepted by CMS Some intentionally submitted with errors 01/02/2015

54 END-TO-END TESTING SE 1409 Volunteer for upcoming ICD-10 End-to-End Testing April 27 – May 1, 2015 Additional opportunity for testing available July 20 – 24, 2015 01/02/2015

55 ACKNOWLEDGEMENT TESTING Upcoming testing weeks March 2-6, 2015 June 1-5, 2015 WPS Medicare will be appropriately staffed to handle increased call volume via the EDI Help Desk 01/02/2015

56 ACKNOWLEDGEMENT TESTING Acknowledgment test claims can be submitted anytime up to the October 1, 2015, implementation date Registration is not required for these virtual events 01/02/2015

57 TOP 5 REASONS FOR REJECTS Invalid ICD-10 diagnosis code Some because they used dates of service that were prior to the effective date of code on the CEM reference file Invalid procedure code Caused by CEM issue 01/02/2015

58 TOP 5 REASONS FOR REJECTS Future dates of service used Must use current dates Missing Data Not necessarily related to ICD-10 Other Invalid data not related to ICD-10 01/02/2015

59 CLAIM SUBMISSION ALTERNATIVES PC- ACE-PRO 32 Free Software Available to providers that do not complete the necessary system changes to submit claims with ICD-10 codes by October 1, 2015 Software has been updated to support ICD-10 codes Does not provide coding assistance Allows providers to submit claims in ICD-10 claim submission format 01/02/2015

60 MONITORING YOUR BUSINESS WITH MEDICARE EDI All submitters of electronic claim files should use the tools available to monitor your business Read 999 responses Read 277CA responses Review the Medicare remittances Monitor cash flow Identify and correct any issues identified in a timely manner 01/02/2015

61 ELECTRONIC REMITTANCE ADVICE (ERA) GO GREEN ! Providers are encouraged to switch from receiving standard paper remittance advices to electronic remittance advice Using ERA saves time and Increases productivity Provides electronic payment adjustment information that is portable, reusable, retrievable, and storable 01/02/2015

62 MEDICARE SECONDARY PAYER (MSP) UPDATE MSP hotlines consolidated to one toll free number ( 866) 734-1521 Effective November 17, 2014 Will provide prompts for call routing to the appropriate staff J5/J8, Part A/B 01/02/2015

63 MSP UPDATE CR 8456 Effective October 6, 2014, up to 25 iterations of diagnosis codes associated with MSP no- fault, liability, and workers’ compensation records will be included on the HETS 271 response transaction Diagnosis codes will assist providers in better determining when Medicare is the secondary payer 01/02/2015

64 MSP GROUP HEALTH PLAN (GHP) WORKING AGED POLICY UPDATE CR 8875 Under the MSP Working Aged provisions, “spouse” applies to both opposite and same sex marriages Effective January 2015 01/02/2015

65 BILLING MSP CLAIMS - 5010 MSP claims must be sent electronically Not an Administrative Simplification Compliance Act (ASCA) exception Avoid front end rejections, delays and unprocessable rejections 01/02/2015

66 AVOID DELAYS AND UNPROCESSABLE CLAIMS Important to determine the correct insurance type code Always give the MSP insurance type code Give the complete primary payer’s name and address 01/02/2015

67 AVOID DELAYS AND UNPROCESSABLE CLAIMS Do not confuse the payers Medigap or Medicaid information should not be reported in the primary insurance record Primary paid amount should not exceed the billed amount Primary paid amounts at the claim level should agree with line level 01/02/2015

68 REVALIDATION OF PROVIDER ENROLLMENT INFORMATION All providers enrolled in Medicare prior to March 25, 2011, must revalidate provider enrollment information by March 2015 Only after receiving notification from WPS Medicare 01/02/2015

69 ENHANCED INTERNET-BASED PECOS Facilities are encouraged to utilize PECOS to: Revalidate the CMS-855 Medicare enrollment application Enroll in the Medicare Program Enhanced internet-based PECOS is easy, fast and secure 01/02/2015

70 PROVIDER ENROLLMENT APPLICATIONS To ensure your application is not delayed, take a second look Review your application for the following: Appropriate documentation Completion of all fields in all sections Signed and dated Authorization or Certification statement 01/02/2015


72 PROVIDER ENROLLMENT NAVIGATOR Interactive tool to expedite processing Helps identify required information Asks a series of questions Guides you to correct forms Links provided Ensures submission to correct address Saves time and re-work Contact information Assistance with completion or submission 01/02/2015

73 ENROLLMENT STATUS Status Dates: Assigned Initial Review Development In PECOS Closed Electronic Funds Transfer (EFT) Initial Letter Sent EFT Second Letter Sent EFT Approved Processing Statuses Processing Provider Enrollment Chain and Ownership System (PECOS) is Approved Returned Denial Rejection Recommended Completed 01/02/2015

74 ENROLLMENT APPLICATION STATUS INQUIRY Web based system Confirms receipt of new applications via email Provides Application ID Link to EASI website Provides status during process Current e-mail address in Section 13 will ensure application ID and all other notifications are received. 01/02/2015

75 APPEALS FORM SELECTOR Interactive tool to expedite processing Helps decide if appeal or not Asks a series of questions Guides you to correct form Links provided Ensures submission to correct address Saves time and re-work 01/02/2015



78 INCARCERATED BENEFICIARY CLAIMS Some overpayments for incarcerated beneficiaries were valid and were not refunded If a claim was erroneously designated as a overpayment, you may request a reopening Funds recovered and not subsequently refunded 01/02/2015

79 INCARCERATED BENEFICIARY CLAIM If the facility received a Remittance Advice indicating a temporary allowance without supporting documentation Contact WPS Medicare to request an explanation 01/02/2015

80 WEBSITE SATISFACTION Comments help enhance website Please be specific 01/02/2015

81 SELF SERVICE TOOLS No limits Available when you are No wait, or hold time Easy answers Multiple users at one time Most current information available 01/02/2015


83 DISCLAIMER This program is presented for informational purposes only. Current Medicare regulations will always prevail. 01/02/2015


Similar presentations

Ads by Google