New time limit for filing Medicare claims

Historically, as authorized by statute and the Centers for Medicare and Medicaid Services (CMS), physicians had a minimum time limit for filing Part B claims of 15 months and a potential maximum of 27 months after the service was furnished, depending on the month of the year when the service was furnished. Section 6404 of the Patient Protection and Affordable Care Act (PPACA) changed that by requiring that all claims for services furnished on or after Jan. 1, 2010, must be filed within one calendar year after the date of service, while claims for services furnished before Jan. 1, 2010, must be filed on or before Dec. 31, 2010. In its proposed rule on the 2011 Medicare physician fee schedule, which I mentioned in my previous post (see "Looking ahead to the 2011 Medicare physician fee schedule"), CMS proposes to amend its regulations to be consistent with the statutory changes imposed by the PPACA. 

In the past, CMS had one exception to the timely filing limit. That exception applied when the failure to file “...was caused by error or misrepresentation of an employee, intermediary, carrier, or agent of the Department that was performing Medicare functions and acting within the scope of its authority.” Consistent with the authority provided in Section 6404 of the PPACA, CMS proposes to create two new exceptions.

The first new exception would apply when CMS or one of its contractors determines that the following conditions have been met:

• At the time the service was furnished the beneficiary was not entitled to Medicare; and
• The beneficiary subsequently received notification of Medicare entitlement effective retroactively to or before the date of the furnished service.

The second new exception would apply when CMS or one of its contractors determines that all of the following conditions have been met:

• At the time the service was furnished the beneficiary was not entitled to Medicare;
• The beneficiary subsequently received notification of Medicare entitlement effective retroactively to or before the date of the furnished service; and
• A state Medicaid agency recovered the Medicaid payment for the furnished service from the provider or supplier 11 months or more after the date of service.

In the case of the first new exception, the time to file a claim would be extended through the last day of the 6th calendar month following the month in which the beneficiary received notification of Medicare entitlement effective retroactively to or before the date of the furnished service. In the case of the second new exception, the time to file a claim would be extended through the last day of the 6th calendar month following the month in which the state Medicaid agency recovered the Medicaid payment for the furnished service from the provider or supplier.

For the existing exception, the extension of time is the last day of the 6th calendar month following the month in which the error or misrepresentation is corrected. However, no extension of time will be granted when the request for this particular exception is made to CMS or one of its contractors more than four years after the date of service, consistent with current CMS policy. CMS does not propose to define “date of service” and instead intends to provide “sub-regulatory” guidance on what constitutes the date of service for different services.

CMS's proposals are generally consistent with PPACA, and the proposed additional exceptions are welcome. However, one has to question why CMS is only granting six months for the extended time limit that it proposes for each exception. The PPACA provision essentially provides physicians and others with a 12-month period in which to file claims for services for which they have reason to believe Medicare may be responsible. However, in the exceptions proposed by Medicare, the physician only has six months to file a claim after he or she becomes aware of Medicare’s responsibility. Consistency with PPACA would suggest that the time to file a claim under each exception should be extended through the last day of the 12th month following the month in which the exception applies.

Also, as regards the exception due to error or misrepresentation on the part of Medicare, one would think the extended time limit should be based on the month in which the error or misrepresentation is corrected and the physician has been notified of that fact. As proposed, the extended time limit begins when the error or misrepresentation is corrected, without apparent regard to whether the physician is aware of that fact. Recognizing that there may be some time between when the error or misrepresentation is corrected and when the physician is notified of this fact, it is at the latter point (i.e., the point at which the physician becomes aware of the correction) that the extended time limit should begin from a physician perspective.

Finally, there is a question that CMS does not address with respect to the exception based on retroactive beneficiary enrollment. Namely, the extended time limit commences with notification of the Medicare beneficiary regarding his or her retroactive entitlement effective date. However, if the beneficiary does not, in turn, notify the physician of the retroactive entitlement until after the extended claims filing time limit expires, does the beneficiary remain responsible for payment of the service? Hopefully, CMS will address this question in the final rule.

In the meantime, if you have yet to file a claim for dates of service before 2010, you have until the end of the year to do so, and the 12-month clock is ticking to file claims for services provided this year.

Posted at 03:19PM Jul 30, 2010 by Kent Moore  |  Comments[0]

Don't let PECOS put your practice in a pickle

Many of you have received so many notices from medical supply and home health services advising physicians to update their Medicare enrollment information that you could paper an exam room with them. These notices are correct in stating that federal law requires that claims for supplies and for referred services contain the name and National Provider Identifier (NPI) of the ordering or referring physician and that Medicare contractors who pay these claims must confirm whether the ordering/referring physician has a valid enrollment record in the Provider Enrollment, Chain, and Ownership System (PECOS). However, these notices have also contained some misinformation and caused some confusion. I hope I can clear this up a bit.

First, PECOS is an enrollment system that the Centers for Medicare & Medicaid Services (CMS) adopted for enrolling physicians and other eligible providers in 2003. Physicians who enrolled in Medicare prior to 2003 may not have an enrollment record in PECOS and must go through the enrollment process again to create a PECOS record. CMS has recognized that there are issues with their enrollment process and that many physicians have had difficulty enrolling in PECOS online. In response, CMS has delayed the July 6 activation of edits that would have resulted in denial of claims for supplies or services ordered by a physician not enrolled in PECOS.

Second, physicians who have opted out of Medicare can order supplies and services for their Medicare patients. CMS requires that Medicare contractors establish a PECOS record for physicians with a valid opt-out affidavit. Physicians who have opted out can contact their Medicare contractor to verify their PECOS record.

Physicians who work in specific settings where their services are not typically billed to Medicare should follow CMS guidance when enrolling; the requirements are reduced. Examples of physicians who may take advantage of this guidance are those who practice in public health settings, Tricare, the Veterans Administration, federally qualified health centers and fellowship settings.

If you are not sure whether you have an active enrollment record in PECOS, you can contact your local Medicare contractor or check for your name and NPI on CMS' Ordering/Referring Report. Note that the Ordering/Referring Report will be continuously updated by CMS as many enrollment applications are still in process. If you know that you have recently received approval of your enrollment application from your Medicare contractor but your name is not on Ordering/Referring Report, you should feel comfortable ignoring any PECOS-enrollment-related supplier notices that you might continue to receive. However, if your application has not yet been approved, be sure your staff frequently check the status, as any missing information or documentation can result in your application being returned or eventually rejected.

This enormous undertaking of updating hundreds of thousands of Medicare enrollment applications is in part an effort to reduce the number of fraudulent claims filed under the names of unsuspecting physicians or even deceased or non-existent physicians. Hopefully, the current massive investments in investigating and ending fraud will lead to lesser burdens on the physicians, providers and suppliers who just want honest pay for providing necessary services.

On the other hand, it may just lend credence to Celine's third law: "It is only through honest politicians trying to change the world through laws that true tyranny can come into being through excessive legislation."

Posted at 03:29PM Jul 20, 2010 by Cindy Hughes  |  Comments[0]

Looking ahead to the 2011 Medicare physician fee schedule

While the fate of the 2010 Medicare physician fee schedule is temporarily settled, it is time to look ahead to 2011. 

On July 13, the Centers for Medicare and Medicaid Services (CMS) published its proposed rule on the 2011 Medicare physician fee schedule in the Federal Register. The proposed rule covers a wide array of topics, including changes in Medicare fees, updates to existing Medicare programs (like the Physician Quality Reporting Initiative and e-prescribing incentive payments), and implementation of some provisions of the Patient Protection and Affordable Care Act. 

The bottom-line, good news in the proposed rule is that CMS estimates family physicians will see a 1 percent increase in their Medicare allowed charges in 2011 as a result of changes proposed in the rule, all other things being equal. That is not much, but it is better than the decreases estimated for many other specialties. Of course, any gains could be washed away if Congress and the President do not act to avert the scheduled cut of 21 percent in the Medicare payment rate that will be effective Dec. 1, 2010, under current law.

As in any proposed federal regulation, "the devil is in the details," and I and other AAFP staff are poring over those details in preparing an AAFP response to the proposed rule.  I'll share more on those details in a future post. 

In the meantime, feel free to peruse the proposed rule yourself and share your comments here.

Posted at 02:55PM Jul 16, 2010 by Kent Moore  |  Comments[0]

Have you seen your Medicare "raise"?

It's official. The Medicare Physician Fee Schedule is updated with a 2.2 percent increase for services from June 1, 2010, through Nov. 30, 2010. After failing once again to address the flawed SGR methodology that creates these expensive and cumbersome short-term fixes, Congress passed and the President signed this latest legislation on June 24. But have you seen the money?

If not, it should be forthcoming in short order. The Centers for Medicare & Medicaid Services (CMS) responded promptly to the fix with a message to its contractors to stop paying claims with dates of service after June 1 at the 21.3 percent cut enacted on that date and to hold those claims until the new rates were loaded into the payment system and tested. Claims held during this period will be processed as quickly as possible in the order received, according to CMS. (Some members of the AAFP coding discussion list report having already received payments that reflect the increase.)

In addition to watching for claims paid under the updated fee schedule, your staff may be dealing with claims that were previously paid at the reduced rate and reprocessed to pay the difference. These claims may present some challenges as the co-insurance amounts increase along with the amounts paid by Medicare. Some secondary payers may receive the adjusted Medicare payment notices electronically and automatically pay the difference in co-insurance; others will not. Likewise, any co-insurance due from a patient would increase.

So if you have a patient who previously paid their co-insurance at the reduced level, do you have to send out a statement for an $2 or $3? Not necessarily. The Office of the Inspector General has also responded to the change in fee schedules by issuing guidance that indicates they will not penalize physicians who choose not to bill patients for the difference as long as this is under a policy that applies equally to all Medicare patients or offered in response to financial hardship and does not relate to any kind of inducement to receive more services. Bottom line: If it will cost you more in staff time, printing and postage than the amount being billed, you may want to either write-off the amount or hold the patient balance and bill it when additional charges are incurred.

In the meantime, we will be watching Congress for a solution before Nov. 30, but don't hold your breath. This is an election year. 

Posted at 09:50AM Jul 08, 2010 by Cindy Hughes  |  Comments[0]