Medicare

Recovery Audit Contractors, also known as RAC, is a program that seeks to identify and correct improper payments for services provided to Medicare Parts A & B beneficiaries. This includes both recoupment of overpayments and corrected distribution of underpayments made by CMS.  

The following chart identifies each of the 7 zones for ZPIC and the states/regions within each zone. Links are provided for each zone which contains information about each zone as well as activity and updates in those regions. 

Medicare understands that there are individuals who may not meet the diagnostic criteria for substance abuse, but who are still at risk. To help identify these individuals and take steps to keep them from reaching the level of abuse, Medicare has established a program called the Screening, Brief Intervention, and Referral to Treatment (SBIRT) Services.

Anyone who uses modifier 59 needs to be aware that due to problems with the incorrect usage of this modifier (which by the way is also revised for 2015,) CMS has added four new HCPCS modifiers. An announcement by CMS stated that "CMS is establishing four new HCPCS modifiers to define subsets of the -59 modifier, a modifier used to define a “Distinct Procedural Service.” 

These new codes are:

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.

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