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American Academy of Family Physicians
Wednesday Mar 17, 2010

CMS extends cease fire on referring/ordering edits

This posting is in follow-up to "CMS issues a temporary cease fire," a posting from last December.  I am happy to announce that the Centers for Medicare and Medicaid Services (CMS) has extended the delay in implementation of new rules that give Medicare the authority to reject claims for services or supplies when the ordering physician or health care professional is not enrolled in the Medicare Provider Enrollment, Chain, and Ownership System, or PECOS. The agency is delaying implementation of the new policy until Jan. 3, 2011. 

As of this new date, Medicare will reject claims if the ordering or referring provider does not have an active enrollment record in Medicare’s PECOS or is not of the correct type/specialty to order or refer services to Medicare beneficiaries.  Currently, physicians who submit electronic claims receive a warning message if the ordering/referring provider is not in PECOS or is in PECOS but is not the correct type/specialty to order or refer services.  Despite the warning, the claims hitting these edits will continue to process.  However, such claims will be rejected starting Jan. 3, 2011.

CMS recently posted on its web site the Ordering/Referring Report, a list of physician and non-physician providers who are eligible to order or refer items or services for Medicare beneficiaries because they have an active enrollment record in PECOS and are of a right specialty or type to order or refer items or services.  Physicians and non-physician providers are encouraged to check this list to make sure that they are on it. If not, they need to submit an 855I Provider Enrollment form to their local Medicare contractor and update their enrollment information to have an active enrollment record. This can be done through the on-line, Internet-based PECOS or by mailing a paper application to the local Medicare contractor.

Please see MLN (Medicare Learning Network) Matters article MM6417 for additional information on this initiative as well as for a complete list of types of practitioners who can order or refer Medicare beneficiaries for items or services.

Friday Mar 05, 2010

Fraud, waste and abuse training: What do they want now?

The messages insurers send to physicians regarding government requirements that they complete fraud, waste and abuse training (also referred to as FWA training) are about as clear as mud. Referencing terms such as "downstream, first tier, and related entities," these requests make even a seasoned reader of the Federal Register say "Huh?" If you don't have any dealings with Medicare Advantage plans, you can skip to the last paragraph. For everyone else, here's a translation:

When Congress put forth the Part D prescription benefit program, some changes to the Medicare Advantage (Part C) program were included. Among these were requirements for Part D and Medicare Advantage contractors to develop compliance programs that incorporate measures to detect, prevent, and correct fraud, waste, and abuse.

The Centers for Medicare & Medicaid Services (CMS) then published rules that defined what these compliance programs must include and who must complete them. This is where the "downstream, first tier, and related entities" come in. The Medicare Advantage contractors were instructed to apply their training and education and effective lines of communication requirements to their first tier, downstream, and related entities. Without going into Medicare language, if you contract with a Medicare Advantage plan or provide administrative or health care services to a group that has a contract with a Medicare Advantage plan, you meet one of the definitions, and your practice must complete a FWA training program.

Here's why this is no big deal:
You should already have a compliance program in your practice that includes fraud, waste, and abuse training but even if you don't, there are relatively pain-free versions available for free from Medicare Advantage contractors and the Medicare Learning Network (see the web-based training section). Once you and your staff have completed one FWA training program, you can just complete attestation statements for any Medicare Advantage plan that asks you to complete a program.

The hassle of attestation may soon go away. CMS has recently proposed to modify the fraud training requirement to state that physicians and other providers who have met this requirement through enrollment into the Medicare program are deemed to have met it for Medicare Advantage purposes. The AAFP and multiple other organizations have signed onto a letter supporting this proposal.

Even if you are not participating in Medicare Advantage plans, you still should have a compliance document that outlines expectations and provide training for everyone on your staff (clinicians and administrative staff). A simple first step might be to adopt a Code of Conduct that each person must read and sign upon employment and periodically thereafter. Your practice can be held responsible for what you know or should have known; demonstrating that you are aware of the rules and have attempted to comply may go a long way toward defending your practice if you find yourself in hot water. One word of caution: Don't adopt a compliance document and then not follow it. That could be construed as showing intent to act wrongfully.

Wednesday Mar 03, 2010

2010 Medicare physician fee schedule: What next?

When we last left the 2010 Medicare physician fee schedule (see "2010 Medicare physician fee schedule: the saga continues," Jan. 27, 2010), it was headed down the tracks towards a "Bridge Out!!" sign after Feb. 28. For those of you who don't follow this story on a day-to-day basis, here is what's happened in the interim. 

As typically happens in this story, Congress tried to avert calamity by passing a stop-gap bill just before Feb. 28, 2010. Unfortunately, Sen. Jim Bunning (R-KY) decided to play Snidely Whiplash in this particular installment and used Senate procedures to prevent Congressional action in advance of the deadline. Consequently, Feb. 28 came and went without Congressional intervention, and the fee schedule dropped on March 1. 

Seeking to play Dudley Do-Right in our story, the Centers for Medicare and Medicaid Services (CMS) bravely threw the fee schedule a lifeline and instructed its contractors to hold all Medicare claims with dates of services on or after March 1 for 10 business days to give Congress one more chance. On March 2, Congress and the President took advantage of that lifeline and enacted legislation (H.R. 4691) that extends the 2009 Medicare payment rate through the end of March. This effectively postpones any cut in the 2010 Medicare physician fee schedule until Apr. 1, 2010 – April Fools' Day.  (Coincidence or cruel irony? You decide.)

So now, the 2010 Medicare physician fee schedule will float along at the 2009 rate through at least the end of March, at which point it is scheduled to plunge over the falls to a precipitous 21 percent decline. Will CMS once again be called upon to throw the fee schedule a lifeline? Will Congress be able once again to rescue the fee schedule before total disaster strikes? And how many physicians will stick it out (instead of opting out) to see what happens? Stay tuned! 

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