unleash your medicare super powers! · • numbered mmxxxx or sexxxx –web-based training courses...
TRANSCRIPT
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Unleash Your Medicare Super Powers!
Presented by Mary E. Muchow, Michigan Third Party Payer Day
October 30, 2015 – Mt. Pleasant, MI
Disclaimer
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WPS Medicare has produced this material as an informational reference. Every reasonable effort has been made to ensure the accuracy of this information at the time of publication, however, WPS Medicare makes no guarantee that this information is error-free and bears no liability for the results or consequences of the misuse of this information. The provider alone is responsible for correct submission of claims. The official Medicare Program provisions are contained in the relevant laws, regulations and rulings and can be found on the Centers for Medicare & Medicaid Services (CMS) website at www.cms.gov.
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Agenda
• Changes for WPS Medicare
• Medicare Learning Network (MLN)
• Place of Service (POS) Codes
• National Site Verification (NSV) Initiative
• Limitation on Scope of Review on Redetermination and Reconsideration of Certain Claims
• CMS Secure Net Access Portal (C-SNAP) Enhancements
• Insufficient Documentation
• Nuggets
• Resources
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Changes for WPS Medicare
• Have you noticed our new name/look?
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Medicare Learning Network
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MLN General Information
• CMS home for education, information and resources
• Offers MLN education Products, including
– MLN Matters® articles
• Numbered MMXXXX or SEXXXX
– Web-based training courses (some offer Continuing Education Units)
– MLN Connects®
• National Provider Call Program
• Provider eNews
• Provider electronic mailing lists
• More
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New and Revised Place of Service Codes (POS)
for Outpatient Hospitals
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MLN MM9231
• Effective January 12, 2016; implemented January 4, 2016
• Adds POS code 19 for “Off Campus-Outpatient Hospital and revises POS code 22 from “Outpatient Hospital” to “On Campus-Outpatient Hospital;” and
• Makes minor corrections to POS 17 (Walk-in Retail Health Clinic) and 26 (Military Treatment Facility)
• Includes additional information related to POS codes 19 and 22
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National Site Visit Verification (NSV) Initiative
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MLN SE1520
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• NSV is part of the CMS Fraud Prevention Initiative and assists in CMS efforts to prevent fraud and abuse in the Medicare program, starting with the enrollment process
– MSM Security Services, LLC and its subcontractors will perform either site visits or detailed reviews to verify enrollment related information and collect specific information based on pre-defined checklists and procedures determined by CMS
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Seeking Verification?
• To verify that a site visit has been ordered by CMS, contact your MAC
• To verify that an inspector is credentialed to complete a site verification (inspectors will possess a photo ID and an authorization letter from CMS), call MSN Security Services
– 855-220-1071; 7:00 AM – 8:00 PM ET
– Leave message after 8:00 PM ET for next business day callback
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Limiting the Scope of Review on
Redeterminations and Reconsiderations of
Certain Claims
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Who preforms the redetermination or
reconsideration level of an appeal?
• Redetermination (1st level appeal)
– Performed by Medicare Administrative Contractor (MAC)
• Reconsideration (2nd level appeal)
– Performed by Qualified Independent Contractor (QIC)
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MLN SE1521
• Applies to redetermination or reconsideration requests received by MACs or QICs on or after August 1, 2015
• For appeal of claims following a post-payment review or audit, the MAC or QIC will limit review to the reason(s) the claim or line item at issue was initially denied
– Includes claims initially paid by Medicare and subsequently reopened and reviewed by, for example, a Zone Program Integrity Contractor (ZPIC), Recovery Auditor (RA) , MAC, or Comprehensive Error Rate Testing (CERT) contractor
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National Site Verification MLN SE1521
(continued)
• For appeal of claims following a pre-payment basis, MACs or QICs may continue to develop new issues and evidence at their discretion and may issue unfavorable decisions for reasons other than those specified on the initial determination
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Insufficient Documentation
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*Wikipedia lists 360 delivered “Holy…” exclamations by Robin, most directly related to the plot.
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Medicare Fee-For-Service 2014 Improper
Payments Report
• Insufficient documentation main driver of projected improper payments
– 8.2% of total errors, compared to 6.1% of total errors for 2013
– $29.49 billion
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Proportion of Improper Payments Attributed to
Insufficient Documentation by Clinical Setting
(for 2014 report period)
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WPS GHA Michigan Part B Providers
• Insufficient Documentation errors assessed by the Comprehensive Error Rate Testing (CERT) contractor
– January through March 2015 – 69% of total errors
– April through June – 74% of total errors
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C-SNAP Enhancements
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C-SNAP Enhancements
• Make corrections to existing Part B claims through the Clerical Error Reopen function
• Upload documentation in response to Additional Documentation Request (ADR) letters
• Upload Part B appeals attachments and check status of Part A or Part B appeal requests
• Submit a refund electronically to Medicare for either a voluntary overpayment or one requested by Medicare
• Search for the status of any refunds submitted via C-SNAP
• More!
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Nuggets
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HIPAA Standards – Health Care Provider
Taxonomy Code (HPTC)
• Standards implementation guide states that the HPTC information is
– “Required when the payer’s adjudication is known to be impacted by the provider taxonomy code” and “If not required by this implementation guide, do not send.”
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Medicare - HPTCs
• Medicare does not use HPTCs to adjudicate claims
– No expectation to see HPTCs on claims
– If used, Medicare will validate any HPTC that a provider happens to supply against the National Uniform Claim Committee HPTC code set
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Medicare Advantage (MA) – Part C
• WPS GHA is unable to address coverage/payment issues for beneficiaries enrolled in Part C plans
– Contact the Medicare Advantage plan directly
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Recovery Auditor (RA) Update
• Effective June 4,2015, CMS has withdrawn the Requests for Quotes for the next round of RA contracts
• CMS to update Statement of Work and release new Requests for Proposals
• Meanwhile, current RAs will continue active recovery auditing through at least December 31, 2015
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Resources
• WPS GHA Website Portal
– www.wpsmedicare.com
• MLN General Information Web Page
– https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index.html
• MM9231
– https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9231.pdf
• SE1520
– https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1520.pdf
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Resources (continued)
• SE1521
– https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1521.pdf
• C2C Solutions - QIC Part B North Website
– https://www.c2cinc.com/QICPartBNorth.aspx
• CMS Medicare Fee-For-Service 2014 Improper Payments Report
– https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Downloads/MedicareFeeforService2014ImproperPaymentsReport.pdf
• C-SNAP Website
– www.medicareinfo.com
• CGI Federal - Recovery Auditor Website
– https://racb.cgi.com/default.aspx
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Thank you for your attention!
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Sometimes, you gotta wake-up,Look in the mirror, and say…
“I’m going to rock today!”