Showing posts with label Payment. Show all posts
Showing posts with label Payment. Show all posts
Per Diem agreement and allowed amount calculation
Per Diem
Per Diem is a per day negotiated rate which represents an allowance that includes all services for that day.
Per Diem agreements reimburse based on the admission date of the member.
The following terminology is used when referring to per diem contracts:
• Inliers- Inpatient cases reimbursed based on room and board per diem rates
• Outliers- Inpatient cases reimbursed as a DRG carve-out or based on catastrophic reimbursement.
Per Diem Hierarchy for a Standard Base Agreement
Each inpatient case in a per diem contract is evaluated using the following payment hierarchy:
• Implant Carve-out - Typically reimbursed in addition to inliers and outliers
• Catastrophic - Outlier
• DRG Carve-outs as case rate with additional day per diem - Outlier
• Per Diem Rates - Inlier
Once a claim meets the criteria for a step in the hierarchy table, then the reimbursement calculation method is based on that applicable step.
Calculating the Inpatient Allowed Amount
Amounts displayed for example purposes only. These examples illustrate allowed amount calculations, not the Florida Blue payment because member deductible, coinsurance, and/or copayment liability have not been applied. Determination of the allowed amount for inpatient and outpatient services is made based upon the terms of your Agreement.
Per Diem Examples
Per Diem payment rate is based on room and board revenue codes (e.g., med/surg, ICU, psychiatric) ranging from 110-219. The following examples illustrate the per diem methods for determining payment for inpatient admissions. Per Diem Examples
DRG Hierarchy and calculation of allowed amount
DRG Hierarchy for a Standard Base Agreement
Each inpatient case for a DRG contract is evaluated using the following payment hierarchy:
• Low Stay Outlier
• High Charge/High Stay Outlier
• DRG Value Inlier
Once a claim meets the criteria for a step in the hierarchy table, then the reimbursement calculation method is based on that applicable step. For example, if a case meets the qualification as a low stay case and a high charge case, it will be reimbursed based on the low stay allowance.
Note: The hierarchy for a hospital that provides tertiary services is different from the hierarchy list above.
Calculating the Inpatient Allowed Amount
Amounts displayed for example purposes only. These examples illustrate allowed amount calculations, not the Florida Blue payment because member deductible, coinsurance, and/or copayment liability have not been applied.
Determination of the allowed amount for inpatient and outpatient services is made based upon the terms of your Agreement.
DRG Examples
The following examples illustrate the various methods for determining the allowed amount for inpatient admissions.
Use the following “case” for the calculations:
• DRG = DRG 202 Bronchitis and Asthma, with complication or major complication
• Conversion Price = $3,000
• Low (Length of Stay) Trim Point = 2 days*
• High (Length of Stay) Trim Point = 12 days*
• Contracted Negotiated Low Stay Per Diem = $750
• Contracted Negotiated High Stay Per Diem = $800
• Relative Weight = 0.8446
• DRG Value = $2,534 (Conversion Price x Relative Weight)
*Trim point is a numerical value that represents the minimum (in the case of the low trim point) and the maximum (in the case of the high trim point) number of days for which payment will be made at the DRG value for hospital services. Length of Stay Examples
Where Can I Check the Fee schedule for DME, physician fee?
Q. Where can I find fee schedules for my location and line of business?
A. Select your location (Florida, Puerto Rico, or the U.S. Virgin Islands) and line of business (Part A or Part B) on the homepage of the First Coast Service Options (First Coast) Medicare provider website. This will allow you to view information that pertains specifically to your geographic location as well as your type of business. After you have selected your location, you may easily select your line of business and go directly to the ”Fee Schedules” page in one step -- just select “Fee Schedules” from the category list on the Part A or Part B homepage.
You can also access the “Fee Schedules” page for your line of business from the “Quick Find” drop-down menu located in the left-hand navigation area on each page of the website.
Once you have arrived on the “Fee Schedules” page (Part A or Part B), you’ll have access to:
• The latest news and information about fee schedules in the “News” information box
• Location-specific fee information for Part A and Part B for most Medicare-covered procedure codes with First Coast’s easy-to-use, interactive look-up tool.
• Printable Part B portable document format (PDF) fee schedules and text-only fee schedule data files that can be imported into a spreadsheet or database.
• Fee schedules and fee schedule-related information from previous payment years in First Coast’s comprehensive archive
http://medicare.fcso.com/Fee_lookup/fee_schedule.asp
Q. Where can I find fees for durable medical equipment, prosthetics/orthotics, and supplies?
A. Fees for local and joint jurisdiction durable medical equipment, prosthetics/orthotics, and supplies (DMEPOS) may be found in First Coast Service Options’ fee schedule lookup and on the Centers for Medicare & Medicaid Services (CMS) website at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html
Q. Where can I find fees for physician fee schedule services?
A. Fees for fee schedule services paid under the Medicare physician fee schedule database (MPFSDB), for Part A as well as Part B, may be found in First Coast Service Options’ fee schedule lookup, and under fee schedule data files for compressed, tab-delimited files. Additional information may be found here for Part A or here for Part B, and on the Centers for Medicare & Medicaid Services (CMS) website at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html external link.
Q. Where can I find fees for clinical laboratory services?
A. Fees for clinical laboratory services may be found in First Coast’s fee schedule lookup and under fee schedule data files for compressed, tab-delimited files. Additional information may be found here, and on the Centers for Medicare & Medicaid Services (CMS) website at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/index.html external link.
A. Select your location (Florida, Puerto Rico, or the U.S. Virgin Islands) and line of business (Part A or Part B) on the homepage of the First Coast Service Options (First Coast) Medicare provider website. This will allow you to view information that pertains specifically to your geographic location as well as your type of business. After you have selected your location, you may easily select your line of business and go directly to the ”Fee Schedules” page in one step -- just select “Fee Schedules” from the category list on the Part A or Part B homepage.
You can also access the “Fee Schedules” page for your line of business from the “Quick Find” drop-down menu located in the left-hand navigation area on each page of the website.
Once you have arrived on the “Fee Schedules” page (Part A or Part B), you’ll have access to:
• The latest news and information about fee schedules in the “News” information box
• Location-specific fee information for Part A and Part B for most Medicare-covered procedure codes with First Coast’s easy-to-use, interactive look-up tool.
• Printable Part B portable document format (PDF) fee schedules and text-only fee schedule data files that can be imported into a spreadsheet or database.
• Fee schedules and fee schedule-related information from previous payment years in First Coast’s comprehensive archive
http://medicare.fcso.com/Fee_lookup/fee_schedule.asp
Q. Where can I find fees for durable medical equipment, prosthetics/orthotics, and supplies?
A. Fees for local and joint jurisdiction durable medical equipment, prosthetics/orthotics, and supplies (DMEPOS) may be found in First Coast Service Options’ fee schedule lookup and on the Centers for Medicare & Medicaid Services (CMS) website at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html
Q. Where can I find fees for physician fee schedule services?
A. Fees for fee schedule services paid under the Medicare physician fee schedule database (MPFSDB), for Part A as well as Part B, may be found in First Coast Service Options’ fee schedule lookup, and under fee schedule data files for compressed, tab-delimited files. Additional information may be found here for Part A or here for Part B, and on the Centers for Medicare & Medicaid Services (CMS) website at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html external link.
Q. Where can I find fees for clinical laboratory services?
A. Fees for clinical laboratory services may be found in First Coast’s fee schedule lookup and under fee schedule data files for compressed, tab-delimited files. Additional information may be found here, and on the Centers for Medicare & Medicaid Services (CMS) website at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/index.html external link.
Policy Guideline for provider performed unlisted CPT code
Overview
Some services or procedures performed by providers might not have specific Current Procedure Codes (CPT) or HCPCS codes. When submitting claims for these services or procedures that are not otherwise specified, unlisted codes are designated. Unlisted codes provide the means of reporting and tracking services and procedures until a more specific code is established.
According to the Current Procedural Terminology Instructions for use of the CPT Codebook, select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code. Any service or procedure must be adequately documented in the medical record.
Supporting Documentation Requirements
Because unlisted and unspecified procedure codes do not describe a specific procedure or service, it is necessary to submit supporting documentation when filing a claim. Pertinent information should include:
• A clear description of the nature, extent, and need for the procedure or service.
• Whether the procedure was performed independent from other services provided, or if it was performed at the same surgical site or through the same surgical opening.
• Any extenuating circumstances which may have complicated the service or procedure.
• Time, effort, and equipment necessary to provide the service.
• The number of times the service was provided.
When submitting supporting documentation, designate the portion of the report that identifies the test or procedure associated with the unlisted procedure code. Required information must be legible and clearly marked.
Provider Billing Guidelines and Documentation
• Claims submitted with unlisted procedure codes and without supporting documentation will be denied.
• Please submit paper claims for unlisted procedure codes. Electronic claims for unlisted procedure codes may be denied, as attachments are not accepted electronically at this time.
• Claims submitted with an unlisted procedure code will be denied if determined that a more appropriate procedure or service code that most closely approximates the service performed is available.
• No additional reimbursement is provided for special techniques/equipment submitted with an unlisted procedure code.
• Unlisted procedure codes appended with a modifier may be denied. (Exception: Unlisted codes for DME, orthotics and prosthetics require appropriate NU, RR or MS modifier.)
• When performing two or more procedures that require the use of the same unlisted CPT code, the unlisted code should only be reported once to identify the services provided (excludes unlisted HCPCS codes; for example, DME/ unlisted drugs).
Medical Record Documentation and Physician Queries
Harvard Pilgrim will not accept retrospectively amended medical records or physician queries beyond 30 days from the service date. Harvard Pilgrim considers medical record documentation and/or physician queries upon review as the official record to support services provided for the basis of coverage or reimbursement determination. Clinical documentation or physician queries amended over 30 days from the service will not be accepted to defend reimbursement, increase reimbursement, or consideration of a previously denied claim.
Some services or procedures performed by providers might not have specific Current Procedure Codes (CPT) or HCPCS codes. When submitting claims for these services or procedures that are not otherwise specified, unlisted codes are designated. Unlisted codes provide the means of reporting and tracking services and procedures until a more specific code is established.
According to the Current Procedural Terminology Instructions for use of the CPT Codebook, select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code. Any service or procedure must be adequately documented in the medical record.
Supporting Documentation Requirements
Because unlisted and unspecified procedure codes do not describe a specific procedure or service, it is necessary to submit supporting documentation when filing a claim. Pertinent information should include:
• A clear description of the nature, extent, and need for the procedure or service.
• Whether the procedure was performed independent from other services provided, or if it was performed at the same surgical site or through the same surgical opening.
• Any extenuating circumstances which may have complicated the service or procedure.
• Time, effort, and equipment necessary to provide the service.
• The number of times the service was provided.
When submitting supporting documentation, designate the portion of the report that identifies the test or procedure associated with the unlisted procedure code. Required information must be legible and clearly marked.
Provider Billing Guidelines and Documentation
• Claims submitted with unlisted procedure codes and without supporting documentation will be denied.
• Please submit paper claims for unlisted procedure codes. Electronic claims for unlisted procedure codes may be denied, as attachments are not accepted electronically at this time.
• Claims submitted with an unlisted procedure code will be denied if determined that a more appropriate procedure or service code that most closely approximates the service performed is available.
• No additional reimbursement is provided for special techniques/equipment submitted with an unlisted procedure code.
• Unlisted procedure codes appended with a modifier may be denied. (Exception: Unlisted codes for DME, orthotics and prosthetics require appropriate NU, RR or MS modifier.)
• When performing two or more procedures that require the use of the same unlisted CPT code, the unlisted code should only be reported once to identify the services provided (excludes unlisted HCPCS codes; for example, DME/ unlisted drugs).
Medical Record Documentation and Physician Queries
Harvard Pilgrim will not accept retrospectively amended medical records or physician queries beyond 30 days from the service date. Harvard Pilgrim considers medical record documentation and/or physician queries upon review as the official record to support services provided for the basis of coverage or reimbursement determination. Clinical documentation or physician queries amended over 30 days from the service will not be accepted to defend reimbursement, increase reimbursement, or consideration of a previously denied claim.
How much payment would get Assitant Surgeon, Co- Surgery and Team surgery
Assistant Surgeon Services
Harvard Pilgrim reimburses assistant surgeon services when the assistant at surgery is a physician, a physician assistant, or a nurse practitioner consistent with CMS’ determination of approved procedure codes payable to an assistant surgeon.
• Assistant surgeon services are reimbursed at 16% of the fee schedule/allowable amount.
• Secondary surgical procedures are reimbursed at 8% of the fee schedule/allowable amount.
Assistant Surgeon Services (in Maine only)
Registered nurse/first assistants and physician assistants are reimbursed as assistant surgeons at a rate equal to 85% of the assistant surgeon 16% allowable rate.
Co-Surgery
Co-surgery is reimbursed at 62.5% of the fee schedule/allowable amount.
Team Surgery
Team surgery is reimbursed after individual consideration and review of operative notes according to the percentage of surgery performed by each respective surgeon.
Attempted Service (discontinued procedure)
Attempted inpatient surgery is reimbursed at 50% of the fee schedule/allowable amount.
Reduced Services
Reduced services are reimbursed at 50% of the fee schedule/allowable amount.
Procedures
Kyphoplasty, vertebroplasty, and radiologic supervision and interpretation, vertebroplasty for multiple myeloma, monostatic and solitary myeloma, spinal cord hemangioma, secondary malignant neoplasm bone and bone marrow, osteoporotic vertebral collapse and vertebral hemangioma.
First Assistant in Surgery
Louisiana Medicaid will reimburse for only one first assistant in surgery. Ideally, the first assistant to the surgeon should be a qualified physician. However, in those situations when a physician does not serve as the first assistant; qualified, enrolled, advanced practice registered nurses and physician assistants may function in the role of a surgical first assistant and submit claims for their services under their Medicaid provider number. The reimbursement of claims for more than one first assistant is subject to recoupment.
Reimbursement
• Unless otherwise excluded by the Medicaid Program, coverage of services will be determined by individual licensure, scope of practice, and terms of the physician collaborative agreement. Collaborative agreements must be available for review upon
request by authorized representatives of the Medicaid program.
• Immunizations and KIDMED medical, vision, and hearing screens are reimbursed at 100% of the physician fee on file. All other payable procedures are reimbursed at 80% of the physician fee on file.
• Qualified CNS/CNPs who perform as first assistant in surgery should use the “AS” modifier to identify these services.
Harvard Pilgrim reimburses assistant surgeon services when the assistant at surgery is a physician, a physician assistant, or a nurse practitioner consistent with CMS’ determination of approved procedure codes payable to an assistant surgeon.
• Assistant surgeon services are reimbursed at 16% of the fee schedule/allowable amount.
• Secondary surgical procedures are reimbursed at 8% of the fee schedule/allowable amount.
Assistant Surgeon Services (in Maine only)
Registered nurse/first assistants and physician assistants are reimbursed as assistant surgeons at a rate equal to 85% of the assistant surgeon 16% allowable rate.
Co-Surgery
Co-surgery is reimbursed at 62.5% of the fee schedule/allowable amount.
Team Surgery
Team surgery is reimbursed after individual consideration and review of operative notes according to the percentage of surgery performed by each respective surgeon.
Attempted Service (discontinued procedure)
Attempted inpatient surgery is reimbursed at 50% of the fee schedule/allowable amount.
Reduced Services
Reduced services are reimbursed at 50% of the fee schedule/allowable amount.
Procedures
Kyphoplasty, vertebroplasty, and radiologic supervision and interpretation, vertebroplasty for multiple myeloma, monostatic and solitary myeloma, spinal cord hemangioma, secondary malignant neoplasm bone and bone marrow, osteoporotic vertebral collapse and vertebral hemangioma.
First Assistant in Surgery
Louisiana Medicaid will reimburse for only one first assistant in surgery. Ideally, the first assistant to the surgeon should be a qualified physician. However, in those situations when a physician does not serve as the first assistant; qualified, enrolled, advanced practice registered nurses and physician assistants may function in the role of a surgical first assistant and submit claims for their services under their Medicaid provider number. The reimbursement of claims for more than one first assistant is subject to recoupment.
Reimbursement
• Unless otherwise excluded by the Medicaid Program, coverage of services will be determined by individual licensure, scope of practice, and terms of the physician collaborative agreement. Collaborative agreements must be available for review upon
request by authorized representatives of the Medicaid program.
• Immunizations and KIDMED medical, vision, and hearing screens are reimbursed at 100% of the physician fee on file. All other payable procedures are reimbursed at 80% of the physician fee on file.
• Qualified CNS/CNPs who perform as first assistant in surgery should use the “AS” modifier to identify these services.
Insurance payment for E & M service on Global day and multiple procedures
Significant, Separately Identifiable E&M with Global Day Service—Same Day
Policy will apply to all professional services performed in an office place of service, when significant, separately identifiable E/M service (appended with 25 modifier) and any service that has a global period indicator as designated by CMS of 0, 10, 90 or YYY is performed on the same day, E&M service will be reimbursed at 50% of the contracted allowable. When the E&M value is greater than the procedure, the reduction will be applied to the global procedure code.
Bundled Services
Harvard Pilgrim reimburses only the most intensive CPT code when:
• A procedure is considered to be normally included as part of a more comprehensive code.
• A single, more comprehensive CPT code more accurately describes a group of procedures.
• If a procedure that is generally carried out as an integral part of a larger surgical procedure is performed alone and independent of other surgical services, it is reimbursable.
Multiple Procedures
• When multiple procedures are performed at the same session, the primary procedure is reimbursed at 100% of the allowable rate and all subsequent reimbursable procedures are paid at 50% of the allowable rate.
• Harvard Pilgrim determines the primary procedure based on the highest allowable rate, not the charge.
Bilateral Surgeries
• Bilateral surgeries are reimbursed at 150% of the allowable rate.
• Bilateral assistant surgeons are reimbursed at 16% of the allowable 150% amount.
Professional, Multiple and Bilateral Surgery Services Performed During the Same Operative Session
When a bilateral procedure code and surgical procedure(s) are performed at the same session and eligible for multiple procedure reduction, claim will be subject to multiple procedure reduction and bilateral procedure payment adjustment in accordance with Harvard Pilgrim payment policy. If the bilateral procedure is the secondary procedure, multiple procedure reduction and bilateral procedure payment adjustment will be applied.
Add-on Codes
• Add-on codes are reimbursed at 100% of the allowable rate and are not subject to the multiple procedure reduction.
• Add-on codes are only those codes designated by CPT and identified by a specific descriptor that includes the phrase
“each additional” or “list separately in addition to the primary procedure.”
• Add-on codes are reimbursable only when billed with their primary procedure.
Cosmetic Surgery
Cosmetic surgery is reimbursable with prior authorization of any cosmetic surgery exceptions, including, but not limited to:
• Repair of an accidental injury (e.g., repair of the face following a serious automobile accident).
• Improved function of a malformed body part.
• Treatment of severe burns.
• For additional information, refer to the Cosmetic, Reconstructive and Restorative Procedures Payment Policy.
E&M services provided within global period
Based on the CMS global surgical period:
• FCHP does not separately reimburse for any E&M service when reported with major surgical procedures (90-day global surgical period)
• FCHP does not separately reimburse for any E&M service when reported with minor procedures with a 10-day post-op period.
• FCHP does separately reimburse for new patient E&M services and E&M services described in Proceure as applying to new or established patients when reported with minor procedures with a 0-day post-op period.
• FCHP does consider reimbursement for services rendered during the global period if the appropriate modifier -24 is appended to the E&M procedure code and medical notes are included.
Services rendered in the office after-hours or on weekends or holidays
• FCHP reimburses Proceure Code 99050 for services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (e.g. holidays, Saturday or Sunday), in addition to basic service.
• FCHP reimburses Proceure Code 99051 for services provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service.
Policy will apply to all professional services performed in an office place of service, when significant, separately identifiable E/M service (appended with 25 modifier) and any service that has a global period indicator as designated by CMS of 0, 10, 90 or YYY is performed on the same day, E&M service will be reimbursed at 50% of the contracted allowable. When the E&M value is greater than the procedure, the reduction will be applied to the global procedure code.
Bundled Services
Harvard Pilgrim reimburses only the most intensive CPT code when:
• A procedure is considered to be normally included as part of a more comprehensive code.
• A single, more comprehensive CPT code more accurately describes a group of procedures.
• If a procedure that is generally carried out as an integral part of a larger surgical procedure is performed alone and independent of other surgical services, it is reimbursable.
Multiple Procedures
• When multiple procedures are performed at the same session, the primary procedure is reimbursed at 100% of the allowable rate and all subsequent reimbursable procedures are paid at 50% of the allowable rate.
• Harvard Pilgrim determines the primary procedure based on the highest allowable rate, not the charge.
Bilateral Surgeries
• Bilateral surgeries are reimbursed at 150% of the allowable rate.
• Bilateral assistant surgeons are reimbursed at 16% of the allowable 150% amount.
Professional, Multiple and Bilateral Surgery Services Performed During the Same Operative Session
When a bilateral procedure code and surgical procedure(s) are performed at the same session and eligible for multiple procedure reduction, claim will be subject to multiple procedure reduction and bilateral procedure payment adjustment in accordance with Harvard Pilgrim payment policy. If the bilateral procedure is the secondary procedure, multiple procedure reduction and bilateral procedure payment adjustment will be applied.
Add-on Codes
• Add-on codes are reimbursed at 100% of the allowable rate and are not subject to the multiple procedure reduction.
• Add-on codes are only those codes designated by CPT and identified by a specific descriptor that includes the phrase
“each additional” or “list separately in addition to the primary procedure.”
• Add-on codes are reimbursable only when billed with their primary procedure.
Cosmetic Surgery
Cosmetic surgery is reimbursable with prior authorization of any cosmetic surgery exceptions, including, but not limited to:
• Repair of an accidental injury (e.g., repair of the face following a serious automobile accident).
• Improved function of a malformed body part.
• Treatment of severe burns.
• For additional information, refer to the Cosmetic, Reconstructive and Restorative Procedures Payment Policy.
E&M services provided within global period
Based on the CMS global surgical period:
• FCHP does not separately reimburse for any E&M service when reported with major surgical procedures (90-day global surgical period)
• FCHP does not separately reimburse for any E&M service when reported with minor procedures with a 10-day post-op period.
• FCHP does separately reimburse for new patient E&M services and E&M services described in Proceure as applying to new or established patients when reported with minor procedures with a 0-day post-op period.
• FCHP does consider reimbursement for services rendered during the global period if the appropriate modifier -24 is appended to the E&M procedure code and medical notes are included.
Services rendered in the office after-hours or on weekends or holidays
• FCHP reimburses Proceure Code 99050 for services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (e.g. holidays, Saturday or Sunday), in addition to basic service.
• FCHP reimburses Proceure Code 99051 for services provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service.
Features of EPS with direct deposit or Virtual Card Payments:
Electronic Payments and Statements EPS
• Receive payments and EOBs five to seven days faster than with paper
• Multiple claim payments generated in one day for the same payer are combined into one deposit or VCP and one electronic EOB for easy reconciliation
• Simplified processing and reconciliation – automate payment posting using the 835/ERA or continue with your existing paper process using our EOB printing options
• Print either a single consolidated file (less paper) containing all EOBs for a given deposit or print individual EOBs to submit to other carriers for your
secondary claim submissions
• EOBs are available for 13 months and can be downloaded as PDF files to store on your own system
• Reduced risk of lost, misrouted and stolen checks
• Potential elimination of bank lockbox fees
• Practice management software and technical expertise are NOT required.
• You can post payments the same way you do today
EPS with direct deposit:
• No credit card processing fees
• While funds are deposited to your account, UnitedHealthcare will not debit or deduct claim adjustments from your checking or savings account. You can also contact
your bank to ensure that you have appropriately placed controls over the electronic funds transfers to and from your account.
EPS with Virtual Card Payments:
• Virtual Card Payments can be processed using the same method leveraged by your organization to process credit card transactions. Please note, your current credit card processing fees will apply. Please confirm those rates with your bank of choice directly.[2]
• Banking information is not shared outside your organization.
• Receive payments and EOBs five to seven days faster than with paper
• Multiple claim payments generated in one day for the same payer are combined into one deposit or VCP and one electronic EOB for easy reconciliation
• Simplified processing and reconciliation – automate payment posting using the 835/ERA or continue with your existing paper process using our EOB printing options
• Print either a single consolidated file (less paper) containing all EOBs for a given deposit or print individual EOBs to submit to other carriers for your
secondary claim submissions
• EOBs are available for 13 months and can be downloaded as PDF files to store on your own system
• Reduced risk of lost, misrouted and stolen checks
• Potential elimination of bank lockbox fees
• Practice management software and technical expertise are NOT required.
• You can post payments the same way you do today
EPS with direct deposit:
• No credit card processing fees
• While funds are deposited to your account, UnitedHealthcare will not debit or deduct claim adjustments from your checking or savings account. You can also contact
your bank to ensure that you have appropriately placed controls over the electronic funds transfers to and from your account.
EPS with Virtual Card Payments:
• Virtual Card Payments can be processed using the same method leveraged by your organization to process credit card transactions. Please note, your current credit card processing fees will apply. Please confirm those rates with your bank of choice directly.[2]
• Banking information is not shared outside your organization.
How to appeal against PQRS payment adjustment ?
2016 PQRS Payment Adjustment and Informal Review Process
On September 11, CMS began distributing letters to Physician Quality Reporting System (PQRS) individual Eligible Professionals (EPs), EPs providing services at Critical Access Hospitals billing under method II, and group practices about the 2016 PQRS negative payment adjustment. The letter indicates that an individual or group did not satisfactorily report 2014 PQRS quality measures in order to avoid the 2.0% 2016 negative PQRS payment adjustment.
If I received the payment adjustment letter, what are my options?
If you believe that you have been incorrectly assessed the 2016 PQRS negative payment adjustment, you can submit an informal review through November 9:
• Requests must be submitted electronically via the Communication Support Page under the Related Links section of the Physician and Other Health Care Professionals Quality Reporting Portal.
https://www.qualitynet.org/portal/server.pt/community/pqri_home/212
• See the fact sheet and Analysis and Payment web page for more information
For additional questions, contact the QualityNet Help Desk at 866-288-8912 (TTY 1-877-715-6222) or via qnetsupport@hcqis.org from 7am to 7pm CT Monday through Friday.
On September 11, CMS began distributing letters to Physician Quality Reporting System (PQRS) individual Eligible Professionals (EPs), EPs providing services at Critical Access Hospitals billing under method II, and group practices about the 2016 PQRS negative payment adjustment. The letter indicates that an individual or group did not satisfactorily report 2014 PQRS quality measures in order to avoid the 2.0% 2016 negative PQRS payment adjustment.
If I received the payment adjustment letter, what are my options?
If you believe that you have been incorrectly assessed the 2016 PQRS negative payment adjustment, you can submit an informal review through November 9:
• Requests must be submitted electronically via the Communication Support Page under the Related Links section of the Physician and Other Health Care Professionals Quality Reporting Portal.
https://www.qualitynet.org/portal/server.pt/community/pqri_home/212
• See the fact sheet and Analysis and Payment web page for more information
For additional questions, contact the QualityNet Help Desk at 866-288-8912 (TTY 1-877-715-6222) or via qnetsupport@hcqis.org from 7am to 7pm CT Monday through Friday.
How much interest payment provider has to pay medicare for overpayments?
Medicare Regulation provides for the charging and payment of interest on overpayments and underpayments to Medicare providers. The Secretary of Treasury certifies an interest rate quarterly. Treasury utilizes the most comprehensive data available on consumer interest rates to determine the certified rate. Interest is assessed on delinquent debts in order to protect the Medicare Trust Funds.
EFFECTIVE DATE: July 20, 2015
*Unless otherwise specified, the effective date is the date of service.
IMPLEMENTATION DATE: July 20, 2015
SUBJECT: Notice of New Interest Rate for Medicare Overpayments and Underpayments - 4th Qtr Notfication for FY 2015
Background: Medicare Regulation 42 CFR section 405.378 provides for the assessment of interest at the higher of the current value of funds rate (one percent for calendar year 2015) or the private consumer rate as fixed by the Department of the Treasury.
B. Policy: The Department of the Treasury has notified the Department of Health and Human Services that the private consumer rate has been changed to 9.75 percent
Number Requirement
9288.1 The Medicare contractors shall implement an interest rate of 9.75 percent effective July 20, 2015 for Medicare overpayments and underpayments.
Period Interest Rate
February 7, 2001 – April 25, 2001 14.125%
April 26, 2001 - August 6, 2001 13.75%
August 7, 2001 – October 30, 2001 13.25%
October 31, 2001 – January 31, 2002 13.25%
February 1, 2002 – May 7, 2002 12.625%
May 8, 2002 – August 7, 2002 11.75%
August 8, 2002 – November 18, 2002 12.625%
November 19, 2002 – February 10, 2003 11.25%
February 11, 2003 – April 27, 2003 10.75%
April 28, 2003 – August 10, 2003 11.625%
August 11, 2003 – November 2, 2003 12.125%
November 3, 2003 –February 3, 2004 12.00%
February 4, 2004 – May 6, 2004 12.00%
May 7, 2004 – August 8, 2004 11.875%
August 9, 2004 – November 11, 2004 11.75%
November 12, 2004 – February 7, 2005 12.00%
February 8, 2005 – April 24, 2005 11.875%
April 25, 2005 – July 21, 2005 12.00%
July 22, 2005 – November 2, 2005 12.00%
November 3, 2005 – January 24, 2006 12.25%
January 25, 2006 – April 23, 2006 11.875%
April 24, 2006 – July 18, 2006 12.125%
July 19, 2006 – October 17, 2006 12.625%
October 18, 2006 – January 18, 2007 12.375%
January 19, 2007 – April 19, 2007 12.5%
April 20, 2007 – July 19, 2007 12.375%
July 20, 2007 – October 18, 2007 12.625%
October 19, 2007 – January 17, 2008 12.5%
January 18, 2008 – April 17, 2008 12.125%
April 18, 2008 – July 23, 2008 11.375%
July 24, 2008 – October 21, 2008 11.125%
October 22, 2008 – January 22, 2009 11.375%
January 23, 2009 – April 15, 2009 11.375%
April 16, 2009 – July 16, 2009 11.00%
July 17, 2009 – October 21, 2009 11.25%
October 22, 2009 – January 24, 2010 10.875%
January 25, 2010 – April 22, 2010 11.25%
April 23, 2010 – July 20, 2010 10.875%
July 21, 2010 – October 21, 2010 11.00%
October 22, 2010 – January 23, 2011 10.75%
January 24, 2011 – April 18, 2011 11.25%
April 19, 2011 – July 17, 2011 11.00%
July 18, 2011 --- October 18, 2011 11.50%
October 19, 2011 ---October 19, 2011 10.78%
October 20, 2011----January 18, 2012 10.875%
January 19, 2012 --- April 17, 2012 10.50%
April 18, 2012 --- July 17, 2012 10.875%
July 18, 2012 ---- October 17, 2012 11.00%
October 18, 2012 ---- January 16, 2013 10.375%
January 17, 2013 --- April 16, 2013 10.625%
April 17, 2013 ---July 16, 2013 10.125%
July 17, 2013 ---October 17, 2013 10.375%
October 18, 2013---January 20, 2014 10.125%
January 21, 2014----April 16, 2014 10.25%
April 17, 2014---July17, 2014 10.125%
July 18, 2014 – October 19, 2014 9.625%
October 20, 2014—January 20, 2015 10.75%
January 21, 2015 ---April 16, 2015 10.50%
April 17, 2015 ----July 19, 2015 9.875%
July 20, 2015 ---- 9.75%
EFFECTIVE DATE: July 20, 2015
*Unless otherwise specified, the effective date is the date of service.
IMPLEMENTATION DATE: July 20, 2015
SUBJECT: Notice of New Interest Rate for Medicare Overpayments and Underpayments - 4th Qtr Notfication for FY 2015
Background: Medicare Regulation 42 CFR section 405.378 provides for the assessment of interest at the higher of the current value of funds rate (one percent for calendar year 2015) or the private consumer rate as fixed by the Department of the Treasury.
B. Policy: The Department of the Treasury has notified the Department of Health and Human Services that the private consumer rate has been changed to 9.75 percent
Number Requirement
9288.1 The Medicare contractors shall implement an interest rate of 9.75 percent effective July 20, 2015 for Medicare overpayments and underpayments.
Period Interest Rate
February 7, 2001 – April 25, 2001 14.125%
April 26, 2001 - August 6, 2001 13.75%
August 7, 2001 – October 30, 2001 13.25%
October 31, 2001 – January 31, 2002 13.25%
February 1, 2002 – May 7, 2002 12.625%
May 8, 2002 – August 7, 2002 11.75%
August 8, 2002 – November 18, 2002 12.625%
November 19, 2002 – February 10, 2003 11.25%
February 11, 2003 – April 27, 2003 10.75%
April 28, 2003 – August 10, 2003 11.625%
August 11, 2003 – November 2, 2003 12.125%
November 3, 2003 –February 3, 2004 12.00%
February 4, 2004 – May 6, 2004 12.00%
May 7, 2004 – August 8, 2004 11.875%
August 9, 2004 – November 11, 2004 11.75%
November 12, 2004 – February 7, 2005 12.00%
February 8, 2005 – April 24, 2005 11.875%
April 25, 2005 – July 21, 2005 12.00%
July 22, 2005 – November 2, 2005 12.00%
November 3, 2005 – January 24, 2006 12.25%
January 25, 2006 – April 23, 2006 11.875%
April 24, 2006 – July 18, 2006 12.125%
July 19, 2006 – October 17, 2006 12.625%
October 18, 2006 – January 18, 2007 12.375%
January 19, 2007 – April 19, 2007 12.5%
April 20, 2007 – July 19, 2007 12.375%
July 20, 2007 – October 18, 2007 12.625%
October 19, 2007 – January 17, 2008 12.5%
January 18, 2008 – April 17, 2008 12.125%
April 18, 2008 – July 23, 2008 11.375%
July 24, 2008 – October 21, 2008 11.125%
October 22, 2008 – January 22, 2009 11.375%
January 23, 2009 – April 15, 2009 11.375%
April 16, 2009 – July 16, 2009 11.00%
July 17, 2009 – October 21, 2009 11.25%
October 22, 2009 – January 24, 2010 10.875%
January 25, 2010 – April 22, 2010 11.25%
April 23, 2010 – July 20, 2010 10.875%
July 21, 2010 – October 21, 2010 11.00%
October 22, 2010 – January 23, 2011 10.75%
January 24, 2011 – April 18, 2011 11.25%
April 19, 2011 – July 17, 2011 11.00%
July 18, 2011 --- October 18, 2011 11.50%
October 19, 2011 ---October 19, 2011 10.78%
October 20, 2011----January 18, 2012 10.875%
January 19, 2012 --- April 17, 2012 10.50%
April 18, 2012 --- July 17, 2012 10.875%
July 18, 2012 ---- October 17, 2012 11.00%
October 18, 2012 ---- January 16, 2013 10.375%
January 17, 2013 --- April 16, 2013 10.625%
April 17, 2013 ---July 16, 2013 10.125%
July 17, 2013 ---October 17, 2013 10.375%
October 18, 2013---January 20, 2014 10.125%
January 21, 2014----April 16, 2014 10.25%
April 17, 2014---July17, 2014 10.125%
July 18, 2014 – October 19, 2014 9.625%
October 20, 2014—January 20, 2015 10.75%
January 21, 2015 ---April 16, 2015 10.50%
April 17, 2015 ----July 19, 2015 9.875%
July 20, 2015 ---- 9.75%
Medicare Overpayment Collection Process
If you are a Medicare Fee-For-Service provider who submits claims to Medicare Administrative Contractors, or MACs, you will benefit from this podcast! It will give you information to help you comply with requirements for the collection of Medicare physician and supplier overpayments, including the definition of an overpayment, the collection process, and resources.
This podcast is based on the MLN fact sheet titled "The Medicare Overpayment Collection Process" which CMS issued to help physicians and suppliers comply with Federal law requiring CMS to recover all identified overpayments.
The fact sheet included three helpful pieces of information which we will be discussing with you today:
• First, the definition of an overpayment
• Second, the overpayment collection process and
• Third, resources to find additional information about the process.
You should consider this important information, and take the necessary steps to meet Medicare requirements. The fact sheet information is intended as an educational guide and doesnot ensure compliance with Medicare regulations.
Let's begin with the definition of a Medicare physician or supplier overpayment. It is a payment a physician or supplier receives that exceeds amounts due and payable under Medicare statute and regulations. Once the overpayment is determined, the amount becomes a debt owed by the debtor to the Federal government. Federal law requires CMS to seek the recovery of all identified overpayments.
In Medicare there are four (4) ways that physician or supplier overpayment occur:
• One (1) Duplicate submission of the same service or claim;
• Two (2) Payment to the incorrect payee;
• Three (3) Payment for excluded or medically unnecessaary services; and
• Four (4) A pattern of furnishing and billing for excessive or non-covered services.
Now we'ill discuss the Overpayment Collection Process. This begins when Medicare discovers an overpayment of $10 or more.
This first demand letter is sent requesting payment. This post will explains that interest accrues from the date of the letter if the overpayment is not received by the 31st calendar day.
If no response is received from the physician or supplier 30 calendar days after the date of the first demand letter, a second demand letter may be sent.
If a full payment is not received 40 calendar days after the date if the first demand letter, recoupment procedures will begin on day 41. Recoupment means that the overpayment will be recovered from current payments due or from future claims submitted. If a debt has not been paid or recouped (unless a valid appeal is filed) an Intent to Refer letter is sent within 120 days indicating that the overpayment may be eligible for referral to the Department of the Treasury for offset or collection.
Next we will briefly describe extended repayment plans, rebuttals, appeals and their respective timeliness requirements.
If the physician or supplier is unable to pay the entire amount of the overpayment in full they may request an extended repayment plan from the Medicare Contractor.
A physician or supplier may submit a rebuttal statement to the Contractor within 15 calendar days from the date of a demand letter. The rebuttal statement explains or provides evidence why recoupment should not be initiated. The rebuttal process is not considered an appeal, and does not stop the Contractor’s recoupment activities.
If a physician or supplier disagrees with an overpayment decision, they may file an appeal with the Contractor that issued the original decision. A redetermination is the first level of appeal in which a qualified employee if the Contractor conducts an independent review of the decision. Section 1893 paragraph (f) (2) (a) of the Social Security Act provides limitations on the recoupment of Medicare overpayments. Overpayments subject to Section 935 paragraph (f) (2) of the Medicare Modernization Act (or MMA) must be filed within 120 calendar days from the date of the demand letter.
In order to stop the initial recoupment process, the redetermination request must be filed within 30 days from the date of the demand letter. If the redetermination request is received and validated later than 30 days from the date of the demand letter, the recoupment process will stop for those overpayments subject to Section 935 paragraph (f) (2) of the MMA. Any recoupment already taken will not be refunded to the physician or supplier.
Following an unfavorable or partially favorable redetermination decision, a physician or supplier may request a second level of appeal or reconsideration by a Qualified Independent Contractor (or OIC - "quick"). A request for reconsideration by a QIC must be filed within 180 calendar days of the date the reconsideration is received. in order to stop the recoupment process, a reconsideration must be filed within 60 days from the redetermination decision date. The recoupment process will stop when the reconsideration request is received and validated by the QIC. After the QIC's decision or dismissal, the recoupment process will resume for any overpayment amount that was not paid in full - regardless of whether the physician or supplier requests further appeal levels.
Medicaid increases the payment of Pediatric
Pediatric Physician Rate Increase
Effective January 1, 2015, Current Procedural Terminology (CPT®) codes 99201 through 99496 will be reimbursed with an enhanced rate to pediatric physicians billing fee-for-service with one of the following specialty codes: 001, 019, 023 035, 036, 037, 038, 039, 043, 049, 059, 101,102. The Physician Evaluation and Management Fee Schedule will be amended to reflect this change.
Providers receiving reimbursement through a Medicaid managed care plan should refer to their contract with each plan to determine whether this change will impact their reimbursement from the plan.
Q: When is it acceptable to collect the deductible from the beneficiary?
This is the most sighted question from provider.
A: When assignment is accepted, Medicare Part B recommends:
• Since it is difficult to predict when deductible/coinsurance amounts will be applicable - and over-collection is considered program abuse - do not collect these amounts until you receive Medicare Part B payment.
• If you believe you can accurately predict the coinsurance amount and wish to collect it before Medicare Part B payment is received, note the amount collected for coinsurance on your claim form. (We do not recommend that you collect the deductible prior to receiving payment from Medicare Part B because, as noted above, over-collection is considered program abuse and can cause a portion of the provider's check to be issued to beneficiaries on assigned claims.)
• Do not show any amounts collected from patients if the service is never covered by Medicare Part B or you believe, in a particular case, the service will be denied payment. Where patient paid amounts are shown for services that are denied payment, a portion of the provider's check may go to the beneficiary.
How is the Medicare Part B annual deductible applied to payment?
A. For each calendar year, a certain cash deductible exists that must be met before payment may be made by Medicare.
• The deductible for 2013 and 2014 is $147.00.
Patient expenses are applied toward the deductible based on incurred, rather than paid expenses, and are based on Medicare allowed amounts. Non-covered expenses do not count toward the deductible.
If an individual does not have Part B benefits for an entire calendar year (i.e., insurance coverage begins after the first month of the year), he or she is still subject to the full deductible for the calendar year. Medical expenses they incurred during the year, but before they are actually entitled to Medicare, cannot be applied to the deductible.
Although the date of service generally determines when expenses were incurred, the order in which expenses are applied to the deductible is based on when the bills are actually received.
• Note: Services not subject to the deductible cannot be used to satisfy the deductible.
A: When assignment is accepted, Medicare Part B recommends:
• Since it is difficult to predict when deductible/coinsurance amounts will be applicable - and over-collection is considered program abuse - do not collect these amounts until you receive Medicare Part B payment.
• If you believe you can accurately predict the coinsurance amount and wish to collect it before Medicare Part B payment is received, note the amount collected for coinsurance on your claim form. (We do not recommend that you collect the deductible prior to receiving payment from Medicare Part B because, as noted above, over-collection is considered program abuse and can cause a portion of the provider's check to be issued to beneficiaries on assigned claims.)
• Do not show any amounts collected from patients if the service is never covered by Medicare Part B or you believe, in a particular case, the service will be denied payment. Where patient paid amounts are shown for services that are denied payment, a portion of the provider's check may go to the beneficiary.
How is the Medicare Part B annual deductible applied to payment?
A. For each calendar year, a certain cash deductible exists that must be met before payment may be made by Medicare.
• The deductible for 2013 and 2014 is $147.00.
Patient expenses are applied toward the deductible based on incurred, rather than paid expenses, and are based on Medicare allowed amounts. Non-covered expenses do not count toward the deductible.
If an individual does not have Part B benefits for an entire calendar year (i.e., insurance coverage begins after the first month of the year), he or she is still subject to the full deductible for the calendar year. Medical expenses they incurred during the year, but before they are actually entitled to Medicare, cannot be applied to the deductible.
Although the date of service generally determines when expenses were incurred, the order in which expenses are applied to the deductible is based on when the bills are actually received.
• Note: Services not subject to the deductible cannot be used to satisfy the deductible.
Frequency of Billing for Providers Submitting Institutional Claims with Outpatient Services
Repetitive Part B services furnished to a single individual by providers that bill institutional claims shall be billed monthly (or at the conclusion of treatment). The instructions in this subsection also apply to hospice services billed under Part A, though they do not apply to home health services. Consolidating repetitive services into a single monthly claim reduces CMS processing costs for relatively small claims and in instances where bills are held for monthly review. Services repeated over a span of time and billed with the following revenue codes are defined as repetitive services:
Type of Service Revenue Code(s)
DME Rental 0290 – 0299
Respiratory Therapy 0410, 0412, 0419
Physical Therapy 0420 – 0429
Occupational Therapy 0430 – 0439
Speech-Language Pathology 0440 – 0449
Skilled Nursing 0550 – 0559
Kidney Dialysis Treatments 0820 – 0859
Cardiac Rehabilitation Services 0482, 0943
Hospitals in Maryland that are under the jurisdiction of the Health Services Cost Review Commission are subject to monthly billing cycles.
Where there is an inpatient stay, or outpatient surgery, or outpatient hospital services subject to OPPS, during a period of repetitive outpatient services, one bill for repetitive services shall nonetheless be submitted for the entire month as long as the provider uses an occurrence span code 74 on the monthly repetitive bill to encompass the inpatient stay, day of outpatient surgery, or outpatient hospital services subject to OPPS. CWF and shared systems must read occurrence span 74 and recognize the beneficiary cannot receive non-repetitive services while receiving repetitive services, and consequently, is on leave of absence from the repetitive services. This permits submitting a single, monthly bill for repetitive services and simplifies Contractor review of these bills.
How often Medicare paid for providers
Frequency of Billing for Providers
Different types of providers are paid based on different payment policies depending upon the circumstance of the provider. These payment policies are described in detail in the chapters related to the provider type. The following billing requirements are to strike a balance between program administration efficiency and maintaining cash flow for providers.
Standard System Maintainer (SSM) shall ensure that providers adhere to these requirements.
Inpatient Billing From Hospitals and SNFs
Non PPS Hospitals and SNFs
Inpatient services in TEFRA hospitals (i.e., hospitals excluded from inpatient prospective payment system (PPS), cancer and children’s hospitals) and SNFs are billed:
• Upon discharge of the beneficiary;
• When the beneficiary’ benefits are exhausted;
• When the beneficiary’s need for care changes; or
• On a monthly basis.
Hospitals in Maryland that are under the jurisdiction of the Health Services Cost Review Commission are subject to monthly billing cycles.
Providers shall submit a bill to the FI when a beneficiary in one of these hospitals ceases to need a hospital level of care (occurrence code 22). FIs shall not separate the occurrence code 31 and occurrence span code 76 on two different bills. Each bill must include all applicable diagnoses and procedures. However, interim bills are not to include charges billed on an earlier claim since the “From” date on the bill must be the day after the “Thru” date on the earlier bill.
SNF providers shall follow the billing instructions provided in Chapter 6 (SNF Inpatient Part A Billing), Section 40.8 (Billing in Benefits Exhaust and No-Payment Situations) for proper billing in benefits exhaust and no-payment situations.
Different types of providers are paid based on different payment policies depending upon the circumstance of the provider. These payment policies are described in detail in the chapters related to the provider type. The following billing requirements are to strike a balance between program administration efficiency and maintaining cash flow for providers.
Standard System Maintainer (SSM) shall ensure that providers adhere to these requirements.
Inpatient Billing From Hospitals and SNFs
Non PPS Hospitals and SNFs
Inpatient services in TEFRA hospitals (i.e., hospitals excluded from inpatient prospective payment system (PPS), cancer and children’s hospitals) and SNFs are billed:
• Upon discharge of the beneficiary;
• When the beneficiary’ benefits are exhausted;
• When the beneficiary’s need for care changes; or
• On a monthly basis.
Hospitals in Maryland that are under the jurisdiction of the Health Services Cost Review Commission are subject to monthly billing cycles.
Providers shall submit a bill to the FI when a beneficiary in one of these hospitals ceases to need a hospital level of care (occurrence code 22). FIs shall not separate the occurrence code 31 and occurrence span code 76 on two different bills. Each bill must include all applicable diagnoses and procedures. However, interim bills are not to include charges billed on an earlier claim since the “From” date on the bill must be the day after the “Thru” date on the earlier bill.
SNF providers shall follow the billing instructions provided in Chapter 6 (SNF Inpatient Part A Billing), Section 40.8 (Billing in Benefits Exhaust and No-Payment Situations) for proper billing in benefits exhaust and no-payment situations.
When Beneficiary Statement is Not Required for Physician/Supplier Claim
A. Enrollee Signature Requirements
A request for payment signed by the enrollee must be filed on or with each claim for charge basis reimbursement except as provided below. All rules apply to both assigned and unassigned claims unless otherwise indicated.
1. When no enrollee signature required:
a. Claim submitted for diagnostic tests or test interpretations performed in a medical facility which has no contact with enrollee.
b. Unassigned claim submitted by a public welfare agency on a bill which is paid.
c. Enrollee deceased, bill unpaid and the physician or supplier agrees to accept Medicare approved amount as the full charge.
2 When signature by mark is permitted: The enrollee is unable to sign his name because of illiteracy or physical handicap.
3. When another person may sign on behalf of the enrollee:
a. Enrollee who is resident of a nonprofit retirement home gives power of attorney to the administrator of the home.
b. Enrollee physically or mentally unable to transact business: The request may be signed by a representative payee, legal representative, relative, friend, representative of an institution providing the enrollee care or support, or of a governmental agency providing him/her assistance.
c. Enrollee physically or mentally unable to transact business and full documentation is supplied that the enrollee has no one else to sign on his behalf: The physician, supplier, or clinic may sign.
d. Enrollee deceased and bill paid or liability assumed: Person claiming payment should sign. If Form CMS-1500 was signed before the enrollee dies, claimant should sign separate request for underpayment.
4. When request retained in file may cover extended future period:
a. Assignment in files of welfare agency covers all services furnished during the period when the enrollee is on medical assistance.
b. Authorization in files of organization approved under §30.2.8.3 covers all services paid for by that organization under that procedure.
c. Assignment in the files of group practice prepayment plan covers services furnished by the plan during the period of the enrollee’s membership.
d. Assignment in the files of a participating provider (hospital, SNF, home health agency, outpatient physical therapy or speech-language pathology provider or comprehensive rehabilitation facility) or ESRD facility covers physician services for which the provider or facility is authorized to bill, and may cover the physician services furnished in the provider or facility as follows:
• Inpatient services - effective for period of confinement.
• Outpatient services - effective indefinitely.
e. Assignment in files of individual physician, supplier (except in the case of unassigned claims for rental of durable medical equipment) or qualified reassignee under §30.2 is effective indefinitely
Would Medicare pay after provider termination
Reviewing Inpatient Bills for Services After Suspension, Termination, Expiration, or Cancellation of Provider Agreement, or After a SNF is Denied Payment for New Admissions
A SNF may be denied payment for new admissions, but not readmissions, as an option to termination of its provider agreement for noncompliance with one or more requirements of participation. The SNF may only be reimbursed for covered services furnished on or after the effective date of denial of payments if such services were furnished to beneficiaries who were admitted to the SNF before the effective date of termination or expiration.
EXAMPLE:
Effective date of denial of payment - 9-30
Beneficiary admitted before 9-30 - pay for covered Part A or B services
Beneficiary admitted on or after 9-30 - deny payment under Part A or B
NOTE: An inpatient who goes on leave from the SNF before or after the effective date of denial of payments for new admissions is not considered a new admission when returning from leave.
The contractor is notified of SNF payment denials through the Form CMS-2007. It must install appropriate edits or other safeguards to prevent incorrect payments to the provider.
The contractor obtains a list of Medicare inpatients when a SNF or hospital agreement is terminated, or after a SNF is denied payment for new admissions to assure that nonpayment spell of illness bills are filed.
A SNF may be denied payment for new admissions, but not readmissions, as an option to termination of its provider agreement for noncompliance with one or more requirements of participation. The SNF may only be reimbursed for covered services furnished on or after the effective date of denial of payments if such services were furnished to beneficiaries who were admitted to the SNF before the effective date of termination or expiration.
EXAMPLE:
Effective date of denial of payment - 9-30
Beneficiary admitted before 9-30 - pay for covered Part A or B services
Beneficiary admitted on or after 9-30 - deny payment under Part A or B
NOTE: An inpatient who goes on leave from the SNF before or after the effective date of denial of payments for new admissions is not considered a new admission when returning from leave.
The contractor is notified of SNF payment denials through the Form CMS-2007. It must install appropriate edits or other safeguards to prevent incorrect payments to the provider.
The contractor obtains a list of Medicare inpatients when a SNF or hospital agreement is terminated, or after a SNF is denied payment for new admissions to assure that nonpayment spell of illness bills are filed.
How much is Medicaid copay - out of pocket and what are the exemption cases
Beginning January 1, 2014, some services will be assigned copay amounts for Medicaid Members. The following copays will apply to claims with a date of service on or after January 1, 2014:
Service TIER 1 Up to 50.00% FPL TIER 2 50.01-100.00% FPL TIER 3 100.01% FPL and above
Inpatient Hospital (Acute Care 11x) --- $0 $35 $75
Office Visit (Physicians and Nurse Practitioners) (99201-99205, 99212-99215 only for office visits for new and established patients based on level of care) --- $0 $2 $4
Non-Preferred Drugs ---- $2 $4 $8
Non-Emergency use of Emergency Department - Hospital only (Lowest level (99281) of Emergency Room visits in hospitals. The definition of this visit is an emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and straightforward medical decision making.) ---------- $8 $8 $8
Any outpatient surgical services rendered in a physician’s office, ASC or Outpatient Hospital excluding emergency rooms. --- $0 $2 $4
Maximum Out of Pocket (OOP):
Each calendar year quarter, Members will have a maximum out of pocket (OOP) payment. The OOP is the most the Member will ever be required to pay in any given quarter regardless of the number of healthcare services received. The following table shows the OOP for each tier level.
Tier Level Out of Pocket Maximum
1 (Up to 50.00% FPL) $8
2 (50.01-100.00% FPL) $71
3 (100.01% FPL and above) $143
Quarters
January 1 – March 31, 2014
April 1 – June 30, 2014
July 1 – September 30, 2014
October 1 – December 31, 2014
Exemptions:
The following populations and services are exempt from copays:
Pregnant Women including pregnancy-related services up to 60 days post-partum;
Children under age 21;
Native American and Alaska natives;
Intermediate Care Facility or MR services;
Preventive services for children under age 18;
Provider-preventable services;
Individuals in Nursing Homes,
Receiving Hospice services,
Medicaid Waiver services, or covered through the Breast and Cervical Cancer Treatment Program;
Family Planning services and Emergency services.
Additional exemptions for Pharmacy include diabetic testing supplies syringes and needles, BMS approved Home Infusion supplies and 3-day emergency supplies.
Service TIER 1 Up to 50.00% FPL TIER 2 50.01-100.00% FPL TIER 3 100.01% FPL and above
Inpatient Hospital (Acute Care 11x) --- $0 $35 $75
Office Visit (Physicians and Nurse Practitioners) (99201-99205, 99212-99215 only for office visits for new and established patients based on level of care) --- $0 $2 $4
Non-Preferred Drugs ---- $2 $4 $8
Non-Emergency use of Emergency Department - Hospital only (Lowest level (99281) of Emergency Room visits in hospitals. The definition of this visit is an emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and straightforward medical decision making.) ---------- $8 $8 $8
Any outpatient surgical services rendered in a physician’s office, ASC or Outpatient Hospital excluding emergency rooms. --- $0 $2 $4
Maximum Out of Pocket (OOP):
Each calendar year quarter, Members will have a maximum out of pocket (OOP) payment. The OOP is the most the Member will ever be required to pay in any given quarter regardless of the number of healthcare services received. The following table shows the OOP for each tier level.
Tier Level Out of Pocket Maximum
1 (Up to 50.00% FPL) $8
2 (50.01-100.00% FPL) $71
3 (100.01% FPL and above) $143
Quarters
January 1 – March 31, 2014
April 1 – June 30, 2014
July 1 – September 30, 2014
October 1 – December 31, 2014
Exemptions:
The following populations and services are exempt from copays:
Pregnant Women including pregnancy-related services up to 60 days post-partum;
Children under age 21;
Native American and Alaska natives;
Intermediate Care Facility or MR services;
Preventive services for children under age 18;
Provider-preventable services;
Individuals in Nursing Homes,
Receiving Hospice services,
Medicaid Waiver services, or covered through the Breast and Cervical Cancer Treatment Program;
Family Planning services and Emergency services.
Additional exemptions for Pharmacy include diabetic testing supplies syringes and needles, BMS approved Home Infusion supplies and 3-day emergency supplies.
CO 253 - Medicare EOB sequestration payment reduction code
New Claim Adjustment Reason Code (CARC) to Identify a Reduction in Payment Due to Sequestration
This article is based on CR 8378 which informs Medicare contractors about a new Claim Adjustment Reason Code (CARC) reported when payments are reduced due to Sequestration. Make sure that your billing staffs are aware of these changes.
As required by law, President Obama issued a sequestration order on March 1, 2013, canceling budgetary resources across the Federal Government. As a result, Medicare Fee-For-Service claims, with dates of service or dates of discharge on or after April 1, 2013, incur a two percent reduction in Medicare payment. The Centers for Medicare & Medicaid services (CMS) previously assigned CARC 223 (Adjustment code for mandated Federal, State or Local law/regulation that is not already covered by another code and is mandated before a new code can be created) to explain the adjustment in payment.
Effective June 3, 2013, a new CARC was created and will replace CARC 223 on all applicable claims.
The new CARC is as follows:
• 253 - Sequestration - Reduction in Federal Spending
Also, Medicare contractors will not take any action on claims processed prior to implementation of CR8378.
The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC statement of Work. The contractor is not obliged to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements.
The claims payment adjustment shall be applied to all claims after determining coinsurance, any applicable deductible, and any applicable Medicare Secondary Payment adjustments.
Though beneficiary payments for deductibles and coinsurance are not subject to the 2 percent payment reduction, Medicare’s payment to beneficiaries for unassigned claims is subject to the 2 percent reduction. The Centers for Medicare & Medicaid Services encourages Medicare physicians, practitioners, and suppliers who bill claims on an unassigned basis to discuss with beneficiaries the impact of sequestration on Medicare’s reimbursement.
For example:
The Net Medicare Payment for the claim line is $104.46 and the Medicare Payment Reduction was $2.13.
* Add $104.46 to $2.13, which is $106.59
* $104.46 represents Medicare’s Payment for the service or item and $2.13 represents the Medicare Payment Reduction related to the service or item
* Enter the Sum, which is $106.59, as ‘Medicare Paid (incl. Medicare Reduction(s)) Amount’
How will Medicare physician payments be affected?
• All Medicare physician claims with a date of service on or after April 1 will be subject to a 2 percent payment cut.
• Costs for physician-administered drugs included on the physician claim will also be subject to the 2 percent cut.
• The cut will be applied to the payment itself, not the underlying “allowed charge” in the Medicare fee schedule. As a result, beneficiary copayments and deductibles will not change. In other words, the 2 percent cut is imposed only on the 80 percent of the allowed charge that a participating physician would receive directly from
Medicare. The 20 percent copayment amount (and any deductible) that the physician collects from the patient will be based on the full allowed charge amount.
• With respect to unassigned claims for services provided by nonparticipating physicians, the 2 percent cut will be applied to the Medicare payment made to the beneficiary (but not to the limiting charge amount).
How long will the sequestration last?
• The Budget Control Act requires that $1.2 trillion in federal spending cuts be achieved over the course of nine years. So, unless Congress takes action to change the law, federal spending will be subject to sequestration until 2022.
• Because the American Taxpayer Relief Act that was signed into law in January delayed the 2013 sequester for two months (with a budget offset), the Defense and discretionary program cuts are less severe now than they will be in coming years.
• As an entitlement program, the Medicare payment cut is treated a little differently than the cuts being imposed on programs subject to the appropriations process. The Medicare cut will never be higher than 2 percent.
• Importantly, the Medicare cuts each year are not cumulative. So, the 2 percent cut this year will not be followed by another 2 percent cut next year, and so forth, producing a cumulative double-digit cut at the end of the sequestration period. In other words, this year’s 2 percent cut will simply remain in place every year through 2022 (unless Congress takes action to stop it).
What are the prospects of Congressional action to stop the sequester?
• With all the fiscal deadlines facing Congress this year, the sequester will remain a subject for debate. However, we are mid-way through the fiscal year and, barring a major backlash, it is expected that the sequester cuts will remain in effect through at least Sept 30, 2013.
• The future of sequestration beyond 2013 is likely to depend on whether or not Congress and the White House are able to reach a new budget agreement to address deficit and spending concerns.
This article is based on CR 8378 which informs Medicare contractors about a new Claim Adjustment Reason Code (CARC) reported when payments are reduced due to Sequestration. Make sure that your billing staffs are aware of these changes.
As required by law, President Obama issued a sequestration order on March 1, 2013, canceling budgetary resources across the Federal Government. As a result, Medicare Fee-For-Service claims, with dates of service or dates of discharge on or after April 1, 2013, incur a two percent reduction in Medicare payment. The Centers for Medicare & Medicaid services (CMS) previously assigned CARC 223 (Adjustment code for mandated Federal, State or Local law/regulation that is not already covered by another code and is mandated before a new code can be created) to explain the adjustment in payment.
Effective June 3, 2013, a new CARC was created and will replace CARC 223 on all applicable claims.
The new CARC is as follows:
• 253 - Sequestration - Reduction in Federal Spending
Also, Medicare contractors will not take any action on claims processed prior to implementation of CR8378.
The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC statement of Work. The contractor is not obliged to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements.
The claims payment adjustment shall be applied to all claims after determining coinsurance, any applicable deductible, and any applicable Medicare Secondary Payment adjustments.
Though beneficiary payments for deductibles and coinsurance are not subject to the 2 percent payment reduction, Medicare’s payment to beneficiaries for unassigned claims is subject to the 2 percent reduction. The Centers for Medicare & Medicaid Services encourages Medicare physicians, practitioners, and suppliers who bill claims on an unassigned basis to discuss with beneficiaries the impact of sequestration on Medicare’s reimbursement.
For example:
The Net Medicare Payment for the claim line is $104.46 and the Medicare Payment Reduction was $2.13.
* Add $104.46 to $2.13, which is $106.59
* $104.46 represents Medicare’s Payment for the service or item and $2.13 represents the Medicare Payment Reduction related to the service or item
* Enter the Sum, which is $106.59, as ‘Medicare Paid (incl. Medicare Reduction(s)) Amount’
How will Medicare physician payments be affected?
• All Medicare physician claims with a date of service on or after April 1 will be subject to a 2 percent payment cut.
• Costs for physician-administered drugs included on the physician claim will also be subject to the 2 percent cut.
• The cut will be applied to the payment itself, not the underlying “allowed charge” in the Medicare fee schedule. As a result, beneficiary copayments and deductibles will not change. In other words, the 2 percent cut is imposed only on the 80 percent of the allowed charge that a participating physician would receive directly from
Medicare. The 20 percent copayment amount (and any deductible) that the physician collects from the patient will be based on the full allowed charge amount.
• With respect to unassigned claims for services provided by nonparticipating physicians, the 2 percent cut will be applied to the Medicare payment made to the beneficiary (but not to the limiting charge amount).
How long will the sequestration last?
• The Budget Control Act requires that $1.2 trillion in federal spending cuts be achieved over the course of nine years. So, unless Congress takes action to change the law, federal spending will be subject to sequestration until 2022.
• Because the American Taxpayer Relief Act that was signed into law in January delayed the 2013 sequester for two months (with a budget offset), the Defense and discretionary program cuts are less severe now than they will be in coming years.
• As an entitlement program, the Medicare payment cut is treated a little differently than the cuts being imposed on programs subject to the appropriations process. The Medicare cut will never be higher than 2 percent.
• Importantly, the Medicare cuts each year are not cumulative. So, the 2 percent cut this year will not be followed by another 2 percent cut next year, and so forth, producing a cumulative double-digit cut at the end of the sequestration period. In other words, this year’s 2 percent cut will simply remain in place every year through 2022 (unless Congress takes action to stop it).
What are the prospects of Congressional action to stop the sequester?
• With all the fiscal deadlines facing Congress this year, the sequester will remain a subject for debate. However, we are mid-way through the fiscal year and, barring a major backlash, it is expected that the sequester cuts will remain in effect through at least Sept 30, 2013.
• The future of sequestration beyond 2013 is likely to depend on whether or not Congress and the White House are able to reach a new budget agreement to address deficit and spending concerns.
what is Remittance Voucher
Description
The remittance voucher displays the disposition of all claims processed during the claims cycle. A remittance voucher is mailed each week if the fiscal agent processed any claims or put any claims in “Suspend” status. If the provider receives payment by paper check, the check is mailed separately.
Role of the Remittance Voucher
The remittance voucher plays an important role in communications between the provider and Medicaid. It tells what happened to the claims submitted for payment–whether they were paid, suspended, or denied. It provides a record of transactions and assists the provider in resolving errors so that denied claims can be resubmitted.
The provider must reconcile the remittance voucher with the claim in order to determine if correct payment was received.
The remittance voucher contains one or more of the following sections, depending on the type of claims filed, the disposition of those claims, and any new billing or policy announcements:
· Remittance Voucher Banner Page Message
· Disposition Category by Groups
· Summary Section
Remittance Voucher Banner Page Message
When Medicaid or the fiscal agent discovers billing problems encountered by all or selected provider types, a remittance voucher banner message is printed as the first page of the voucher. Suggestions for avoiding problems, explanations of policy, and new or changed procedure codes are described. Training sessions
are also announced on the remittance voucher banner page.
Disposition Category by Groups
Claims are listed by disposition category (paid, denied, or suspended) in alphabetical order by the recipient’s last name. Voids and adjustments are also listed separately.
Suspend Status
All claims in the “Suspend” status are reported each week until adjudicated as “Paid” or “Denied.” If one line on a claim form suspends, then the entire claim will suspend until all of the claim lines can be adjudicated.
Summary Section
The remittance voucher summary section reports the number of claim transactions, and the total payment or check amount. If the account shows a prior negative balance, it will be carried forward weekly until eliminated.
The remittance voucher displays the disposition of all claims processed during the claims cycle. A remittance voucher is mailed each week if the fiscal agent processed any claims or put any claims in “Suspend” status. If the provider receives payment by paper check, the check is mailed separately.
Role of the Remittance Voucher
The remittance voucher plays an important role in communications between the provider and Medicaid. It tells what happened to the claims submitted for payment–whether they were paid, suspended, or denied. It provides a record of transactions and assists the provider in resolving errors so that denied claims can be resubmitted.
The provider must reconcile the remittance voucher with the claim in order to determine if correct payment was received.
The remittance voucher contains one or more of the following sections, depending on the type of claims filed, the disposition of those claims, and any new billing or policy announcements:
· Remittance Voucher Banner Page Message
· Disposition Category by Groups
· Summary Section
Remittance Voucher Banner Page Message
When Medicaid or the fiscal agent discovers billing problems encountered by all or selected provider types, a remittance voucher banner message is printed as the first page of the voucher. Suggestions for avoiding problems, explanations of policy, and new or changed procedure codes are described. Training sessions
are also announced on the remittance voucher banner page.
Disposition Category by Groups
Claims are listed by disposition category (paid, denied, or suspended) in alphabetical order by the recipient’s last name. Voids and adjustments are also listed separately.
Suspend Status
All claims in the “Suspend” status are reported each week until adjudicated as “Paid” or “Denied.” If one line on a claim form suspends, then the entire claim will suspend until all of the claim lines can be adjudicated.
Summary Section
The remittance voucher summary section reports the number of claim transactions, and the total payment or check amount. If the account shows a prior negative balance, it will be carried forward weekly until eliminated.
Insurance Claims Processing cycel - different stage
Paper Claim Handling
When the Medicaid fiscal agent receives a paper claim, it is screened for missing information and necessary attachments. If information or documentation is missing, the claim will not be entered into the Florida Medicaid Management Information System (FMMIS). It will be returned to the provider with a Return to Provider (RTP) letter that will state the reason the claim is being returned. The provider needs to correct the error, attach any missing documentation, and return the claim to the fiscal agent for processing.
Claim Entry
Data entry operators image and key into FMMIS each paper claim that passes initial screening. Electronic claims are loaded by batch into FMMIS by the fiscal agent’s data processing staff.
Claim Adjudication
FMMIS analyzes the claim information and determines the status or disposition of the claim. This process is known as claim adjudication.
Disposition of Claim
A claim disposition can be:
· Paid: payment is approved in accordance with program criteria.
· Suspended: the claim is put on “hold” so it can be analyzed in more detail by the fiscal agent or AHCA Medicaid.
· Denied: payment cannot be made because the information supplied indicates the claim does not meet program criteria, or information necessary for payment was either erroneous or missing.
Processing Time Frames
Claims are processed daily. Payments are made on a weekly basis. Under normal conditions a claim can be processed from receipt to payment within 7 to 30 days.
When the Medicaid fiscal agent receives a paper claim, it is screened for missing information and necessary attachments. If information or documentation is missing, the claim will not be entered into the Florida Medicaid Management Information System (FMMIS). It will be returned to the provider with a Return to Provider (RTP) letter that will state the reason the claim is being returned. The provider needs to correct the error, attach any missing documentation, and return the claim to the fiscal agent for processing.
Claim Entry
Data entry operators image and key into FMMIS each paper claim that passes initial screening. Electronic claims are loaded by batch into FMMIS by the fiscal agent’s data processing staff.
Claim Adjudication
FMMIS analyzes the claim information and determines the status or disposition of the claim. This process is known as claim adjudication.
Disposition of Claim
A claim disposition can be:
· Paid: payment is approved in accordance with program criteria.
· Suspended: the claim is put on “hold” so it can be analyzed in more detail by the fiscal agent or AHCA Medicaid.
· Denied: payment cannot be made because the information supplied indicates the claim does not meet program criteria, or information necessary for payment was either erroneous or missing.
Processing Time Frames
Claims are processed daily. Payments are made on a weekly basis. Under normal conditions a claim can be processed from receipt to payment within 7 to 30 days.
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