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Tuesday, June 28, 2016

CMS places some limits on review of Medicare claim denials

If you’ve ever appealed a Medicare claim denial only to see it struck down for new reasons that the reviewers found in the course of their review, help may be coming.

The Centers for Medicare & Medicaid Services (CMS) recently told its Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) to change how they review certain claim denials. Specifically, CMS says they should limit their review of redeterminations and reconsiderations of claims denied following a complex prepayment review, a complex post-payment review, or an automated post-payment review to the reason or reasons the claim or line item was denied in the first place.  

CMS acknowledged that MACs and QICs generally have discretion while conducting appeals to develop new issues and review all aspects of coverage and payment related to the claim or line item. As a result, while the original reason for the denial may be resolved, this expanded review may result in a denial of the appeal for new reasons. The revised instructions prohibit the contractors from doing that in certain situations, which is good news for physicians and others who initiate such appeals.

However, MACs and QICs will still have the discretion to develop new issues and evidence for claims denied as a result of automated pre-payment review. MACs will also continue to follow existing procedures for adjusting claims after successful appeals, meaning CMS will process the adjustments and may suspend them because of system edits. Claim adjustments that remain unpaid because of additional system-imposed limitations (e.g., frequency limits or Correct Coding Initiative edits) may result in new denials with full appeal rights.

In addition, if a MAC or QIC conducts an appeal of a claim or line item that was denied on pre- or post-payment review because of insufficient documentation, the contractor will review all applicable coverage and payment requirements for the item or service at issue, which means the claim could subsequently be denied for lacking medical necessity. If you receive requests for additional documentation, please be careful to respond quickly and completely to prevent the possibility of expanded review of the whole claim.

Finally, CMS is applying the new guidance only to appeals received by a MAC or QIC on April 18 or later. Prior denials based on expanded evidence will not be reopened.

As noted, the CMS guidance provides some good news to physicians and other providers of Medicare services. But CMS has placed a number of limits on this guidance, and you will need to be aware of the phase and type of review (e.g., pre- or post-payment, automated or complex) to which a claim is subject and consider the possibility of subsequent system edits and denials when determining whether to appeal.   

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Friday, June 24, 2016

Make sure to recertify EIDM users by June 30

Time is running out if your practice hasn’t recertified its user accounts in the Enterprise Identity Management (EIDM) system. Letting those accounts lapse could complicate reviewing your Quality and Resource Use Reports (QRURs) later.

Individual practitioners and providers’ security officials (SOs) have until June 30 to log into the system and recertify who in the practice has the right to access the system. The Centers for Medicare & Medicaid Services (CMS) requires users to recertify annually. Failure to recertify user roles will result in those roles being revoked. Once revoked, the user must go through the process of requesting the role from the SO or individual practitioner again.

The SO and individual practitioners can log into the CMS Enterprise Portal using existing credentials and access the list of users who require recertification. The list is located under the “View and Manage Access” page under the “Annual Certification” link on the left-hand side of the screen. If you experience issues, you can contact the QualityNet Help Desk at 1-866-288-8912. The QualityNet Help Desk can also tell you who the SOs are for your Tax Identification Number (TIN).

Maintaining access to the EIDM system is critical for the QRUR. CMS releases a mid-year QRUR and an annual QRUR. The 2015 mid-year reports were released in April, while the 2015 annual reports will be available in the fall. These reports provide information on a TIN’s performance on cost and quality measures. Practices can use the QRUR to review their performance and identify areas where improvement may be needed. Reviewing today will help practices prepare for the implantation of the Medicare Access and CHIP Reauthorization Act (MACRA).

– Erin Solis is the Regulatory Compliance Strategist at the American Academy of Family Physicians

Thursday, June 23, 2016

How much can you charge patients for their health information?

The Office for Civil Rights (OCR) within the U.S. Department of Health and Human Services recently addressed patients’ rights to access their protected health information (PHI) under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Much of the guidance focuses on the fees that a covered entity, such as your practice, may charge patients requesting copies of their own PHI.

According to OCR, you can charge patients for:

1.    labor costs (including preparation of an explanation or summary when agreed to by the individual)
2.    supply costs related to the creation of either the electronic or paper copy (e.g., paper, toner, CD, or USB drive)
3.    postage costs when the individual requests the information be mailed

The OCR guidance indicates that permissible labor costs may include only the labor “for creating and delivering the electronic or paper copy in the form and format requested or agreed upon by the individual, once the PHI that is responsive to the request has been identified, retrieved, or collected, compiled and/or collated, and is ready to be copied.” (Emphasis added) That means you cannot charge for reviewing the request or searching for and retrieving the information.

The OCR also emphasizes that you may not charge individuals for system maintenance, data storage and maintenance, or the administrative costs associated with outsourcing your office’s response to requests for PHI. OCR further notes that if you use systems that allow individuals to access their PHI through electronic health record technology, you may not charge labor or supply costs.

The OCR guidance says that when calculating the fees you charge, they may reflect your actual costs, your average costs, or a flat fee. If using actual costs, they must be reasonable and calculated upon each request. OCR says that you can charge average costs as a standard rate (e.g., a per-page fee if you maintain the requested PHI in paper form and the individual requests a paper copy). The OCR adds that “per page fees are not permitted for paper or electronic copies of PHI maintained electronically.” Finally, you can charge a flat fee but only for electronic copies of electronically maintained PHI, and the flat fee cannot exceed $6.50.

Regardless of the fee method used, you must notify individuals in advance of any fees that could be charged for their requests for PHI at the time the details of the request are being arranged. Failure to provide such notice could potentially be a HIPAA violation.

If a patient requests that you send their PHI to a third party, you must treat that request the same under HIPAA as if the patient were requesting it be sent to them directly. However, if a third party initiates the request for PHI, the limitations on copying fees do not apply. So, you should ask whether the request was a direction from the patient or a request from a third party.

Finally, the OCR guidance discusses the relationship between HIPAA and state law. Specifically, when it comes to an individual's right to access his or her own PHI, HIPAA trumps state law if HIPAA provides individuals with greater access to their PHI. That means if your state law allows you to charge higher fees or to limit an individual’s access, HIPAA will preempt that state law.

Needless to say, now may be a good time to review your policies and procedures for granting access to individuals’ PHI, including whether and how you charge for copies of that information.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

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