Sunday, January 18, 2015

End Stage Renal Disease Facility Providers

This page provides basic information about being certified as a Medicare and/or Medicaid End Stage Renal Disease (ESRD) provider and includes links to applicable laws, regulations, and compliance information.
ESRD is that stage of renal impairment that appears irreversible and permanent, and requires a regular course of dialysis or kidney transplant to maintain life.

Types of ESRD Facilities:

•    Renal Transplantation Center
A hospital unit which is approved to furnish, directly, transplantation and other medical and surgical specialty services required for the care of ESRD transplant patients, including inpatient dialysis furnished directly or under arrangement.  A renal transplantation center may also be a renal dialysis center.
•    Renal Dialysis Center
A renal dialysis center is a hospital unit that is approved to furnish the full spectrum of diagnostic, therapeutic, and rehabilitative services required for the care of ESRD dialysis patients (including inpatient dialysis furnished directly or under arrangement and outpatient dialysis).  A hospital need not provide renal transplantation to qualify as a renal dialysis center.
•    Renal Dialysis Facility
A renal dialysis facility is a unit that is approved to furnish dialysis service(s) directly to ESRD patients.
•    Self Dialysis Unit
A self-dialysis unit is a unit that is part of an approved renal transplantation center, renal dialysis center, or renal dialysis facility, and which furnishes self-dialysis services.

ESRD Application Requirement

Filing of Application
To establish eligibility to provide ESRD services under Medicare, an applicant must complete Part I of the End Stage Renal Disease Application and Survey and Certification Report, Form CMS-3427.
Application must be made:
•    To request initial approval;
•    To request expansion or addition of stations;
•    For change in location;
•    For change of ownership (CHOW).  Ownership means the responsibility and liability for operational decisions of a health care enterprise.  A CHOW only occurs when there is a change in the identity of the governing body having ultimate operational responsibility for carrying out ESRD care in the facility; and/or
•    For change in service(s) provided, including reuse.

The State Survey Agency certifies compliance with health and safety standards, using the Survey Procedures and Interpretive Guidelines for End Stage Renal Disease Facilities.  Additional statutory and regulatory requirements include furnishing data and information for ESRD program administration, and participation in network activities.  The State Survey Agency assists the CMS Regional Office in gathering specified information relating to these regulations.

Wednesday, January 7, 2015

who is Home Health Providers

This page provides basic information about being certified as a Medicare and/or Medicaid home health provider and includes links to applicable laws, regulations, and compliance information.

A Home Health Agency (HHA) is an agency or organization which:
•    Is primarily engaged in providing skilled nursing services and other therapeutic services;Has policies established by a group of professionals (associated with the agency or organization), including one or more physicians and one or more registered professional nurses, to govern the services which it provides;
•    Provides for supervision of above-mentioned services by a physician or registered professional nurse;
•    Maintains clinical records on all patients;
•    Is licensed pursuant to State or local law, or has approval as meeting the standards established for licensing by the State or locality;
•    Has in effect an overall plan and budget for institutional planning;
•    Meets the federal requirements in the interest of the health and safety of individuals who are furnished services by the HHA; and
•    Meets additional requirements as the Secretary finds necessary for the effective and efficient operation of the program.
For purposes of Part A home health services under Title XVIII of the Social Security Act, the term “home health agency” does not include any agency or organization which is primarily for the care and treatment of mental diseases.

A Home Health Agency may be a public, nonprofit or proprietary agency or a subdivision of such an agency or organization.

1.    Public agency is an agency operated by a State or local government.  Examples include State-operated HHAs and county hospitals.  For regulatory purposes, “public” means “governmental.”
2.    Nonprofit agency is a private (i.e., nongovernmental) agency exempt from Federal income taxation under §501 of the Internal Revenue Code of 1954.  These HHAs are often supported, in part, by private contributions or other philanthropic sources, such as foundations.  Examples include the nonprofit visiting nurse associations and Easter seal societies, as well as nonprofit hospitals.
3.    Proprietary agency is a private, profit-making agency or profit-making hospital.

Tuesday, December 30, 2014

Hospital visit definiton


This page provides basic information about being certified as a Medicare and/or Medicaid hospital provider and includes links to applicable laws, regulations, and compliance information.

A hospital is an institution primarily engaged in providing, by or under the supervision of physicians, inpatient diagnostic and therapeutic services or rehabilitation services. Critical access hospitals are certified under separate standards. Psychiatric hospitals are subject to additional regulations beyond basic hospital conditions of participation. The State Survey Agency evaluates and certifies each participating hospital as a whole for compliance with the Medicare requirements and certifies it as a single provider institution.
Under the Medicare provider-based rules it is possible for ‘one' hospital to have multiple inpatient campuses and outpatient locations. It is not permissible to certify only part of a participating hospital. Psychiatric hospitals that participate in Medicare as a Distinct Part Psychiatric hospital are not required to participate in their entirety.

However, the following are not considered parts of the hospital and are not to be included in the evaluation of the hospital's compliance:

•    Components appropriately certified as other kinds of providers or suppliers. i.e., a distinct part Skilled Nursing Facility and/or distinct part Nursing Facility, Home Health Agency, Rural Health Clinic, or Hospice; Excluded residential, custodial, and non-service units not meeting certain definitions in the Social Security Act; and,

•    Physician offices located in space owned by the hospital but not functioning as hospital outpatient services departments

Accredited Hospitals - A hospital accredited by a CMS-approved accreditation program may substitute accreditation under that program for survey by the State Survey Agency. Surveyors assess the hospital's compliance with the Medicare Conditions of Participation (CoP) for all services, areas and locations covered by the hospital's provider agreement under its CMS Certification Number (CCN).

Although the survey generally occurs during daytime working hours (Monday through Friday), surveyors may conduct the survey at other times. This may include weekends and times outside of normal daytime (Monday through Friday) working hours. When the survey begins at times outside of normal work times, the survey team modifies the survey, if needed, in recognition of patients' activities and the staff available.
All hospital surveys are unannounced.

•    Should an individual or entity (hospital) refuse to allow immediate access upon reasonable request to either a State Agency , CMS surveyor, a CMS-approved accreditation organization, or CMS contract surveyors, the hospital's Medicare provider agreement may be terminated.
•    The CMS State Operations Manual (SOM) provides CMS policy regarding survey and certification activities.

Thursday, December 18, 2014

What is hospice care and length of the stay


The term “hospice care” means the following items and services provided to a terminally ill individual by, or by others under arrangements made by, a hospice program under a written plan (for providing such care to such individual) established and periodically reviewed by the individual's attending physician and by the medical director (and by the interdisciplinary group described in paragraph (2)(B)) of the program—

•    (A) nursing care provided by or under the supervision of a registered professional nurse,
•    (B) physical or occupational therapy, or speech-language pathology services,
•    (C) medical social services under the direction of a physician,
•    (D)(i) services of a home health aide who has successfully completed a training program approved by the Secretary and o    (ii) homemaker services,
•    (E) medical supplies (including drugs and biologicals) and the use of medical appliances, while under such a plan,
•    (F) physicians' services,
•    (G) short-term inpatient care (including both respite care and procedures necessary for pain control and acute and chronic symptom management) in an inpatient facility meeting such conditions as the Secretary determines to be appropriate to provide such care, but such respite care may be provided only on an intermittent, nonroutine, and occasional basis and may not be provided consecutively over longer than five days,
•    (H) counseling (including dietary counseling) with respect to care of the terminally ill individual and adjustment to his death, and
•    (I) any other item or service which is specified in the plan and for which payment may otherwise be made under this title.
The care and services described in subparagraphs (A) and (D) may be provided on a 24-hour, continuous basis only during periods of crisis (meeting criteria established by the Secretary) and only as necessary to maintain the terminally ill individual at home.

Hospice Terminal Diagnoses

The table also shows that the frequency of some hospice terminal diagnoses has changed over time, with relatively fewer cancer patients and relatively more non-cancer patients as a percentage of total hospice patients.  Lung cancer has been recognized as the most common diagnosis among Medicare hospice patients every year since 1998. However, in 2006 non-Alzheimer's dementia became the most common diagnosis among Medicare hospice patients.  The percentage of Medicare hospice patients with lung cancer dropped from 16% in 1998 to 9% in 2009.  In addition, we are seeing a notable increase in the number of neurologically-based diagnoses.  We are also seeing a marked increase in non-specific diagnoses such as “Debility, Not Otherwise Specified”, and “Adult Failure to Thrive”.

Average Length of Stay

Along with the shift in the mix of hospice patients, there exists a significant increase in the average length of stay (LOS) for hospice patients.  In 1998, the average LOS for hospice patients was 48 days, but by 2006 it had risen to 73 days (a 52% increase).  Since 2006, the average LOS has begun to decline slightly, dropping to 71 days in 2009, which is a 48% increase from 1998.  Charts 1 and 2 show that the average LOS varies by diagnosis.  For the top twenty diagnoses in 2009, the average LOS ranged from 27 days for chronic kidney disease to 106 days for Alzheimer's disease and other degenerative conditions.  While the average LOS from 1998–2009 for hospice patients with diagnoses such as chronic kidney disease or cancers has remained relatively stable, the average LOS rose significantly for most other diagnoses, thought it has recently begun to decline slightly.  Charts 1 and 2 graphically demonstrate the difference in the changes in lengths of stay for cancers versus other diagnoses in the top 20 list.

Monday, December 8, 2014

SIMPLY Healthcare plans will no longer available county details

Simply Healthcare Plans and its affiliates, Better Health and Clear Health Alliance continue to serve more than 190,000 Medicare and Medicaid members throughout Florida. Our commitment to provide value to both our members and providers is of the atmost importance. Through Simply Healthcare Medicare Advantage Plans alone, we deliver healthcare coverage to over 20,000 Medicare Beneficiaries in Miami-Dade, Polk, Orange, Osceola and Seminole counties.

As of January 1st, 2015, Simply Healthcare Plans will no longer be available to Medicare beneficiaries residing in Broward, Palm Beach, Duval, Clay, Brevard, Hillsborough, Hernando, Pasco and Pinellas counties in Florida.

This is to advise you that your Medicare patients will be receiving a formal notice from Simply Healthcare dated Oct. 2, 2014. The CMS approved letter will be sent to the affected members which will provide information to help them make informed decisions about their Medicare coverage options for 2015. These members will also receive instructions about their eligibility to enroll in another Medicare health plan. If your Medicare patients do not sign up for a new plan by the end of 2014, their current coverage will end Dec, 31, 2014. Your Medicare patients will then be covered through Original Medicare beginning Jan 1, 2015.

The status of your Simply Healthcare Provider Agreement will not be affected. We are continuously evaluating our Medicare Advantage products to ensure that they meet our member needs for access, cost and quality.

Thursday, November 27, 2014

Managed Medical Assistance (MMA) Program FAQs

1.    What if I want to change plans?

If you have been approved for Medicaid, you may change your plan during the first 90 days of your enrollment. After the 90 days you will only be able to change your plan during your open enrollment period or with a State-approved good cause reason.

2.    What is open enrollment?
Open Enrollment is the 60-day period each year when you can change plans without state approval. Open Enrollment occurs yearly on the anniversary date of your first enrollment into the plan.

3.    What is the no change period?
The no change period is the time period between the end of your initial first 90 days of enrollment and your 60-day annual open enrollment period. No change period also exists between your 60-day open enrollment periods going forward. Please refer to the below chart for reference. You will receive reminder letters assisting you with these time periods.

4.  What is "good cause"?
This is a State-approved reason to change plans during the no change period.

5.    What happens to my plan if I relocate or my address changes?
If your address changes, you may need to select another plan if your region has changed. You may need to contact the Department of Children and Families (DCF) at 1-866-762-2237 or the Social Security Administration (SSA) at 1-800-772-1213 to report a change in address.

6.    Will enrolling into the MMA program cancel my Medicare?
No, the MMA program will not cancel your Medicare. You are allowed to be enrolled in this program and Medicare at the same time because they cover different services.

7.    Will my current providers, including doctors, hospital, mental health or transportation to covered services, be available in the new program?
Each plan must cover all of the Medicaid services listed in the Program Information page of this website. However, each plan will have its own network of providers, which may include your current providers and or facilities. When you receive your enrollment packet, review the list of services provided by each plan. You may want to pick the plan that has most of the doctors and service providers that are important to you.

8.    What if no Managed Medical Assistance (MMA) plans include all of my current providers?
The plan you pick will be required to cover your services with your current providers for up to 60 days while you move to new providers in your new plan’s network. You may want to pick the plan that has most of the doctors and services that are important to you.

9.    If I enroll in an MMA plan, will it change my enrollment in a Medicaid waiver?
No. If you are enrolled in an MMA plan, your enrollment in a Medicaid waiver will not change and your waiver services will not change.

10.    What if my current plan stops providing services while I am still enrolled?
Your current plan is required to provide services until your last day of enrollment. You need to call the following number if this is happening to you: 1-888-419-3456.

11.    Will enrollment in an MMA plan cancel my Long-term Care plan enrollment?
No. If you or your family members are enrolled in a Long-term Care plan, you can also enroll in an MMA plan.

12.    If my Long-term Care plan is also an MMA plan, can I choose it to be my MMA plan?

13.    I have a special health care need. Are there special plans that will cover my needs?
Yes. All MMA plans cover people with special health care needs. There may also be special plans in your area for your health care needs. Also, if you have a child with a special health care need, the state’s Children’s Medical Services Network plan may be available to you. You may want to choose MMA plans that best meet your family’s needs.

14.    I am pregnant.  How do I enroll my baby in my MMA plan?
The State will enroll your baby in the same MMA plan where you are enrolled.  This will begin when your baby is born.  Please tell your MMA plan and your doctor that you are pregnant.  Your MMA plan can help you get the care you need.  You can also change your baby’s MMA plan up to 90 days after the month your baby is born.

15.    Once I receive my packet, how do I enroll?
Your packet will contain information about the different ways you can enroll in a plan, including online, by phone, or in person if you or your family member have special needs. Your information packet will tell you how to enroll. You will be informed about your options and rights prior to enrolling.

Managed Medical Assistance (MMA) Program - Mandatory Recipients Only: For those who are required to enroll in a plan.

1.    What if my current plan will not participate in the MMA program?
If your current plan will not participate in the MMA program, you must pick a different plan. The plan you pick must cover your services with your current providers for up to 60 days while you move to new providers in the plan’s network. You may want to pick the plan that has most of the doctors and service providers that are important to you.

2.    What if I do not choose an MMA plan?
If you do not choose an MMA plan in time, the State will choose one for you. Your packet includes the name of the MMA plan that would be chosen for you and the MMA plan’s start date. Also keep in mind that you will have 90 days to change your MMA plan from the date your enrollment in the plan begins. After 90 days, you may only change your plan during Open Enrollment or with a State-approved reason. Open Enrollment is a period of time, once a year, that allows you to change plans without a State-approved good cause reason.

3.    If I am enrolled in a Long-term Care plan do I need to enroll in an MMA plan, too?
Yes. If you or your family member are enrolled in a Long-term Care plan, you will need to choose an MMA plan for medical services covered by Medicaid.

4.    .I am enrolled in the Medicaid MediPass program. Can I stay under MediPass?
No. The MediPass program is going away. You must choose an MMA plan that best fits your needs.

5.    I am enrolled in a Medicaid dental plan. Can I stay in it?
No. The Medicaid dental plans are going away. Dental services are now being covered by the MMA plans. You will want to choose an MMA plan that best meets your needs.

6.    I am enrolled in a Medicaid prepaid mental health plan. Can I stay in it?
No. The Medicaid prepaid mental health plans are going away. Mental health services are now being covered by the MMA plans. You will want to choose an MMA plan that best meets your needs.

7.    I am on straight Medicaid (fee-for-service Medicaid). I received a letter that stated I must choose an MMA plan. Can I choose to stay on straight Medicaid or fee-for-service?
Because of changes in Florida law, most people on Medicaid must enroll in an MMA plan and cannot stay on fee-for-service Medicaid. If you do not choose an MMA plan by the date stated in the letter, the State will choose one for you.

Tuesday, November 18, 2014

What is MMA PLAN and what does it covers?

Statewide Medicaid Managed Care (SMMC) – Managed Medical Assistance (MMA) Program

In 2011, the Florida Legislature created a new program called Statewide Medicaid Managed Care (SMMC). Because of this program, the Agency for Health Care Administration (AHCA) will need to change how some individuals receive their health care from the Florida Medicaid Program.

There are two different parts that make up the SMMC program:

•    The Managed Medical Assistance (MMA) Program

•    The Long-term Care (LTC) Program

Medicaid recipients who qualify and become enrolled in MMA will receive all health care services (other than long-term care) from a managed care plan. Medicaid recipients who qualify and become enrolled in LTC will receive long-term care services from a Long-term Care managed care plan.

What does the Statewide Medicaid Managed Care program do?

Florida’s SMMC program is changing the way Medicaid health care services are provided. This means that Medicaid members will receive their health care services through a managed care plan. Keep in mind that MMA plans will cover services such as prescriptions, doctors’ visits and hospital stays.

All MMA plans offer the following health care services:

•    Physician services, including physician assistant services

•    Prescription drugs

•    Hospital inpatient services

•    Hospital outpatient services

•    Mental health services

•    Early periodic screening diagnosis and treatment services for recipients under age 21

•    Emergency services

•    Ambulatory surgical treatment center services

•    Advanced registered nurse practitioner services

•    Optical services and supplies

•    Dental services

•    Medical supplies, equipment, prosthesis, and orthoses

•    Chiropractic services

•    Nursing care

•    Family planning services and supplies (some exception)

•    Podiatric services

•    Healthy Start services (some exception)

•    Physical, occupational, respiratory, and speech therapy services

•    Hearing services

•    Laboratory and imaging services

•    Home health agency services

•    Renal dialysis services

•    Hospice services

•    Respiratory equipment and supplies

•    Optometrist services

•    Rural health clinic services

•    Birthing center services

•    Substance abuse treatment services

•    Transportation to access covered services

Note: The SMMC program will not change your Medicare benefits.

Sunday, November 9, 2014

Proper billing of therapy CPT code 97110

The most common service provided by physical therapists in outpatient settings and billed to the Medicare program under the Part B benefit is therapeutic exercise (CPT® code 97110). The purpose of this article is to address claim billing errors and the Comprehensive Error Rate Testing (CERT) findings related to therapy procedure 97110 for insufficient documentation and incorrect coding.

Therapy code 97110 is a timed code and therefore subject to Medicare’s guidelines outlined in Chapter 5 of the "Medicare Claims Processing Manual," Section 20.2 external pdf file. The guidelines apply to all timed services rendered to the patient in one session. First Coast Service Options (First Coast) provides the local coverage determination (LCD) ID L29289 that includes documentation requirements for therapy services. Both of these resources should be used to ensure that your provider is documenting and billing 97110 correctly to prevent documentation errors, coding errors, and payment recoupment.

Insufficient documentation errors

Insufficient documentation is the leading cause of CERT errors for First Coast. Below are examples of insufficient documentation determined by the CERT contractor when reviewing outpatient therapy documentation:
• Missing total time spent in therapy
• Missing billing provider signed and dated treatment notes
• Missing plan of care or plan of treatment
• Missing progress notes that support medical necessity

LCD documentation requirements

• Therapy services must relate directly and specifically to a written treatment plan. The plan must be established before treatment is begun.
• The signature and professional identity of the person who established the plan, and the date it was established must be recorded with the plan.

• The plan of care shall contain, at minimum, the following information:
• Diagnosis
• Long term treatment goals; and
• Type, amount, duration and frequency of therapy services
• The progress report provides justification for the medical necessity of treatment. Contractors shall determine the necessity of services based on the delivery of services as directed in the plan and as documented in the treatment notes and progress report.
• Documentation for therapeutic exercise (97110) must show objective loss of joint motion, strength, mobility (e.g., degrees of motion, strength grades, level of assistance, etc.).
• Therapeutic exercise is considered medically necessary if at least one of the following conditions is present and documented:
• The patient has weakness, contracture, stiffness secondary to spasm, spasticity, decreased range of motion, gait problem, balance and/or coordination deficits, abnormal posture, muscle imbalance; or
• The patient needs to improve mobility, stretching, strengthening, coordination, control of extremities, dexterity, range of motion, or endurance as part of activities of daily living training, or re-education.
• Total treatment minutes of the patient, including those minutes of active treatment reported under the timed codes and those minutes represented by the untimed codes, must be documented.

Billing for timed codes

Incorrect coding is the second leading cause of CERT errors for outpatient therapy services. An incorrect coding error is assessed if the correct number of units is not reported according to the documentation received. If a service represented by a 15-minute timed code is performed in a single day for at least 15 minutes, bill that service as one unit. If the service is performed for at least 30 minutes, bill that service as two units.

It is not appropriate to count all minutes of treatment in a day toward the units for one code if other services were performed for more than 15 minutes. When more than one service represented by 15-minute timed codes is performed in a single day, the total number of minutes of service determines the number of timed units billed. Total treatment time does not include time for services that are not billable (e.g, rest periods).

If any 15-minute timed service performed for seven minutes or less on the same day as another 15-minute timed service also performed for seven minutes or less, and the total time of the two is eight minutes or greater, bill one unit for the service performed for the most minutes. Apply the same logic when three or more different services are provided for seven minutes or less.

The expectation is that a therapist’s direct patient contact time for each unit will average 15 minutes in length. If a therapist has a consistent practice of billing less than 15 minutes for a unit, these situations could become subject for review. If more than one 15-minute timed CPT® code is billed during a single calendar day, the total number of timed units that can be billed is constrained by the total treatment minutes for that day.

Example No. 1
8 minutes of therapeutic exercise (97110)
8 minutes of manual therapy (97140)
Total = 16 timed minutes
The appropriate billing in this example is one unit. You should select 97110 or 97140 to bill because each unit was performed for the same amount of time and only one unit is allowed.

Example No. 2
33 minutes of therapeutic exercise (97110)
7 minutes of manual therapy (97140)
Total = 40 timed minutes

The appropriate billing in this example is three units. Bill two units of 97110 and one unit of 97140, and count the first 30 minutes of 97110 as two full units. Compare the remaining time for 97110 (33-30 = 3 minutes) to the time spent on 97140 (7 minutes) and bill the larger, which is 97140.

Tuesday, October 28, 2014

Medicare Payment Floor Standards detailed review`

The “payment floor” establishes a waiting period during which time the contractor may not pay, issue, mail, or otherwise finalize the initial determination on a clean claim. The “payment floor date” is the earliest day after receipt of the clean claim that payment may be made.

The payment floor date is determined by counting the number of days since the day the claim was received, i.e., the count begins the day after the day of receipt.

There are different waiting periods, and thus different payment floor dates, for electronic claims and paper claims. The waiting periods are 13 days for electronic claims and 26 days for paper claims. For the purpose of implementing the payment floor, the following definitions apply:

An “electronic claim” is a claim submitted via central processing unit (CPU) to CPU transmission, tape, direct data entry, direct wire, or personal computer upload or download. A claim that is submitted via digital FAX/OCR, diskette, or touch-tone telephone is not considered as an electronic claim.

A “paper claim” is submitted and received on paper, including fax print-outs. This also includes a claim that the contractor receives on paper and then reads electronically with OCR technology

Also, for the purpose of implementing the payment floor, effective 7/1/04 and for the duration of the HIPAA contingency plan implementation, an electronic claim that does not conform to the requirements of the standard implementation guides adopted for national use under HIPAA, including electronic claims submitted electronically using pre-HIPAA formats supported by Medicare, is considered to be a paper claim.

Based on the waiting periods, the payment floor dates are as follows:

Claim Receipt Date                     Payment Floor Date

10-01-93 through 6/30/04       14th day for EMC 27th day for paper claims
07-01-04 and later                  14th day for HIPAA-compliant EMC
                27th day for paper and non-HIPAA EMC
01/01/2006 and later 29th day for paper

Except as noted below, the payment floor applies to all claims. The payment floor does not apply to: “no-payment claims, RAPs submitted by Home Health Agencies, and claims for PIP payments.

NOTE: The basis for treating a non-HIPAA-compliant electronic claim as a paper claim for the purpose of determining the applicable payment floor is as follows: Effective October 16, 2003, HIPAA requires that claims submitted to Medicare electronically comply with standard claim implementation guides adopted for national use under HIPAA. A claim submitted via direct data entry (DDE), if DDE is supported by the contractor is considered to be a HIPAA-compliant electronic claim. A contingency plan has been approved to enable claims to continue to be submitted temporarily after October 15, 2003 in a pre-HIPAA electronic format supported by Medicare. Effective July 1, 2004, the Medicare contingency plan is being modified to encourage migration to HIPAA formats. Effective July 1, 2004, for purposes of the payment floor, only those claims submitted in a HIPAA-compliant format will be paid as early as the 14th day after the date of receipt. Claims submitted on paper after July 1, 2004 will not be eligible for payment earlier than the 27th day after the date of receipt. All claims subject to the 27-day payment floor, including non-HIPAA electronically submitted claims, are to be reported in the paper claims category for workload reporting purposes. Effective January 1, 2006, paper claims will not be eligible for payment earlier than the 29th day after the date of receipt.

This differentiation in treatment of HIPAA-compliant and non-HIPAA-compliant electronic claims does not apply to Contractor Performance Evaluation (CPE) reviews of carriers and FIs conducted by CMS. For CPE purposes, carriers and FIs must continue to process the CPE specified percentage of clean paper and clean electronic (HIPAA or non-HIPAA) claims within the statutorily specified timeframes. Effective for claims received January 1, 2006 and later, clean paper claims will no longer be included in CPE scoring for claims processing timeliness.

Thursday, October 16, 2014

What is Other Claims (other than clean) and Data Element matrix

Claims that do not meet the definition of “clean” claims are “other” claims. “Other” claims require investigation or development external to the carrier or FI’s Medicare operation on a prepayment basis. “Other” claims are those that are not approved by CWF for payment that the FI identifies as requiring outside development. Examples are claims on which the provider’s FI/carrier:

• Requests additional information from the provider or another external source. This includes routine data omitted from the bill, medical information, or information to resolve discrepancies;

• Requests information or assistance from another contractor. This includes requests for charge data from the carrier, or any other request for information from the carrier;

• Develops Medicare Secondary Payer (MSP) information;

• Requests information necessary for a coverage determination;

• Performs sequential processing when an earlier claim is in development; and

• Performs outside development as a result of a CWF edit.

Data Element Requirements Matrix

The matrix (See Exhibit 1) specifies data elements, which are required, not required, and conditional for FI claims. The matrix does not specify item or field/record content and size. Refer the electronic billing instructions (UB-04 and ANSI 837) on the CMS Web site to build these additional edits. If a claim fails any one of these “content” or “size” edits, the FI returns the unprocessable claim to the supplier or provider of service.

The FIs must provide a copy of the matrix listing the data element requirements, and attach a brief explanation to providers of service and suppliers. The matrix is not a comprehensive description of requirement that need to be met in order to submit a compliant transaction.

Medical Billing

What is the overall Billing process?

The physician doesn’t get paid for his services immediately after they are rendered. Majority of the patients have insurance coverage and details of such coverage are provided to the physician before treatment. It is the responsibility of the physician to submit claims to the insurance company and get paid for his services. Submitting Claims and getting paid is a lengthy process and involves a lot of rules and regulatory systems and is very complicated. The physician needs to adhere to all these rules before submitting claims. This is the concept of Medical Billing. Sometimes the physician cannot provide his entire attention to this activity. He entrusts this activity to Billing Companies. This is a process of the physician providing rights to Billing Companies to bill Medical Insurance claims in order to save his time energy, and money.

After the provider renders services to the patient, the billing company will submit bills to the insurance company/ payer, using the insurance information that was last provided, as well as information about the reason for the examination, and the exact type of procedure performed.

Medical coding is the process of converting Medical terms to numeric code and it required Medical knowledge skills.

Medical billing is the process of submitting the claims and get paid behalf of provider.

I have listed the important process in Medical Billing. Each process is very important.

1. Insurance verification.

2. Demo and Charge entry process.

3. Claim submission.

4. Payment posting.

5. Action on denials or Denial management or Account receivables.

Insurance verification

Process started from here and usually front desk people are doing this process. Its a process of verifying the patients insurance details by calling insurance or through online verification. If this department works well, we could resolve more problem. We have to do this even before patient appointment.

Demo and Charge entry process

Demographic entry is nothing but capturing all the information of patients. It should be error free.

Charge-entry is one of the key departments in Medical Billing. Key department?? Yes, that's true. It is the keying-in department in Medical Billing. After receiving the super bills from the Doctor's office, it gets passed through the coding department, and then comes to the charge-entry department.

A Charge-entry person also has one other vital role to perform. That is, to look-up the codes entered in the claim, and to assign the relevant charges for those codes.

Claim submission Process

The next step after demographics and charge entry is claim generation. Claims may be paper claims or electronic claims. There are various types of forms for paper claims. The most widely used form is Health Care Finance Admin-1500 designed by the Health Care Financing Administration.

Electronic transmission of claims is the modern way of sending claims with less paper work. The most common means of transmission are through internet . The claim information is directly loaded into the insurance company's computer system or to the clearing house.

Payment Posting Process

Once the claims reach the carriers and they complete processing, they issue a check and prepare an Explanation of Benefits . The checks and the Explanation of Benefits would be sent to the pay-to address with the carrier or in the Health Care Finance Administrators.

In this processing we have accounted the money into the account as per the Explanation of Benefits. Now a days we are using Electronic payment posting also.

Action on denials or Denial management or Account Receivables

This is a most important function in the process flow of data. Unless this is taken care of, insurance balance will only be on an upward trend.

Problem in Medical Billing

•Inaccurate or lack of coding

• Incomplete claims

• Lack of supporting documentation

• Poor communication with the payer

• Not billing for services rendered

* Not being follow up AR balance claims

The person who is doing this process will be called Medical billing specialist.

Who is Medical Billing Specialist.

Medical billing Specialist is the one who is handling the below process and having well knowledge in each and every process.

* Insurance verification process

* Patient demographic and charge entry process.

* Submitting the claims by electronic as well as paper method. Tracking various claim submission report.

* Payments posting process for insurance as well as patient.

* Denial management.

* Insurance followup management.

* Insurance appeal process.

* Handling patient billing inquiries.

* Patient statement process.

* Preparing monthly reports such as revenue report and account receivable report and as per the provider requirement.

Medical Billing Specialists are in charge of reviewing patient charts and documents. They prepare and review all medical insurance claims based on the rules and regulations of insurance companies. Medical Billing Specialists also review insurance communications, payment and rejection notices to properly track all claims and payments.

Medical Billing specialist Professional

If a person is computer literate he is a fit enough candidate to take up the profession of medical billing and medical coding. However he will need to be trained and be aware of a lot of new information before he can start working effectively. He has to learn about the medical billing software and must be familiar with and master the various commands used while working with it.

Who are medical coders and how is it related to medical billing? Medical billing is a sub specialty of medical coding. Medical coding is the first step in the billing process. All patient records are maintained using the ICD-9 index system so that it is compliant with the federal rules.

A medical Biller’s most important skill includes filling up of the various medical forms correctly without any mistakes what so ever. All information required should be complete without any mistake at all. And the work will be include the following

Patient demographic entry

Insurance enrollment

Charge entry

Insurance verification

Billing and reconciling of accounts

Payment posting

Insurance authorization

Medical coding

Scheduling and rescheduling

Account receivable follow-ups and collections

Is it worth taking a medical billing program?

Usually don't spend too much cost on Medical billing program because the program will not do anything with real experience. What you learn from these kind of program will not be going to match with when you are working in the real environment. Hence just use as the start kind of program and get the real time experience even in small salary and later you can come up with more demanding one.

Problem of In House Processing of Medical Claims

Medical claims are generally very complex and have long extended details. While processing medical claims, one has to be highly critical and do efficient follow-up in order to get results. The process requires a lot of time and effort. And even after all this, there can be cases where files get lost or a small error can ruin the entire lot and everything has to be re-submitted again. Usually practice staff can be held up with lot of current work rather than submitting the claim and resubmitting the corrected claim hence it will lead to time delay on payment flow and it will affect all the relationship with in the practice. Even cost wise is also not effective when compare to outsourcing.

Advantage of Medical Billing Outsource

Medical Billing Company helps you in managing all your billing requirements proficiently. By choosing right medical billing company, you can get benefit such as improved financial strength.

Medical Billing task is very tedious and time consuming. However, billing must require more accuracy and special attention to strengthen the financial condition of clinical or hospital. You can do this task at own or assign to clinical staff but you have to be pleased with low patients satisfaction. Medical billing company can help you in supportive task. By efficient medical service, you will get highly satisfied patients.

A Medical Billing service can improve the efficiency of your billing system, reduce denials, cut down operating costs, boost reimbursements and save valuable time that can be devoted to patient care. These services are better equipped to adapt to continuously changing billing codes and industry requirements.

* Prince is low compare to doing it in house

* Dedicated Highly Skilled Professionals

* No need to maintain the hardware . Ability to perform Medical Billing remotely, using the software of your choice

* Usually Maximum reimbursements and fewer denials

* Accuracy is high when compare

* Faster transaction

Question need to ask when Medical Billing Outsourcing

1. Check with their referral and how long they are doing this business.

2. Are they HIPAA compliance

3. Where they are doing their work. If possible just visit there.

4. Data security.

5. Compare the price with others.

6. what are the reports they will provide

7. Your specialty wise question

8. Their software skills.

Services and process involved in Medical Billing

* Coding ( CPT, ICD-9, and HCPCS)

* Patient Demographics Entry

* Charge Entry – All specialties

* Payment Posting (Manual and Electronic)

* Payment Reconciliation

* Denials/rejections analysis, re-billing

* Accounts Receivable Follow-up

* Systemic A/R projects, re-billing

* Collection Agency Reporting

* Refunds

Medical Billing Salary Range

Depending on the education qualification, the hourly rate varies from $12-$15. Another most important factor that affects billing pay is how long someone has worked in the field. Medical specialist with experience of 1 year earns around $12 per hour. Those who have more experience in billing earn up to $16 per hour. However, the geographic location also plays a role in pay scale. For instance, areas where cost of living is high, the pay will be more. Billers who work in New York City, Houston, Chicago and California are able to pull a good amount of salary. Work locations such as hospital, billing company or private practice will also affect the salary. Since there are lots of factors which affect the salary of billing, it is really not easy to predict the pay scale. Studies have shown that 50% of people earned around $35,000-$45,000 annually.

Most of the medical Billers are paid hourly, rather than annually. While Biller who is experienced can earn around $40,000 a year as an independent contractor working from home, a billing and coding specialist who runs his own firm can earn $100,000 a year. However, people who are searching for home based job should be very careful. There is lots of fraud going on in this field. These spammers charge hundred to thousand dollars and in exchange they claim they will help to get a placement in billing. They also promise that medical billing job can earn a substantial amount of money and no experience required. But in reality, those who paid to get a job end up with no job, no money. Billing is a very competitive field, so without experience or training in medical billing field, it is almost impossible to get a job.

Selecting Medical Billing Software - 10 things to consider

1. The first step is to evaluate your needs. And when evaluating different systems look for a package that goes one step ahead of billing. Choose a medical practice management system MPP. This will handle considerably more that just medical billing.

2. Determine whether the system handles electronic transmission of claims, direct billing for patients, co-pays, co-insurance, and expenses not covered by insurance.

3. Weigh the pros and cons of different medical billing systems and ask to see a system in operations. Always check out the references yourself.

4. Look for a medical billing management system that is user friendly. When a vendor demonstrates get your office staff to be present. This way you will be able to check how the software functions. Any software must be easy to use to be productive. The system should be fool proof.

5. Ask whether the medical billing software is a traditional system, one that will work on your office computers or an application service provider system (ASP), one that will process data at the software company’s data center.

6. Always get quotes from at least three medical billing software providers.

7. Ask whether they are offering an evaluation period or trial. This will enable you to know in actuality whether the system works or not.

8. Find out about training your office people, up-gradation of system, and whether the software is compatible with your office computer systems

.9. Find out whether the system will handle appointment scheduling, maintenance of records and so on apart from electronic medical records, SOAP notes, and billing. Choose a system that is comprehensive.

10. An ideal Medical Billing software system must include aspects like payment posting, reconciliation; follow up, secondary submission, and patient billing.Choose a transparent billing system that enhances your office efficiency. Install a system that you can use not one that will lead to frustration and problems.Medical billing systems must free your time and that of your office staff not make you run in circles. Choose a system with care.


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