Archive for October, 2011


New Incentives for Providers to Work Together Through Accountable Care Organizations

Monday, October 24th, 2011

HHS Announces New Incentives When Caring for People With Medicare

New tools help doctors and other healthcare providers improve quality of care

Thu Oct 20 – People with Medicare will be able to benefit from a new program designed to encourage primary care doctors, specialists, hospitals, and other healthcare providers to coordinate their care under a final regulation issued today by the Department of Health and Human Services (HHS).  Created by the Affordable Care Act, these final rules on Accountable Care Organizations add to the menu of options for providers looking to better coordinate care for patients and will make it easier for providers to deliver high quality care and use healthcare dollars more wisely.

The initiatives announced today are just two of several efforts made possible by the Affordable Care Act to help bring better health, better care and lower costs not just to Medicare beneficiaries, but to all Americans.  For example, the Bundled Payments for Care Improvement Initiative and Comprehensive Primary Care Initiative offer alternatives to coordinate and improve healthcare.

The two initiatives launched today – the Medicare Shared Savings Program and the Advance Payment model – will help providers form Accountable Care Organizations and reflect the significant input provided by stakeholders as well as lessons learned by innovators in care coordination in the private sector.

  • The Medicare Shared Savings Program will provide incentives for participating healthcare providers who agree to work together and become accountable for coordinating care for patients.  Providers who band together through this model and who meet certain quality standards based upon, among other measures, patient outcomes and care coordination among the provider team, may share in savings they achieve for the Medicare program.  The higher the quality of care providers deliver, the more shared savings the providers may keep.
  • The Advance Payment model will provide additional support to physician-owned and rural providers participating in the Medicare Shared Savings Program who also would benefit from additional start-up resources to build the necessary infrastructure, such as new staff or information technology systems.  The advanced payments would be recovered from any future shared savings achieved by the Accountable Care Organization.

The Shared Savings Program final rule is posted at:

The CMS press release is available at:

The Advanced Payment solicitation is posted at:

For more information, fact sheets are posted at: and

The joint CMS and HHS Office of Inspector General (OIG) Interim Final Rule with Comment Period addressing waivers of certain fraud and abuse laws in connection with the Shared Savings Program is posted at:

The Antitrust Policy Statement is posted at: and

The Internal Revenue Service (IRS) Fact Sheet, Tax-Exempt Organizations Participating in the Medicare Shared Savings Program through Accountable Care (FS-2001-11), will be posted at:

For additional information you may view the CMS Fact Sheets  (10/20) posted at:

Federal Register Links:


Stark Waivers:

Advanced Payment:


Problem with September 2011 Influenza Vaccine Pricing

Thursday, October 20th, 2011

Description of the Problem

For dates of service in September 2011, influenza vaccinations are being priced using the 2010-2011 influenza season rates.

What This Means to You

Providers are receiving incorrect payment for influenza vaccination claims. If you identify influenza vaccinations where you were paid incorrectly, please hold your appeal requests. As soon as the pricing files are updated you will be notified and you may request an adjustment of your claims. Until the new pricing files are uploaded National Government Services cannot reprocess any claims. If you have not already submitted your influenza vaccinations for September, please consider holding your claims until the new pricing files are in effect.

Current Status

10/20/2011: National Government Services is aware of this issue and is working in collaboration with the Centers for Medicare & Medicaid Services (CMS) in order to rectify the pricing disparity as soon as possible. Thank you for your patience.

National Government Services, Inc.

Corporate Communications


URGENT NOTICE – Compliance deadline Jan.1, 2012

Thursday, October 20th, 2011

2011 Version of Advance Beneficiary Notice of Noncoverage Must Be Used Beginning Sun Jan 1, 2012

Only 10% of the NGS’ Medicare provider volume has tested their HIPAA Version 5010 claims on an individual basis.  If you bill electronically, please be sure that you or your billing vendor, clearinghouse or service provider has successfully tested your claims submission before the January 1, 2012 deadline (i.e. the first two weeks of December).  Please make sure, by asking them, if you have not asked them, already.  Not doing so will have serious negative cash flow implications – your claims will not be paid.  If you do not have an Administrative Simplification Compliance Act (ASCA) waiver, you will not be permitted to default to paper claim filing.

In May 2011, CMS released an updated version of the Advance Beneficiary Notice of Noncoverage (ABN) (form CMS-R-131), which will replace the 2008 version of this form.  The 2011 version contains no substantive changes from the 2008 version of the notice and was approved by the Office of Management and Budget.  The 2008 and 2011 ABN notices are identical except that the release date of “3/11” is printed in the lower left hand corner of the new version.  The ABN is used by all providers, practitioners, and suppliers paid under Medicare Part B, as well as hospice providers and religious non-medical healthcare institutions (RNHCIs) paid exclusively under Part A.

When the 2011 ABN was posted to the CMS website on Mon May 16, CMS announced a mandatory use date of Thu Sep 1 and permitted providers and suppliers to begin using the new form immediately.  Subsequently, we received requests from the industry to extend this deadline in order to permit providers and suppliers with pre-printed stockpiles of ABNs time to exhaust their supplies.

Providers and suppliers are allowed to use either the 2008 or 2011 version of the ABN through the end of this year; beginning Sun Jan 1, 2012, they must begin using the 2011 version.  ABNs issued after Sun Jan 1 that are prepared using the 2008 version of the notice will be considered invalid by Medicare contractors.  2008 versions of the ABN that were issued prior to Sun Jan 1 as long-term notification for repetitive services delivered for up to one year will remain effective for the length of time specified on the notice.

Information and a copy of the 2011 version of the ABN (form CMS-R-131) can be found online at, under the “FFS Revised ABN” link.


Responding to EMTALA as a Member of the Medical Staff

Tuesday, October 18th, 2011

Considerations for Medical Staff Bylaws
Professional Discipline • Litigation and Arbitration • Contracts and Business Transactions • White Collar Crime Regulatory Compliance • Practice Formation • Mergers and Acquisitions • Asset Protection and Estate Planning Medical Financial Audits

The Emergency Medical Treatment and Labor Act (EMTALA) requires hospitals with emergency departments (and Critical Access Hospitals) to provide a medical screening examination to any individual who comes to the emergency department and requests such an examination, and prohibits hospitals with emergency departments from refusing to examine or treat individuals with an emergency medical condition (EMC). The provisions of EMTALA apply to all individuals (not just Medicare beneficiaries) who attempt to gain access to a hospital for emergency care. The regulations define “hospital with an emergency department” to mean a hospital with a dedicated emergency department (ED) and define “dedicated emergency department” as any department or facility of the hospital that: (1) is licensed by the state as an emergency department; (2) is held out to the public as providing treatment for emergency medical conditions; or (3) on one-third of the visits to the department in the preceding calendar year actually provided treatment for emergency medical conditions on an urgent basis.

Enforcement of EMTALA is complaint driven, i.e., the investigation of a hospital’s policies and procedures, and any subsequent sanctions, are initiated by a complaint. CMS surveyors review the bylaws, rules, and regulations of the medical staff and the ED policies and procedures manual to help determine if a hospital is in compliance with EMTALA requirements. If the results of a complaint investigation indicate that a hospital violated one or more of the anti-dumping provisions of EMTALA, a hospital may be subject to termination of its provider agreement and/or the imposition of civil monetary penalties (CMPs). CMS refers cases it has investigated to the HHS Office of Inspector General (OIG) when CMS finds violations that appear to fall within the OIG’s EMTALA jurisdiction. CMPs may be imposed by the OIG against both the hospital and individual physicians for EMTALA violations. The OIG can also terminate a physician’s provider agreement for gross and flagrant or repeated EMTALA violations. A physician found to have violated EMTALA may also be sanctioned by the state licensing board, payors and other third-party entities, and be sued by the hospital for indemnification.

TO RECEIVE THE COMPLETE 19-PAGE REPORT, Contact the Nassau County Medical Society at

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You MUST Transition to Version 5010 for Electronic Claims – 1/1/2012

Tuesday, October 4th, 2011

If you use HIPAA electronic standard transactions (such as claims submission), you are required to comply with the Jan. 1, 2012 deadline of moving to version 5010 of these transactions. Make sure your practice is ready so you can avoid rejected claims and cash-flow interruptions.

Please be sure to check with your biller, vendor, practice management software staff and/or clearinghouse to ensure that they have transitioned to version 5010.  Don’t wait until the last minute.


to Transition to Version 5010 for Electronic Claims.

Are you:

  • An individual physician?
  • A physician group practice?
  • A hospital?
  • A home health facility?
  • A hospice facility?
  • A federally qualified health center?
  • A billing service?

Did you know that ALL covered entities must submit version 5010 electronic claims as of January 1, 2012?

Currently, only one percent of National Government Services total electronic data interchange (EDI) trading partners are sending version 5010 production electronic claims. That leaves 99 percent of National Government Services trading partners to transition prior to January 1, 2012. Don’t wait to transition to version 5010, transition NOW to prevent last minute delays, electronic claim file front-end rejections or possible payment delays.

Thank you,

National Government Services, Inc.

Corporate Communications

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