Archive for the ‘MEDICARE UPDATES’ Category

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Medicare EPs Must Attest by February 28 at 11:59 pm ET to Receive 2013 Incentive

Monday, January 13th, 2014

If you are an eligible professional (EP), the last day you can register and attest to demonstrating meaningful use for the 2013 Medicare EHR Incentive Program isFebruary 28, 2014. You must successfully attest by 11:59 p.m. Eastern Standard Time on February 28 to receive an incentive payment for your 2013 participation.

You must attest to demonstrating meaningful use every year to receive an incentive and avoid a payment adjustment.

Medicaid Eligible Professionals
EPs participating in the Medicaid EHR Incentive Program need to refer to their state deadlines for attestation information.

Payment Adjustments
Payment adjustments for EPs will be applied beginning January 1, 2015, to Medicare participants that have not successfully demonstrated meaningful use. The adjustment is determined by your reporting period in a prior year. For more information, visit the payment adjustment tipsheet for EPs.

If you are only eligible to participate in the Medicaid EHR Incentive Program, you are not subject to these payment adjustments.

Resources

Plan Ahead
Review all of the important dates for the EHR Incentive Programs on the HIT Timeline.

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Issues with Processing 1500 Paper Claims Filed to National Government Services

Friday, January 10th, 2014

Beginning on April 1, 2014, all paper claims filed to NGS Medicare must be submitted using the revised form CMS 1500 Version 02/12.    All paper claim submissions using the older format will be returned to providers as unprocessable after April 1, 2014.

To prepare for the change in claim form, NGS implemented a new Optical Character Recognition System (OCR) in November 2013.   We have been experiencing delays with needed updates to this OCR system.   Unfortunately, this has caused a short term need to manually verify all paper claims data. This has increased the overall inventory of paper claims pending validation.

Until these paper claims are completely entered, we cannot currently respond fully to claim status related questions.   In all likelihood, the claims have been received and are awaiting claim detail entry into MCS.   An extensive effort is underway to expedite processing for these outstanding paper claims.

This issue applies only to the small volume of paper claims received.   The vast majority of electronically submitted claims and the claims submitted using the free features on the Connex portal are being processed, meeting all timeliness requirements. Please checkwww.ngsmedicare.com/Connex for details.

We regret the delay in handling the paper claims submitted.

James D. Bavoso

Provider Outreach & Education

National Government Services

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President Obama Signs the Pathway for SGR Reform Act of 2013

Thursday, January 2nd, 2014

New Law Includes Physician Update Fix through March 2014–

On December 26, 2013, President Obama signed into law the Pathway for SGR Reform Act of 2013. This new law prevents a scheduled payment reduction for physicians and other practitioners who treat Medicare patients from taking effect on January 1, 2014. The new law provides for a 0.5 percent update for such services through March 31, 2014. President Obama remains committed to a permanent solution to eliminating the Sustainable Growth Rate (SGR) reductions that result from the existing statutory methodology. The Administration will continue to work with Congress to achieve this goal.

The new law extends several provisions of the Middle Class Tax Relief and Job Creation Act of 2012 (Job Creation Act) as well as provisions of theAffordable Care Act. Specifically, the following Medicare fee-for-service policies have been extended. We also have included Medicare billing and claims processing information associated with the new legislation. Please note that these provisions do not reflect all of the Medicare provisions in the new law, and more information about other provisions will be forthcoming.

Section 1101 – Medicare Physician Payment Update – As indicated above, the new law provides for a 0.5 percent update for claims with dates of service on or after January 1, 2014, through March 31, 2014. CMS is currently revising the 2014 Medicare Physician Fee Schedule (MPFS) to reflect the new law’s requirements as well as technical corrections identified since publication of the final rule in November. For your information, the 2014 conversion factor is $35.8228.

Section 1102 – Extension of Medicare Physician Work Geographic Adjustment Floor – The existing 1.0 floor on the physician work geographic practice cost index is extended through March 31, 2014. As with the physician payment update, this extension will be reflected in the revised 2014 MPFS.

Section 1103 – Extension Related to Payments for Medicare Outpatient Therapy ServicesSection 1103 extends the exceptions process for outpatient therapy caps through March 31, 2014. Providers of outpatient therapy services are required to submit the KX modifier on their therapy claims, when an exception to the cap is requested for medically necessary services furnished through March 31, 2014. In addition, the new law extends the application of the cap and threshold to therapy services furnished in a hospital outpatient department (OPD). Additional information about the exception process for therapy services may be found in the Medicare Claims Processing Manual, Pub.100-04, Chapter 5, Section 10.3.

The therapy caps are determined for a beneficiary on a calendar year basis, so all beneficiaries began a new cap for outpatient therapy services received on January 1, 2014. For physical therapy and speech language pathology services combined, the 2014 limit for a beneficiary on incurred expenses is $1,920. There is a separate cap for occupational therapy services which is $1,920 for 2014. Deductible and coinsurance amounts applied to therapy services count toward the amount accrued before a cap is reached, and also apply for services above the cap where the KX modifier is used.

Section 1103 also extends the mandate that Medicare perform manual medical review of therapy services furnished January 1, 2014 through March 31, 2014, for which an exception was requested when the beneficiary has reached a dollar aggregate threshold amount of $3,700 for therapy services, including OPD therapy services, for a year. There are two separate $3,700 aggregate annual thresholds: (1) physical therapy and speech-language pathology services, and (2) occupational therapy services.

Section 1104 – Extension of Ambulance Add-On PaymentsSection 1104 extends the following two Job Creation Act ambulance payment provisions: (1) the 3 percent increase in the ambulance fee schedule amounts for covered ground ambulance transports that originate in rural areas and the 2 percent increase for covered ground ambulance transports that originate in urban areas is extended through March 31, 2014; and (2) the provision relating to payment for ground ambulance services that increases the base rate for transports originating in an area that is within the lowest 25th percentile of all rural areas arrayed by population density (known as the “super rural” bonus) is extended through March 31, 2014. The provision relating to air ambulance services that continued to treat as rural any area that was designated as rural on December 31, 2006, for purposes of payment under the ambulance fee schedule, expired on June 30, 2013.

Section 1105 – Extension of Medicare Inpatient Hospital Payment Adjustment for Low-Volume Hospitals – The Affordable Care Act allowed qualifying low-volume hospitals to receive add-on payments based on the number of Medicare discharges from the hospital. To qualify, the hospital must have less than 1,600 Medicare discharges and be 15 miles or greater from the nearest like hospital. This provision extends the payment adjustment through March 31, 2014, retroactive to October 1, 2013. Be on the alert for further information about implementation of this provision.

Section 1106 – Extension of the Medicare-Dependent Hospital (MDH) Program – The MDH program provides enhanced payment to support small rural hospitals for which Medicare patients make up a significant percentage of inpatient days or discharges. This provision extends the MDH program until March 31, 2014, and is retroactive to October 1, 2013. Be on the alert for further information about implementation of this provision.

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Brief SGR Update

Thursday, December 19th, 2013

December 19, 2013

Yesterday the US Senate passed by a 64-36 margin a two-year Budget deal that includes a 3-month delay of the 24% Medicare SGR physician payment cut scheduled to go into effect January 1.  Last week, the House of Representatives passed the measure and it is expected to be signed into law by the President.  The 3-month “bridge” also includes a 0.5% update.

It should also be noted that while the proposal mitigated some of the cuts to federal programs imposed as a result of the sequestration, it left in place the vast majority of the $1 trillion in sequestration cuts to many federal programs including the 2% cut in Medicare payments imposed earlier this year.

As has been frequently reported, serious discussions regarding a proposal to enact a full repeal of the SGR formula are occurring on a parallel track and will continue in early 2014.

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AMA ADVOCACY UPDATE

Thursday, November 14th, 2013

AMA submits recommendations to Senate Finance and House Ways & Means
Committees on repealing the SGR
On Oct. 30, the Senate Finance Committee and the House Ways and Means Committee released
a bipartisan, bicameral discussion draft proposal that “would permanently repeal the SGR update
mechanism, reform the fee-for-service (FFS) payment system through greater focus on value
over volume, and encourage participation in alternative payment models.” The AMA submitted
recommendations to the committees on Nov.11, to build upon and strengthen the draft proposal to
best achieve the shared goal of developing a new, more stable Medicare payment and delivery system
that supports high-quality care. The AMA will continue its advocacy efforts with the committees and all
members of Congress to shape and advance legislation this year to eliminate the SGR.
AMA, state and specialty societies urge CMS to intervene in Medicare
Advantage terminations
The AMA and 81 state and specialty societies sent a letter on Nov. 8, urging CMS to take immediate
action to ensure that beneficiaries participating in Medicare Advantage (MA) plans have accurate and
reliable information to make health insurance elections during the 2014 Open Enrollment period, and to
address a lack of MA sponsor transparency on network adequacy. The AMA, state medical associations,
and national medical specialty societies have been contacted by hundreds of physicians who have been
terminated from 2014 MA plan networks in certain markets. The terminations are “without cause” and
have been timed in a manner that undermines the accuracy and reliability of the information Medicare
beneficiaries rely upon to make important decisions about their 2014 health insurance coverage. The
timing and process used to communicate the terminations and modifications to the networks are
inconsistent with CMS guidance and regulations. The AMA, state and specialty societies urged CMS to act
to ensure that the program is transparent and equitable.

AMA submits recommendations to Senate Finance and House Ways & Means Committees on repealing the SGR

On Oct. 30, the Senate Finance Committee and the House Ways and Means Committee released a bipartisan, bicameral discussion draft proposal that “would permanently repeal the SGR update mechanism, reform the fee-for-service (FFS) payment system through greater focus on value over volume, and encourage participation in alternative payment models.” The AMA submitted recommendations to the committees on Nov.11, to build upon and strengthen the draft proposal to best achieve the shared goal of developing a new, more stable Medicare payment and delivery system that supports high-quality care. The AMA will continue its advocacy efforts with the committees and all members of Congress to shape and advance legislation this year to eliminate the SGR.

AMA, state and specialty societies urge CMS to intervene in Medicare Advantage terminations

The AMA and 81 state and specialty societies sent a letter on Nov. 8, urging CMS to take immediate action to ensure that beneficiaries participating in Medicare Advantage (MA) plans have accurate and reliable information to make health insurance elections during the 2014 Open Enrollment period, and to address a lack of MA sponsor transparency on network adequacy. The AMA, state medical associations, and national medical specialty societies have been contacted by hundreds of physicians who have been terminated from 2014 MA plan networks in certain markets. The terminations are “without cause” and have been timed in a manner that undermines the accuracy and reliability of the information Medicare beneficiaries rely upon to make important decisions about their 2014 health insurance coverage. The timing and process used to communicate the terminations and modifications to the networks are inconsistent with CMS guidance and regulations. The AMA, state and specialty societies urged CMS to act to ensure that the program is transparent and equitable.

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EMPIRE BC/BS Changing 2014 Medicare Advantage Individual Plans

Wednesday, October 30th, 2013

Medicare Advantage Outreach and Education Bulletin

Empire BlueCross BlueShield

We want you to know about changes to our individual Medicare Advantage HMO and LPPO plan service areas. These changes will take effect Jan. 1, 2014. Some plan service areas will be eliminated or reduced.

These service area changes do not impact your participation in the Medicare Advantage network.* Employer or union sponsored Medicare Advantage plan members are not affected by these changes. Empire Medicare Advantage member ID cards contain a CMS identifier in the lower right corner of the card. The number will be five characters (XXXXX) followed by three characters (XXX). The member is in an employer or union sponsored plan when the last three digits Start with an eight (8XX).

Empire will continue to offer Medicare Advantage HMO plans in Albany, Bronx, Kings, Nassau, New York, Putnam, Queens, Richmond, Rockland, Saratoga, Schenectady, Suffolk and Westchester counties. Empire will continue to offer Medicare Advantage LPPO plans in Albany, Bronx, Fulton, Kings, Nassau, Rensselaer, Richmond, Rockland, Saratoga, Schenectady, Schoharie and Suffolk counties. Specific plan changes by county are detailed below.

We will no longer offer Empire MediBlue Select HMO plans in Dutchess, Nassau, Orange, Sullivan and Ulster counties. We will reduce the service area of Empire MediBlue Essential HMO plans in Albany, Dutchess, New York, Orange, Putnam, Schenectady and Sullivan counties.

We will reduce the service area of Empire MediBlue Freedom I LPPO plans in Columbia, Delaware, Greene, Montgomery, Warren and Washington counties. We will reduce the service area of Empire MediBlue Freedom II LPPO plans in Clinton, Columbia, Essex, Fulton, Montgomery, Rensselaer, Suffolk, Sullivan, Ulster, Warren and Washington counties. We will reduce the service area of Empire MediBlue Freedom III LPPO plans in Albany, Greene, King, Rensselaer, Saratoga, Schenectady, Schoharie, Warren and Washington counties.

As of Oct. 1, 2013, Empire will not market Medicare Supplement plans. Members that currently participate in one of Empire’s Medicare Supplemental plans will be able to retain their coverage.

Prior to Oct. 2, 2013, Medicare Advantage members affected by these changes will receive a letter from us that explains their Medicare coverage options. Members will continue to have coverage through their current plans until December 31, 2013. It’s important to note that members may have a different network of providers and/or different benefit structure when switching from previous plans.

We are working with Centers for Medicare & Medicaid Services (CMS) to help ensure our members understand options for continuing their Medicare health insurance coverage.

We understand our members may contact their doctors’ offices with questions about their plan when they receive this notification. Our customer service representatives are available to assist them with their concerns. Members may call the customer service telephone number in the

letter they receive from us or they may contact our customer service through the number provided on the back of their member ID cards.

We are always evaluating our Medicare Advantage products to ensure that they meet our members’ needs for access, cost and quality.

If you have any questions, please contact your provider network manager.

* Providers who may receive termination notices for reasons other than service area reductions/eliminations are not impacted by this Notice.

Y0071_13_18026_I 09/03/2013

Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

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E&M “NEW PATIENT” TIP

Tuesday, October 22nd, 2013

New Patient” Visits by Same Physician or Physician Group: Overpayments

Medicare’s Common Working File (CWF) system detects erroneous billings when there are two new patient CPT codes being billed within a three-year period of time by the same physician or physician group. If Medicare discovers that a new patient code has been paid more than one time in a three-year period to the same physician, then Medicare Contractors will consider this an overpayment and will take steps to recoup the payment. If the situation is detected prior to payment of a second claim, the second claim will be rejected. Please share with appropriate staff.

Codes that are checked:

  • CPT codes: 99201-99205, 99324-99328, 99341-99345, 99381-99387, 92002, and 92004
  • The edits will also check to ensure that a claim with one of these new patient CPT codes is not paid subsequent to payment of a claim with an established patient CPT code (99211-99215, 99334-99337, 99347-99350, 99391-99397, 92012, and 92014).

New Patient Definition:
The ‘Medicare Claims Processing Manual,’ Chapter 12, Section 30.6.7 provides that ‘Medicare interpret the phrase ‘new patient’ to mean a patient who has not received any professional services (i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years). For example, if a professional component of a previous procedure is billed in a three-year time period (e.g., a lab interpretation is billed and no E/M service or other face-to-face service with the patient is performed, then this patient remains a new patient for the initial visit).’

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Access to Jurisdiction K Local Coverage Determinations during the Federal Government Shutdown

Friday, October 11th, 2013

Access to Jurisdiction K Local Coverage Determinations during the Federal Government Shutdown

The Centers for Medicare & Medicaid Services (CMS) Coverage Database will not be updated on its usual weekly basis during the federal government shutdown. In the event that the shutdown continues through the Jurisdiction (JK) transition dates of October 18 and October 25, 2013, the JK local coverage determinations (LCDs) will be effective on the transition dates even if they are not viewable as “Active” LCDs for their respective effective dates. These LCDs are currently listed on the “Future” LCD index for the JK states and will continue to be available from that index.

For access to the JK LCDs, use this link: JK LCDs. This will take you to the Index for Maine Part A. The LCDs listed here are the same for all JK states, Part A and Part B.

For access to the JK home health and hospice (HH&H) specific LCDs, use this link: HHH LCDs Effective October 18, 2013.

These links can also be found on the Jurisdiction K Transition Information Web site at http://www.ngsmedicare.com/wps/portal/ngsmedicare/jktransition.

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New Requirements for All Billing Providers to Begin on August 22, 2013

Thursday, August 8th, 2013

As previously announced the NYS Department of Health will soon require all billing providers to sign up for electronic funds transfer (EFT) payments and either Electronic Remittance Advice (ERA) or a PDF version of the paper remittance delivered via eMedNY eXchange.

This requirement will apply to existing providers as their current ETIN Certification is renewed over the next year. The recertification notices sent by eMedNY will alert providers if they are required to sign up for EFT and/or ERA or PDF remittances.
For new providers who submit enrollment applications as of August 23, 2013. Please visit www.emedny.org on or after this date for information and instructions for enrolling new providers. Please pay careful attention to the new requirement for a Certification Statement and an EFT Application to accompany each new enrollment packet for billing providers. For more information click here.

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Energy and Commerce Health Subcommittee Approval of SGR Repeal Bill

Wednesday, July 24th, 2013

FOR IMMEDIATE RELEASE                                                                  July 23, 2013

AMA: In Reforming Medicare, Details Matter

Physicians urge lawmakers to ensure sustainable resources, not increase administrative burden

Statement attributable to: Ardis D. Hoven, MD

President, American Medical Association

“The American Medical Association (AMA) is pleased that the Energy and Commerce Committee and other congressional leaders continue their work to end the broken Medicare physician payment system this year and move toward a Medicare program that rewards high quality care for our nation’s senior citizens and reduces costs. There is clear bipartisan support for fixing this failed formula and making improvements in the program, but the details matter considerably and there is still work to be done to ensure a strong future for Medicare.

“When crafting new payment systems, lawmakers must ensure that funding for Medicare’s payments to physicians is sufficient to allow for sustainable practice environments that give physicians the ability to invest in new ways of improving care for patients. This includes maintaining budget neutrality related to adjustments to correct misvalued codes as part of that ongoing process. Changes to quality reporting requirements should build on the existing system rather than attempting to implement a new regimen that adds administrative burdens and could distract from more effective efforts to improve patient care.

“The AMA and 110 other physician organizations have developed principles for transitioning Medicare to include an array of payment models that allow physicians the flexibility to choose options that will help lower costs and improve the quality of care for patients. We will continue to work with the committee to achieve the best Medicare system for patients and physicians.”

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