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Friday, February 25, 2011

From CMS, the better late than never department

Like the buddy who swears he will pay you the $20 he borrowed from you months ago, the Centers for Medicare and Medicaid Services (CMS) announced recently that it will finally reprocess a large number (i.e., hundreds of millions) of Medicare fee-for-service claims to account for retroactive Medicare payment increases implemented in 2010.  The AAFP and others had urged CMS as recently as December to make good on its debt

On Mar. 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act. Various provisions of the new law were effective Apr. 1, 2010, or earlier and, therefore, were implemented some time after their effective date. In addition, corrections to the 2010 Medicare Physician Fee Schedule (MPFS) were implemented at the same time as the Affordable Care Act revisions to the MPFS, with an effective date retroactive to Jan. 1, 2010.

Due to the retroactive effective dates of these provisions and the MPFS corrections, a large volume of Medicare fee-for-service claims need to be reprocessed.  This week, CMS staff stated on their monthly Open Door Forum for physicians, nurses, and allied health professionals that Medicare contractors will start reprocessing those claims within two weeks, while taking steps to ensure that new claims are accurately processed going forward.  CMS also issued a public notice to this effect. 

In most cases, no requests for adjustments are necessary, as the Medicare contractor will automatically reprocess the claims.  Only claims that include services with submitted charges that are lower than the revised 2010 fee schedule amount cannot be automatically reprocessed.  For those claims, you will need to request a reopening or adjustment. CMS has stated that in this situation, it will waive the normal one-year time limitation for the request for reopening claims, as this meets the “good cause” exception.

CMS has requested that claims not be resubmitted, because they will be denied as duplicate claims. CMS also reminded physicians of the Office of Inspector General's (OIG) policy related to waiving beneficiary cost-sharing amounts attributable to retroactive increases in payment rates based on the operation of new federal statutes or regulations. Specifically, physicians and other providers will not be subject to OIG administrative sanctions if they waive beneficiary liability in this situation, if they follow the criteria in the OIG policy statement.

It is unlikely that you will get all of the money that Medicare owes you all at once.  Adjustments owed to you will be added to future remittance advices as the 2010 claims are reprocessed.  If you have any questions in this regard, CMS advises you contact your local Medicare contractor. 

In the meantime, it might be time to see that buddy about the $20 he owes you. 

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The views expressed here do not necessarily reflect the opinion of FPM or the AAFP. Some payers may not agree with the advice given. This is not a substitute for current CPT and ICD-9 manuals and payer policies. See Terms of Use.

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