Medicare

In 2013, CMS initiated recoveries from providers and suppliers based on data that indicated a beneficiary was incarcerated on the date of service. CMS subsequently discovered that some of the data used was incomplete. Since some of these recoveries might have been erroneous, CMS initiated refunds. Most of the incarcerated beneficiary erroneous overpayment refunds were issued before the end of December 2013, with some subsequent refunds on situations that had been appealed. The process CMS used to expedite the refunds precluded the issuance of a detailed remittance advice (RA).

MSP provisions apply to situations when Medicare is not the beneficiary’s primary health insurance coverage. Before you submit a claim, you must determine whether Medicare is the primary or secondary payer for all inpatient admissions and outpatient encounters, thereby assisting in ensuring the appropriate use of Medicare funds. If another plan, insurer, or program is the primary payer, you must identify such payers on the claim you submit to Medicare.

It is common knowledge that fraud is a large problem for payers, who must spend money paying fraudulent claims as well as on recovery. According to a Forbes article, a health care actuary estimated that private insurers annually “lose perhaps 1 to 1.5 percent in fraud.” Meanwhile, the problem is worse for public insurers. The same actuary estimates that “Medicare and Medicaid may be closer to 10 to 15 percent.” According to the recently released Medicare Fee-for-Service 2013 Improper Payment Rate Report, the improper payment rate increased from 8.5% in 2012 to 10.1% in 2013.

Physician Quality Reporting System (PQRS) 2nd Quarter interim Feedback Dashboard reports are now available.  For eligible professionals and submitted data for claims sent in January 01, 2014 and June 30, 2014.  Data is available on a quarterly basis in order to monitor the status of claims-based individual measures. Dashboard data does not indicate whether or not an incentive payment was earned.

After a claim has been submitted and a reimbursement decision has been made, you or your billing agent receive a Remittance Advice (RA). The RA is a notice of payments and adjustments that the MAC produces as a companion to claim payments or an explanation when there is no payment. It features valid codes and specific values that make up the claim payment.

Some of these codes may identify adjustments, which refer to any changes that relate to how a claim is paid differently from the original billing. There are seven general types of adjustments:

1. Denied claim;

Submitting the CMS-855 Enrollment Application and Billing Effective Date Changes

As of May 14, 2012, the billing effective date can be made retroactive as far back as 30 calendar days from the date the application was received in Medicare's office.

Provider offices must submit the CMS 855 form as soon as the provider begins seeing Medicare patients to ensure their services will be processed by Medicare. With CR7797, the CM-855 form can be now submitted up to 60 days in advance of the provider seeing Medicare patients.

CMS is pleased to announce that the 2013 Physician Quality Reporting System (PQRS) incentive payments are now available for eligible professionals and group practices who submitted data for Medicare Physician Fee Schedule Part B services between January 1, 2013 and December 31, 2013. The PQRS incentive payments are for EPs and group practices who met the PQRS satisfactory reporting criteria, regardless of participation in another program (i.e., Medicare Shared Savings Program Accountable Care Organization, Comprehensive Primary Care Initiative, etc.).

MEASURE COMPLIANCE - Meeting the Patient Electronic Access Objective

Starting in 2014, CMS requires that providers participating in both Stage 1 and Stage 2 of the EHR Incentive Programs must meet the Patient Electronic Access objective, which gives patients access to their health information in a timely manner. Providers participating in Stage 1 are required to meet one patient electronic access measure, and providers participating in Stage 2 need to meet two measures.

Measure #1 for Stage 1 and Stage 2:

CMS has added more PQRS training modules to help simplify the process, including one for beginner, intermediate and advanced PQRS reporting.  The modules are designed to help you find the information you need to satisfactorily participate in PQRS and other programs that offer incentive payments in 2014.

Questions and Answers for Psychologists and PQRS. In 2007, Psychologists had very limited opportunity to participate in PQRS. As of 2014, there are 11 measures available for claims-based reporting and two for registry reporting.  

For the entire article read more here: PracticeCentral.org

Below are the 11 new measures for 2014

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