2010 MEDICARE PART B

2010 MEDICARE PART B

United New York Ambulance Network

March 17, 2010

2 National Government Services, Inc.

Update Agenda

• 2010 Medicare program changes

• NY Medicare / Medicaid Crossovers

• Medicare Fee Schedule

• Ambulance coverage – the basics

• Provider Enrollment / PECOS

• ICD-10-CM/PCS


2010 Medicare Part B Amounts

2009

• Part B Premium– $96.40

• Higher Part B Premium– $85,000/$170,000

• Part B Deductible– $135.00

2010

• Part B Premium– $110.50

• Higher Part B Premium– $85,000/$170,000

• Part B Deductible– $155.00


2010 Medicare Part A Amounts

• Part A Premium– < 30 quarters $461 – 30-40 quarters $254

• Part A Deductible– $1,100

• Part A Coinsurance– $275 (Days 61-90)– $550 (Lifetime Reserve Days)– $137.50 (SNF Coinsurance)


2010 Part B Premium

• Medicare Part B premium will remain the same as 2009 for most beneficiaries

– $96.40 if annual income is below $85,000 (individual) / $170,000 (couple)

• Exceptions

– $110.50 if Enroll in Medicare in 2010

– Beneficiaries with high incomes are subject to higher Part B premium


Medicare Trends

• Medicare Advantage enrollment is above 25% of beneficiaries with potential for changes coming in the marketplace.

• 47 million beneficiaries enrolled in 2010; growing to over 62 million by 2020

• $507 billion in expenditures growing to $898 billion in 2020


Ambulance Update

• National fee schedule in place

• Updates are based on the % increase of the CPI-Urban Consumers

• CPI-U for 2010 is -1.4% which is 0% update.

• Use the Ambulance Service Center at

www.cms.hhs.gov

• 2010 Deductible and coinsurance apply



Ambulance Coverage

The Basics


Emergency Ambulance Transport

• Place the patient’s health in serious jeopardy; • Result in serious impairment of bodily functions; or • Result in serious dysfunction of any bodily organ.

Symptoms or Conditions that May Warrant an Emergency Symptoms or Conditions that May Warrant an Emergency Ambulance Transport Include, But are Not Limited To: Ambulance Transport Include, But are Not Limited To:

• Severe pain or hemorrhage; • Unconsciousness or shock; • Injuries requiring immobilization of the patient; • Patient needs to be restrained to keep from hurting himself or others; • Patient requires oxygen or other skilled medical treatment during

transportation; and Suspicion that the patient is experiencing a stroke or myocardial infarction.


Non - Emergency Ambulance Transports

• Appropriate with a patient who is bed -confined Appropriate with a patient who is bed -confined AND AND his/her his/her condition is such that other methods of transportation are condition is such that other methods of transportation are contraindicated; contraindicated; OROR

• The patient’s condition, regardless of bed-confinement, is such The patient’s condition, regardless of bed-confinement, is such that transportation by ambulance is medically required (patient that transportation by ambulance is medically required (patient poses a danger to him or herself or to others). poses a danger to him or herself or to others).

• Bed-confinement alone is neither sufficient nor necessary to Bed-confinement alone is neither sufficient nor necessary to determine the coverage for Medicare benefits.determine the coverage for Medicare benefits.

• To be considered bed-confined, To be considered bed-confined, the patient must be unable to do the patient must be unable to do all three of the followingall three of the following::

• Get up from bed without assistance; Get up from bed without assistance; • Ambulate; and Ambulate; and • Sit in a chair or wheelchair. Sit in a chair or wheelchair.


Advanced Beneficiary Notice- new form in place

When to use an ABN?

• Patient does not require an ambulance to be transported.

• Air Transport when ground ambulance would suffice

• ALS to BLS

• When it is not needed!

• Partial mileage denial ( Beneficiary is liable)

• Patient is under duress- critically ill circumstance


Ground Ambulance Scenarios: Beneficiary Death

Time of Death Pronouncement

Medicare Payment Determination

-Before dispatch -None

-After dispatch, before beneficiary is loaded onboard ambulance (before or after arrival at the point-of-pickup)

-The provider’s BLS base rate, no mileage or rural adjustment; use the QL modifier when submitting the claim

-After pickup, prior to or upon arrival at the receiving facility

-Medically necessary level of service furnished


Documentation Requirements

• Ambulance suppliers are not required to submit documentation

• Ambulance suppliers are required to retain documentation that contains information about the personnel involved in the transport

and the patient’s condition and to be made available to Medicare

• Ambulance suppliers are also required to obtain a Physician Certification Statement (PCS) for non-emergency transports which states the reason(s) a patient requires non-emergency transportation by ambulance.


How to Avoid Improper Billing

• Be sure that coverage criteria and level of service criteria for ambulance transport are met and that it is backed up with the appropriate documentation

• Communicate the patient’s condition as reported by the dispatch center and as observed by the ambulance crew

• Maintain documentation that will help to determine whether ambulance transports meet program requirements


How to Avoid Improper Billing

• Generally, coverage errors for ambulance transports were due to documentation discrepancies between the ambulance supplier and the third-party provider

(e.g., emergency room records)

• Be sure to include the origin and destination modifiers when billing. Medicare needs to determine whether the coverage and/or level of service is correct


Levels of Service

• Basic Life Support , non-emergency transport (BLS)-A0428

• Basic Life Support, emergency transport (BLS-emergency)-A0429

• Advanced Life Support, non-emergency transport, level 1 (ALS1)-A0426

• Advanced Life Support, emergency transport, level 1 (ALS1-emergency)-A0427


Levels of Service

• Advanced Life Support, level 2 (ALS2)-A0433

• Specialty care transport (SCT)-A0434


Advanced Life Support (ALS) Ambulance

• ALS vehicles must be staffed by at least two people, at least one of whom must be certified as an EMT-Intermediate or an EMT-Paramedic– EMT-Intermediate is qualified as an EMT-basic who

is also certified to perform essential advanced techniques and to administer a limited number of medications

– EMT-Paramedic is qualified as an EMT-Intermediate and possesses skills to administer additional interventions and medications


Advanced Life Support, non-emergency transport, level 1

(ALS1)• Only an ALS crew was qualified to

perform the assessment

• An ALS assessment does not necessarily result in a determination that the patient requires an ALS level of service

• An ALS intervention is a procedure that is required to be done by an emergency medical technician-intermediate (EMT-intermediate) or EMT-Paramedic


Examples of ALSI Services

• The ALS vehicle must have specialized life sustaining equipment and specialized staff. Typical of this type of ambulance are mobile coronary care units staffed by personnel trained and authorized to administer intravenous therapy (IVs), provide anti-shock trousers, establish and maintain a patient's airway, defibrillate the heart, provide EKG monitoring, and perform other advanced life support procedures or services.


Advance Life Support II (ALSII)

• Transportation by ground ambulance vehicle, medically necessary supplies and services, and the administration of at least 3 medications by intravenous push/bolus or by continuous infusion excluding crystalloid, hypotonic, isotonic, and hypertonic solutions (Dextrose, Normal Saline, Ringer’s Lactate);

OR



• Transportation by ground ambulance vehicle, medically necessary supplies and services, and the administration of at least 3 medications by intravenous push/bolus or by continuous infusion excluding crystalloid, hypotonic, isotonic, and hypertonic solutions (Dextrose, Normal Saline, Ringer’s Lactate);

OR



• Transportation, medically necessary supplies and services, and the provision of at least one of the following ALS procedures:

• Manual defibrillation/cardioversion• Endotracheal intubation• Central venous line• Cardiac pacing• Chest decompression• Surgical airway• Intraosseous line

Provider Enrollment Provider Enrollment

PECOSPECOS


Enrollment Revalidation for Providers not in PECOS System

• Providers who have not made changes to enrollment record since 2003 will not be in PECOS

– May need to revalidate enrollment

• NGS is currently sending out revalidation letters

• Providers who receive a letter must respond or billing privileges will be revoked


ReminderPECOS Limitations

• Internet-based PECOS cannot be used for:

– Changes in Taxpayer Identification Number (TIN)

– Changes in Legal Business Name (LBN)

– Enrolling an existing Medicare Part A provider/supplier with Medicare carrier or A/B MAC to bill for Part B services

– Initial applications submitted by Federal Qualified Health Centers, Rural Health Clinics, and End-Stage Renal Disease Facilities


Completing Online Enrollment

Three Basic Steps

1. Must have active NPPES User ID and Password• Additional security clearances needed for groups

– PECOS Identification and Authentication system (PECOS I&A) clearances for Authorized Official

2. Complete online enrollment and submit

3. Print, sign and date, and mail Certification Statement to National Government Services along with all supporting paper documentation within seven (7) days of electronic submission• Signed by AO for groups

Wait at least 15 days before checking status of online application


Medicare Enrollment Timeframes

• Effective date of enrollment is later of:– Date of filing (receipt date)– Date began furnishing services at practice location (if within 30 days)

• Date of filing for online applications based on contractor receipt of Certification Statement

• 30-day retrospective billing guideline as of April 1, 2009

• Reactivation application treated as initial enrollment application


Deactivation of Medicare Provider Numbers

• Medicare PTAN becomes inactive if no valid Medicare claim submitted in 12-month period

• To reactivate, provider must:– Be ready to submit valid claim– Submit appropriate CMS-855 form online or on paper

• Upon reactivation, new PTAN is assigned and new effective date applied

• Providers who received paper checks prior to deactivation are required to complete CMS-588 (EFT Authorization Agreement) to reactivate


National Provider Identifier (NPI) Reminders

• Apply for NPI online – https://nppes.cms.hhs.gov

• Contact NPI Enumerator for assistance with applying for NPI or updating data in NPPES records – 1-800-465-3203 – [email protected]

• FREE NPI Registry – https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do

• CMS' dedicated NPI web page – www.cms.hhs.gov/NationalProvIdentStand


Enhancements/Updates to NPPES

• MLN Special Edition Article SE0914

• Effective On/After September 13, 2009

• Security enhancements:– Users required to select five secret questions and answers for

verification purposes in order to reset own passwords– Users prevented form changing passwords more than once

within 24 hours from last password change

• Revised Electronic File Interchange (EFI) User Manual and Technical Companion Guide


JSM 10158 - Dark Days for Provider Enrollment, Chain and Ownership System (PECOS)

• CMS is implementing “Dark Days” for the implementation of PECOS R7.0

• The CMS will be disabling the PECOS Provider Interface (PI), AKA Internet-based PECOS, on March 29, 2010

• Internet Based PECOS will be enabled on April 5, 2010

• PECOS Dark Days should have minimum impact on your Internet Based PECOS submissions


Listing of all providers in PECOS

• As of January 28, 2010, CMS has made available a file that contains the National Provider Identifier (NPI) and the name (last name, first name) of all physicians and non-physician practitioners who are of a type/specialty that is eligible to order and refer in the Medicare program and who have current enrollment records in Medicare (i.e., they have enrollment records in PECOS that contain an NPI). This file is downloadable from the Medicare provider/supplier enrollment web site: www.cms.hhs.gov/MedicareProviderSupEnroll: click on “Ordering/Referring File” on the left-hand side.


The Top Reasons for the Return of Enrollment/PECOS in Ranking Order

• 2008 Version of the Application

• No signature & No date

• Authorized Official is Not Correct

• Tracking I.D. not found in PECOS


The Top Reasons for the Return of Enrollment/PECOS in Ranking Order

• Signature with no date

• Wrong Contractor

• Individual Rendering Provider & Authorized Official Signatures do not Match

• Dates are more than 6 Months Apart

All changes will also require EFT – 588 form






Complete per agreement


Notify us with 60 days of a change!

D

Billing & Claims Processing Billing & Claims Processing Reminders & UpdatesReminders & Updates


ICD-10-CM/PCS

• New diagnosis coding system

– ICD-10-CM • Replacement for ICD-9-CM, Volumes 1 & 2

– ICD-10-PCS • Replacement for ICD-9-CM, Volume 3 (hospitals)

• Implementation date – October 1, 2013


ICD-10-CM/PCS

• MLN Matters Special Edition Article SE0832 CMS web site - www.cms.hhs.gov/icd10

– Questions and answers– General Equivalence Mappings (crosswalks)– Educational resources– Information on upcoming CMS-sponsored calls and transcripts from completed

calls

• ICD-10-CM/PCS Fact Sheet – General information about the benefits of adopting the new coding

system– Structural differences between ICD-9-CM and ICD-10-CM/PCS– Implementation planning recommendations

• Available for download from CMS Medicare Learning Network


New York Medicare / Medicaid Crossovers

Effective December 3, 2009

• http://www.ngsmedicare.com/Content.aspx?CatID=2&DOCID=21493

• Posted 01/29/2010 - NGS will be sending letters to providers whose claims did not crossover to Medicaid

• Revised 02/01/2010 – NGS has suspend sending letters advising providers claims did not crossover to NYS Medicaid due to the large volume of claims not being accepted by NYS Medicaid for crossover benefits

• If you received a letter previously, contact NYS Medicaid to have your

provider information set up with Medicaid

• We recommend you contact the NYS Medicaid Enrollment Unit at 800-343-9000 and ask about enrolling the NPI


Medicare Claims Crossover to Supplemental Payer Problem

• JSM 10139 for additional Information http://www.ngsmedicare.com/Content.aspx?CatID=2&DOCID=21648

• NGS has informed providers, physicians, and suppliers to an issue that occurred starting on or about January 1, 2010 having a negative impact on their patients’ crossover claims

• Due to a system issue with the Common Working File (CWF), some claims are not crossing over to the supplemental insurance carrier for benefits

• CMS and the CWF System Maintainer are working towards a system solution and recommend:

– Examine your Remittance Advice to determine if your patients' claims are identified as having been crossed over to their supplemental insurers

– Remittance Remark Code MA 18 will indicate a claim has crossed over a supplemental insurer

– If a claim did not crossed over, you are within your rights to submit claims to your patients' insurers for supplemental payment using methodologies acceptable to those entities


Medicare Crossover Reminders

• Allow sufficient time for the Medicare crossover process to work - approximately 15 work days after Medicare’s reimbursement is made, before attempting to balance bill your patients’ supplemental insurers as stated in MLN Matters Article SE0909. http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0909.pdf

• Do not balance bill until written confirmation from Medicare that your patients’ claims will not be crossed over is received, or you’ve received a special notification letter explaining why specified claims cannot be crossed over.


Medicare Crossover Reminders

• January 2010 Issue:

Claims that crossed over to NYS Medicaid are being rejected by Medicaid because they are unable to identify the provider or does not have a provider agreement on file.

• Providers will need to contact NYS Medicaid to have their provider information setup with Medicaid. NYS Medicaid Provider Enrollment: 800-343-9000


Attention Paper Claims Submitters

Posted January 29, 2010

• http://www.ngsmedicare.com/Content.aspx?CatID=2&DOCID=21489

• Prior to February 26, 2010, paper claims received where the health insurance claim number and the beneficiary name did not match were returned to the provider with a development letter advising the provider to correct the problem and submit as a new claim

• CMS has directed contractors to follow the current electronic rejection process with all claims, electronic and paper

• Effective February 26, 2010, paper claims are rejected and returned to the provider with a rejection letter specifying the reason the claims were returned



Stay Informed of Medicare Changes!

• Sign-up for www.ngsmedicare.com list serv

• Attend National Government Services trainings:– Teleconferences – Webinars – In-person seminars

• Complete free computer-based trainings (CBTs) in Medicare University

• Participate in CMS calls– Special topic calls (PQRI, ePrescribing, ICD-10)– Monthly Open Door Forum calls


J13 Medicare Part B News Flash Teleconferences

• Free monthly seminar for CT and NY Part B providers (J13)– Current claims processing issues– New and revised Medicare regulations, materials & LCDs– Tips on how to avoid common claim denials

• For more information and to register for next session:– Events Calendar on www.ngsmedicare.com

• Handout available for download from Events Calendar at least one day prior to teleconference


Ask-the-Contractor Teleconferences (ACTs)

• Free quarterly teleconference for J13 Part B providers

• Similar to Open Door Forums offered by CMS– Providers can ask questions on any topic (no PHI)

• Information / registration for next session:– Events Calendar on www.ngsmedicare.com


Provider Authentication Requirements for Telephone and Written Inquiries

• For calls to IVR or Provider Contact Center

• Three data elements required for provider authentication:

– Your National Provider Identifier (NPI)– Your Provider Transaction Access Number (PTAN)– Last five digits of your tax identification number (TIN)

• Only allowed three attempts to successfully authenticate identity


Effective 12/15/09J13 Contact Information

NY & CT

Interactive Voice Response unit (IVR)

1-877-869-6504

Provider Contact Center: 866-837-0241

Fax on Demand: 866-709-1905

EDI: 877-273-4334

Correspondence: National Government Services

Part B Provider General Written Inquiries

P.O. Box 7052

Indianapolis, IN 43207-7052


Contacting the Telephone Reopening Unit (TRU Line)

• TRU Line – 888-812-8905 - follow prompt

• Part B TRU line hours of operation: Monday - Friday, 8:00 AM to 3:00 PM (Eastern)

• Faxes are accepted and representatives are permitted to accept more than 3 claims per call

• When calling TRU Line, provide the following information: – Beneficiary’s Name – Medicare Health Insurance Claim Number – Your Full Name (first and last name) – Your Phone Number – Provider’s Name – Provider’s Number – Date(s) of Service in Question – Reason for Request


Claim Filing Rules & Limits

Services Rendered: Claim Filing Date

10/01/07 – 09/30/08 12/31/09

10/01/08 – 09/30/09 12/31/10

• 10 % late filing fee assessed for assigned claims not submitted within one year from date of service

• Claims not submitted by time limit are provider-liable– Beneficiary cannot be charged for provider-liable charges


Duplicate Claim Submissions

• Definition – – Claims submitted more than once for services provided by same

provider to same beneficiary for same item(s) or service(s) for same date(s) of service.

• Denials identified on remittance advice with “CO18”

• Inappropriate billing practice with Medicare– Claim payment delays– Investigated as abusive or fraudulent billing

• POE contacting and educating highest duplicate billers


Submitting Duplicate Claims:

• May delay payment– Resubmitting your claim prior to receiving a determination not

only increases administrative costs to the Medicare program but to you as well.

• Could cause you to be identified as an abusive biller; or may result in an investigation for fraud if a pattern of duplicate billing is identified– Although NGS does not believe providers are trying to

deliberately receive duplicate payment by submitting duplicate claims for one service we must remind providers that this is an inappropriate billing practice.


Avoid Duplicate Claims

• Allow 29 days for paper claims and 14 days for electronic claims to be processed

• Electronic Claims Submitters should :– Check your EDI validation report to verify claims were

received and accepted– Check your software system to verify claims’ software

system is not set up for automatic rebill every 30 days or at any other set time intervals

– Ensure that your claims batching process is functioning properly


Avoid Duplicate Claims

• Electronic and Paper Submitters should:– Access the Interactive Voice Response (IVR) System

to determine if a claim has been denied as a duplicate (CO-18)

– Pay close attention to your remittance advice to determine if the denied claim(s) should be resubmitted or appealed

– Make sure that your billing staff or third party billing service knows the Medicare payment floors and claims filing rules


Ambulance Claim Denials

9.50%

9.50%

5%

20%

20%

24%12%

Duplicate Claim

Non-covered trip

Incorrect payer

Item not separately payable

Expense prior to coverage

Other liability

All other

Recovery Audit Contractor Recovery Audit Contractor (RAC)(RAC)

67 National Government Services, Inc.67

RAC Review Process

• Detect and correct past improper payments

• Issues reviewed by RAC will be approved by CMS prior to widespread review

• Approved issues will be posted to RAC website before widespread review

• Claims reviewed on post-payment basis – Use same Medicare policies as claim processing

contractors (NCDs, LCDs, and CMS Manuals)


RAC Contractor

• Region A –

Diversified Collection Services, Inc. (DCS) – CT, DE, ME, MD, MA, RI, NH, NJ, NY, PA & Washington DC– www.dcsrac.com – 333 North Canyons Parkway, Suite 100, Livermore, CA

94551-7661

• CMS RAC Web site: www.cms.hhs.gov/RAC

• CMS RAC e-mail: [email protected]


Know Where Previous Improper Payments Have Been Found

• Look to see what improper payments were found by the RACs– Demonstration findings: www.cms.hhs.gov/rac– Permanent RAC findings: Listed on the RACs’ Web sites

• Look to see what improper payments have been found in – Office of Inspector General (OIG) reports

• www.oig.hhs.gov/reports.asp– Comprehensive Error Rate Testing (CERT) reports

• www.cms.hhs.gov/cert


Diversified Collection Services

www.dcsrac.com

[email protected]

(866) 201-0580


RAC Review Process

• RAC’s are able to look back three years from claim paid date (will not review claims paid prior to October 1, 2007)

• Two types of review:– Automated (no medical record needed)– Complex (medical record required)

• When overpayment identified, a demand letter issued by RAC


When an Overpayment is Identified

• The same process as overpayments identified by A/B MAC (except the demand letter comes from RAC)

• “RAC Discussion Period” – Opportunity for provider to discuss improper payment

determination with RAC outside normal appeal process


Know If You Are Submitting Claims With Improper Payments

• Conduct an internal assessment to identify if you are in compliance with Medicare rules

• Identify corrective actions to implement for compliance

• Keep track of denied claims

• Look for patterns

• Determine what corrective actions you need to take to avoid improper payments


CMS’ 5th Annual Medicare Contractor Provider Satisfaction Survey (MCPSS)

http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE1005.pdf

The 2010 survey is administered by a new contractor, SciMetrika, LLC (public health consulting firm) and will be distributed to a random sample of approximately 30,000 Medicare Fee-for-Service providers nationwide

For specific questions about the MCPSS, call the MCPSS Provider Helpline at 800-835-7012 to speak to a SciMetrika study representative or visit www.cms.hhs.gov/mcpss and www.mcpsstudy.org

Questions will focus on seven business Provider / Contractor functions • Provider Outreach & Education• Provider Inquiries • Claims Processing• Appeals• Provider Enrollment• Medical Review• Provider Audit & Reimbursement


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2010 MEDICARE PART B

News & Politics