DataPlus Blog

:::Holiday Hours:::

2011-12-01T10:36:00.001-06:00

The DataPlus Corporate and Support offices will be closed on the following days for the upcoming Holidays:

Christmas: December 26th, 2011
New Years: January 2nd, 2012

The DataPlus staff would like to wish you a safe and happy Holiday Season!

Stark, False Claims and Anti-Kickback Laws: Easy Ways to Stay Compliant with the Big Three in Healthcare

2011-11-21T10:47:00.000-06:00

Contributed by: www.ManageMyPractice.com

In health care, we are “blessed” with an abundance of rules, policies, standards and laws. In Health Care Regulation in America: Complexity, Confrontation, and Compromise, Robert I. Field, professor of health management and policy at Drexel University School of Public Health, observes the following:
”Regulation shapes all aspects of America’s fragmented health care industry, from the flow of dollars to the communication between physicians and patients. It is the engine that translates public policy into action. While the health and lives of patients, as well as almost one-sixth of the national economy depend on its effectiveness, health care regulation in America is bewilderingly complex.”
Here are some of the most important regulations in health care that you should not only know about, but should be actively managing with a robust compliance plan.

Stark Law (Physician Self-Referral)

When: Section 1877 of the Social Security Act, also known as the physician self-referral law, is commonly referred to as the Stark Law. When enacted in 1989, it applied only to physician referrals for clinical laboratory services. In 1993 and 1994, Congress expanded the prohibition to the additional designated health services listed below.
What: Stark Law “prohibits physicians from making referrals for designated health services (DHS) payable by Medicare to an entity with which he or she (or an immediate family member) has a financial relationship (ownership, investment, or compensation), unless an exception applies,” according to the Centers of Medicare & Medicaid Services (CMS). Specifically covered designated health services include:

Clinical laboratory services
Physical therapy services
Occupational therapy services
Outpatient speech-language pathology services
Radiology and certain other imaging services
Radiation therapy services and supplies
Durable medical equipment (DME) and supplies
Parenteral and enteral nutrients, equipment, and supplies
Prosthetics, orthotics, and prosthetic devices and supplies
Home health services
Outpatient prescription drugs
Inpatient and outpatient hospital services

Penalties: Penalties for violating the Stark Law include denial of payment, refund of payment, imposition of a $15,000 per service civil monetary penalty, and imposition of a $100,000 civil monetary penalty for each arrangement considered to be a circumvention scheme.
The following will help you remain compliant with the Stark Law:
1. Offer all patients a written list of choices for obtaining the care your physicians are recommending.
2. Disclose any financial relationship with any entity that is on the list offered to patients.

False Claims Act

When: Originally enacted during the Civil War, and sometimes known as the Lincoln Law, the False Claims Act (FCA) as we know it today was signed by President Reagan in 1986.
What: Under the FCA, those who knowingly submit – or cause another person or entity to submit – false claims for payment of government funds will be subject to liability. The FCA contains qui tam, or “whistleblower,” provisions.
Penalties: Medicare and Medicaid fraud and abuse prohibit the knowing and willful making of a false statement that affects reimbursement under a federal health program. That provision imposes felony penalties of up to five years’ imprisonment and/or fines up to $250,000 for an individual and $500,000 for an organization.
In addition to criminal penalties, the Office of Inspector General (OIG) may impose civil penalties under the Civil Monetary Penalties Act for submitting false claims. Civil penalties can be up to $11,000, plus three times the amount claimed. According to the Telehealth Resource Center, “The Civil Monetary Claims Act prohibits claims for services not provided as claimed; false or fraudulent claims; claims for physician services not furnished by physicians; or claims for services provided by an excluded physician or provider. The False Claims Act gives the federal government, as well as any person, a cause of action against any person who submits false claims to the government.”
To help your practice remain compliant with the False Claims Act, keep the following in mind:
1. Perform background checks and obtain references on all potential employees, making sure they are not sanctioned by the OIG.
2. Have an audit performed by a third-party biannually to make sure that your billing department is following your compliance policy to the letter.

Anti-Kickback Statute

When: Congress enacted the anti-kickback statute, 42 U.S.C. § 1320a-7b(b), in 1977 as a prohibition against the payment of kickbacks in any form.
What: The anti-kickback statute states that criminal penalties will be issued for individuals or entities that knowingly and willfully offer, pay, solicit, or receive remuneration intended to induce or reward referral of business reimbursable under any of the federal health care programs (Medicare, Medicaid, etc.)
Penalties: The anti-kickback statute is a criminal statute, the violation of which constitutes a felony punishable by a fine of not more than $25,000 per offense and/or imprisonment for up to five years. A conviction also will lead to mandatory exclusion from participation in federal health care programs. The OIG also may impose civil monetary penalties of up to $50,000 for each violation, plus damages of three times the amount of the remuneration.
To help you remain compliant the anti-kickback statute:
1. Seek the advice of an experienced health care attorney before entering into any agreements with parties to pay or receive payment for goods or services where a kickback might be construed.
2. Make sure your compliance plan addresses the acceptance of gifts by physicians and staff.

Put It All Together: Your Compliance Plan

A compliance plan does not have to be long or overly complex. The federal government recommends a seven-component compliance plan that covers the critical points in a simple and easy-to-understand way:
1. Designate a compliance officer, which can be the manager or a staff member.
2. Implement compliance and practice standards, and have all employees sign an agreement to comply with the standards. Make compliance training a part of new employee orientation and conduct annual re-training for all staff.
3. Conduct initial compliance training and education for physician and staff. Training can be outsourced, and is also available online. Document all training.
4. Oversee internal monitoring and auditing, and document the results.
5. Respond appropriately to detected offenses and develop corrective action plans. Document offenses and responses.
6. Develop open lines of communication and encourage employees to discuss compliance at staff meetings, or in one-on-one meetings.
7. Enforce disciplinary standards through well-publicized guidelines.
Make sure that your compliance plan is not just a binder on the shelf! All employees must understand the seriousness of the penalties (There are lots of examples online to illustrate this.) and the importance of compliance to the success of your practice.

Common Sense Billing and Coding Compliance

Compliance can be a little tricky to define, but in the context of health care billing and coding, compliance is all about what we don’t do, rather than what we do. Here are 16 common sense and simply-worded rules:
1. Don’t bill what wasn’t documented.
2. Don’t bill what wasn’t done, thinking it probably was or will be.
3. Don’t provide unnecessary services.
4. Don’t name someone in the medical record or on the claim who wasn’t there.
5. Don’t double bill the payer.
6. Don’t change the place of service to maximize payment.
7. Don’t unbundle services that are part of a single service.
8. Don’t charge for related services during the global period.
9. Don’t upcode or downcode services.
10. Don’t neglect or misuse modifiers that would change the payment.
11. Don’t discount care to patients for referring other patients.
12. Don’t waive patient balances unless a financial need is documented.
13. Don’t keep the money if a patient or payer overpays.
14. Don’t change the diagnosis to achieve payment if the payer denies payment based on the diagnosis.
15. Don’t accept money or gifts to prescribe drugs, refer patients, or order procedures or tests.
16. Don’t direct patients to the facility that you own for a necessary test or procedure without disclosing that you own part or all of the facility.

101 Ideas for Increasing Revenue and Decreasing Expenses in Your Medical Practice

2011-11-16T11:15:00.000-06:00

Contributed by: www.ManageMyPractice.com

BUILD ON WHAT YOU’RE CURRENTLY DOING:

1. Add physician hours – add evening or weekend hours; start your office hours earlier and end hours later.

2. Reduce physician time off – decrease vacation or change weekly days off to 1/2 days off.

3. Set a minimum number of providers to be in the office seeing patients at all times the office is open.

4. Have each provider add one new patient visit to his/her schedule weekly.

5. Add ePrescribing to recoup additional Medicare revenue and streamline prescribing (there are free ePrescribing software packages available, but evaluate them carefully so they don’t add more complexity to the system instead of less.)

6. Report PQRI measures to recoup additional Medicare revenue.

7. Charge patients an out-of-pocket fee for completing patient forms – disability forms, etc. and reserve office visits for treating patients.

8. Choose an EMR that qualifies your practice for the ARRA money (although it has been widely promoted that in a larger practice, an EMR and its associated work will cost more than you will get from the government.)

9. If you are in an underserved or rural area, check to see if there might be grants or funds available locally, in the state or federally, for adding a service to your practice.

10. If your practice does Independent Medical Exams (IMEs), reviews records or depositions, make sure that your fee schedule for such services is current and that the fees are collected before the physician provides the service.

ADD TO YOUR CURRENT SERVICES:

11. Allergy testing & treatment

12. Dispensing pharmaceuticals

13. Dispensing nutriceuticals

14. Dispensing Durable Medical Equipment

15. Group patient visits

16. Coumadin Clinic

17. Heart Failure Clinic

18. Diabetes Education Classes

19. Add primary care to specialty care practices

20. Add specialty care to primary care practices

21. Research

22. Joint Ventures with other practices or hospital

23. Lease space to other entities

24. eVisits (virtual visits or email visits)

25. Elective procedures or services

26. Mid-level providers

27. Walk-in clinic

28. Occupational medicine: drug screens, employment physicals, etc.

29. Hospitalists

30. Medical Director of local nursing homes

31. Complementary & alternative medicine (CAM)

32. Aging in Place services

33. Social worker

34. Concierge practice

35. School team physician

EVALUATE YOUR REVENUE CYCLE MANAGEMENT:

36. Are you renegotiating payer contracts regularly?

37. Do your scheduling staff know how to educate patients about what payers you have contracts with and are in network with and what the patient’s financial responsibility will be?

38. Do staff know what typical new patient charges are to tell the patient?

39. Do you check every patient’s eligibility for insurance benefits immediately prior to every service?

40. Do you have patients sign a financial policy to acknowledge what they are responsible for based on their payer type?

41. Do you copy the patient’s insurance cards at every visit, or at least compare their current card to the card you have on file? Are you able to scan patient insurance cards and driver’s licenses into your practice management (PM) system?

42. Is your PM system able to download the information from the scan into the patient registration screen? If not, do you have a way to confirm that demographic and insurance information has been entered correctly from the cards?

43. Are your charges being posted daily?

44. Does the person who provides the service, or a documentation coding specialist, choose the CPT and ICD9 code?

45. Is the documentation for the charges being completed within 24 hours of the service?

46. Is your encounter form up-to-date with current CPT and ICD9 codes; do you order smaller batches of them so you can change the codes as new services are added in the practice?

47. Do you check the CPT and ICDD9 matching to make sure the codes are valid for the year, the codes adhere to NCCI and LCD edits before you finalize the charges?

48. Do you regularly audit medical records for coding and documentation and give providers feedback on where coding could be improved?

49. Are you using ABNs for Medicare patients who want services that Medicare might not pay for?

50. Do you file claims daily?

51. Do you correct claims daily when they are rejected at the practice management, claims clearinghouse or payer level?

52. Do you correct claims daily when they are rejected at the claim level and are not paid for for reasons that can be corrected?

53. Do you have your contract allowables in your PM system so you know when you are not being paid correctly by contract?

54. Do you appeal unpaid or underpaid claims?

55. Do you check recoupments or requests for refunds from payers and make sure they truly should be refunded?

56. Do you send insurance and patient payments to a lockbox to be scanned and stored digitally for your staff to post from?

57. Do you make payment arrangements in the office for balances after insurance has paid, or payment plans by drafting credit or debit cards?

58. Do you have a policy of not sending statements?

59. Do you collect the patient’s portion of the service at the time of service?

60. Do you collect fees for elective services prior to providing these services?

61. Can your patients make payments online through your website?

62. Do you file a claim with a patient’s estate if they have died?

63. Do you accept cash only from patients who have passed bad checks?

64. Do you accept cash only from patients who have filed bankruptcy with your practice?

65. Do you inadvertently see patients who have been dismissed from your practice?

66. When adding a physician to the practice, do you timeline the credentialing appropriately so the physician can see patients with insurance as well as those without?

67. If your new physician is only partially credentialed with payers, do you have him/her see the patients with payers they are credentialed with and add payers to their schedule load as the credentialing comes through?

68. Do you meet with representatives from your largest payers monthly to establish relationships and bring problems to their attention? (the squeeky wheel theory of payer relations)

69. Are you pre-certing everything that needs pre-certification or pre-authorization or pre-notification to be sure the service will be paid?

70. Are you receiving payments via electronic funds transfer (EFT)?

71. Are you receiving explanation of benefits (EOBs) or remittance advice (RA) electronically?

72. Are you posting your RA electronically?

73. Are you protecting your practice from embezzlement? (see my post on this here.)

74. Is someone in the practice responsible for staying current on changing coding requirements for Medicare, Medicaid, Tricare and commercial payers?

DECREASE EXPENSES:

75. Eliminate overtime. Evaluate the need for additional staff (part-time?) vs. overtime.

76. Send some staff home (sometimes called “low census”) when there are no patients to be seen.

77. Use volunteers. Tap into the local hospital volunteers, or recruit and train your own.

78. Hire an after-school student employee to do routine jobs.

79. Discontinue paying staff for inclement weather closings when the practice is not open.

80. Shop everything. Negotiate existing service contracts. Do not assume anything is non-negotiable. Negotiate the rent.

81. Get rid of yellow pages advertising. It rarely brings you new patients and is primarily a place to look up phone numbers. You will still get your white pages listing free with your phone service.

82. Utilize pre-employment testing to make sure job applicants have the skills you need.

83. Shop postage machines or look into stamps.com.

84. Join a group purchasing entity (hospital, professional association, etc.)

85. Improve your accounting cycle. Invoices and statements are matched up with packing slips and negotiated prices. Use purchase order numbers.

86. Get the payment discount by paying on time or early – ask vendors for an on-time or early payment discount.

87. Make sure office supplies are not going home with the employees. Make sure office supplies that are ordered are “really need” and not “sure would be nice.”

88. Remind patients of their appointments to decrease no-shows. Call patients who no-show and attempt to reschedule (unless they feel better!) Track no-shows and evaluate the reasons for them.

89. Consider charging for no-shows or dismissing patients for no-shows.

90. Have a good recall system in place. If patients leave without scheduling a needed follow-up, make sure that they are called if they have not scheduled within a certain amount of time. Keep track of annual wellness visits and remind patients to schedule them.

91. Take advantage of any discounts offered by your malpractice carrier by completing risk management surveys and having speakers give annual updates on decreasing malpractice claims. Some carriers give discounts for managers who are members of MGMA or Fellows in the ACMPE.

92. Evaluate any discounts on services or products offered by your physicians’ professional associations and societies.

93. Evaluate your leases - are those big old copiers and faxes worth paying for a service contract?

94. Consider speech recognition/voice recognition and eliminate transcription.

95. Review your computer maintenance contracts. Are you paying for maintenance on equipment or software that is no longer being used?

96. Take advantage of online CME for physicians, midlevel providers, clinical staff and managers.

97. Make plans to attend face-to-face seminars well in advance to take advantage of early enrollment discounts and good flight deals.

98. Evaluate outsourcing. Think about outsourcing transcription, coding, billing, pre-authorizations, credentialing, switchboard, payroll, accounting and medical records copying.

99. Replace your answering service with an answering machine educating patients on the limited reasons for calling after hours and giving the number of the physician on call.

100. Destroy archived financial and medical records that you are paying to store, once you have ascertained that they exceed the required time limit.

101. Hold a brainstorming session with the staff and ask for their ideas for increasing revenue and reducing expenses. The people on the front lines will have excellent ideas. In return, do not nickle and dime the staff to death by charging for coffee, reducing parking stipends or eliminating uniform allowances. Keep in mind that for your rank and file staff, having to pay for their own uniforms or paying more for parking might be a deal-breaker that causes them to search for work elsewhere. Try to focus on the bigger items for savings and make sure the staff know you are trying to keep their small benefits in place in appreciation for their work.

Ten Golden Rules for Your Medical Office Staff

2011-11-09T12:31:00.002-06:00

Contributed by: www.ManageMyPractice.com

Sometimes employees do not understand or follow the most basic of workplace guidelines. Here is a simple but comprehensive list that you can tweak to make your own. It covers about 25 basics in a short list of ten “Golden Rules”. Make it part of each job description or personnel handbook and/or post it in strategic places.

1. Report to work on time daily. Be ready at your desk to begin work at the designated time. Leave promptly for lunch and return to work when you should, unless you’ve made special arrangements with your supervisor. Take breaks on the honor system and do not abuse the privilege. Clock in and out faithfully.

2. Command respect from the physicians, managers and employees of (your practice name here) by demonstrating total professionalism in the workplace with your dress, your demeanor and conversation. Represent the practice in a way that would make your Mother and your boss proud of you. Treat your co-workers as you would like to be treated.

3. Be economical by not wasting time or supplies or doing sloppy work that must be re-done.

4. Give every patient your total attention, patience and courtesy. Do not assume you know what the patient is going to say, but listen carefully to the patient (in-person or on the phone) so you can assist them to the best of your ability. Remember how good it feels to be the center of someone’s attention and give that gift to every single patient.

5. Keep your supervisor aware of any problems in your workload, whether too much or too little. Do not expect your supervisor to know if you are falling behind or caught up.

6. Document all interactions with patients and other medical facilities to assist your co-workers in knowing what you have done, and document your resolution of the situation to the customer’s satisfaction.

7. Strive for a positive attitude every single day. Don’t whine.

8. Be a team player. This means both covering for your co-workers and knowing that they will cover you. This means supporting your co-workers to their faces and behind their backs. This means having (your practice name here) goals for your goals, and knowing that your success will be your team’s success, and ultimately, the success of the practice.

9. Clean up your own messes and act as an adult acts in the workplace: responsibly, maturely, and with thought for others. Accept blame for your own mistakes, knowing that everyone makes them, and that if no one is making any mistakes, nothing is improving.

10. Contribute to making (your practice name here) a good place to work. Only you can create a place where everyone enjoys working. Only you can make this place a good place to be.

For more medical office rules, read “21 Common Sense Rules for Medical Offices.”

Steve Jobs, Social Media and iPad enabled voting: A look at what’s next in technology and healthcare.

2011-11-08T14:17:00.001-06:00

Contributed by: www.ManageMyPractice.com

At Manage My Practice, we have always been fascinated by the opportunities created when innovation and technical advancements are applied to the Healthcare system. The intersection of technology and medical practice has always been one of the most exciting spaces in research and development because the challenges of the Human Body are some of the most daunting and emotionally charged of our endeavors. Curing diseases, diagnosing symptoms and improving and saving lives are among our most noble callings, so naturally they inspire some of our brightest thinkers and industry leaders.
As managers, providers and employees, we always have to be looking ahead at how the technology on our horizon will affect how our organizations administer health care. In the spirit of looking forward to the future, we present “2.0 Tuesday”, a weekly feature on Manage My Practice about how technology is impacting our practices, and our patient and group outcomes.
We hope you enjoy looking ahead with us, and share your ideas, reactions and comments below!

Steve Jobs thought iCloud had the potential to store Medical Data

Apple’s recently announced iCloud service let’s you store pictures, movies, music, and documents in Apple’s “cloud”, or Internet storage system, and retrieve them with your iPhones, iPods, iPads, and Mac computers. Dr. Iltifat Husain, writing for the IMedicalApps blog notes that in the new biography of the Apple founder, Jobs mentioned that he thought even personal medical data would one day be stored in Apple’s iCloud. Cloud storage is all the rage right now in a lot of different areas of technology, but Jobs saying that medical data would be stored on the consumer end next to vacation photos and favorite songs represents a very bold vision of the future of patient data.

Researchers using Social Media to study attitudes about Public Health

A team led by Marcel Salathé, PhD at Pennsylvania State University published a study last month in PLoS Computational Biology that used “tweets” gathered from the social network Twitter to analyze how the public felt about the H1N1 influenza vaccine in 2009. Although Social Media research has limitations, Christine S. Moyer, writing for the American Medical Association’s Amednews.com notes that the results were similar to traditional phone surveys conducted by the Centers for Disease Control, and provides some other examples of how Social Media has been used to understand public health trends.

Interesting EHR/EMR data from the Soliant Health Blog

Medical staffing specialist Soliant Health had very eye-opening list of statistics about EHR/EMR implementations on their blog last week. My personal favorite: Hospitals using EHR/EMR systems have a 3 to 4% lower mortality rate than those that don’t. Very interesting numbers.

HealthWorks Collective predicts changes in healthcare communications after ACA

Healthworks Collective‘s Susan Gosselin makes some predictions about how the communications between and among providers and patients are going to be changed by the Affordable Care Act (or Healthcare Reform)- and what both groups will demand from a changing system. Great stuff!

Oregon to help disabled voters cast ballots using iPads

In today’s local and congressional elections, five counties in the state of Oregon are going to be equipping local officials with iPads preloaded with special touch-interface software to accompany people with physical or visual impairments, or who would otherwise have a hard time making it to the polls. The 9 to 5 Mac blog is reporting that the pilot program features hardware donated by Apple, and could soon spread statewide by the next election.

2012 Medicare Deductibles and Premiums: Is This the Year You’ll Collect Deductibles at Time of Service?

2011-11-08T09:57:00.003-06:00

CMS just announced the new numbers for premiums and deductibles for 2012. Now is the ideal time to think about Medicare deductibles and what your policy is on collecting deductibles at time of service.
If you’ve been hesitant to collect deductibles, ask yourself if you can handle the loss or delay of payment of $140 per Medicare patient. Most practices can’t. If you are thinking about collecting deductibles and other front-end collection techniques, my book “The Smart Manager’s Guide to Collecting at Checkout” is your guide to making it happen for your healthcare group. Click here to read more.

MEDICARE PART B (covers a portion of the cost of physicians’ services, outpatient hospital services, certain home health services, durable medical equipment, and other items)

In 2012, the Part B deductible will be $140, a decrease of $22 from 2011.
The standard Medicare Part B monthly premium will be $99.90 in 2012, a $15.50 decrease over the 2011 premium of $115.40.
The standard premium is set to cover one-fourth of the average cost of Part B services incurred by beneficiaries aged 65 and over, plus a contingency margin. The contingency margin is an amount to ensure that Part B has sufficient assets and income to (i) cover Part B expenditures during the year, (ii) cover incurred-but-unpaid claims costs at the end of the year, (iii) provide for possible variation between actual and projected costs, and (iv) amortize any surplus assets. Most of the remaining Part B costs are financed by Federal general revenues. (In 2012, about $2.9 billion in Part B expenditures will be financed by the fees on manufacturers and importers of brand-name prescription drugs under the Affordable Care Act.)
The largest factor affecting the contingency margin for 2012 is the current law formula for physician fees, which will result in a payment reduction of about 29 percent in 2012. For each year from 2003 through 2011, Congress has acted to prevent smaller physician fee reductions from occurring. The 2012 reduction is almost certain to be overridden by legislation enacted after Part B financing has been set for 2012. In recognition of the strong possibility of increases in Part B expenditures that would result from similar legislation to override the decrease in physician fees in 2012, it is appropriate to maintain a significantly larger Part B contingency reserve than would otherwise be necessary. The asset level projected for the end of 2012 is adequate to accommodate this contingenIn 2012, Social Security monthly payments to enrollees will increase by 3.6 percent. The dollar increase in benefit checks is expected to be large enough on average to cover the increase in the Part B premium of $3.50 that most beneficiaries will experience. For those who were paying the standard premium of $115.40, their benefits checks will only increase.

MEDICARE PART A (inpatient hospital, skilled nursing facility, and some home health care)

Approximately 99% of Medicare beneficiaries do not pay a premium since they or their spouses have at least 40 quarters of Medicare-covered employment
Some enrollees age 65 and over and certain persons with disabilities who have fewer than 30 “quarters of coverage” obtain Part A coverage by paying a monthly premium ($451 for 2012) set according to a statutory formula.
Those who have between 30 and 39 “quarters of coverage” may buy into Part A at a reduced monthly premium rate which is $248 for 2012, the same amount as in 2011.
The Part A deductible paid by a beneficiary when admitted as a hospital inpatient will be $1,156 in 2012, an increase of $24 from this year’s $1,132 deductible.
The Part A deductible is the beneficiary’s cost for up to 60 days of Medicare-covered inpatient hospital care in a benefit period. Beneficiaries must pay an additional $289 per day for days 61 through 90 in 2012, and $578 per day for hospital stays beyond the 90th day in a benefit period.
For beneficiaries in skilled nursing facilities, the daily co-insurance for days 21 through 100 in a benefit period will be $144.50 in 2012, compared to $141.50 in 2011.

MEDICARE PART D (medications)

The estimate for the average 2012 Part D premium for basic coverage is $30. This is slightly lower than the actual average for 2011 of $30.76.
The estimate for the average 2012 Part D premium for supplemental coverage is $8. The estimate for the average 2012 total Part D premium is $38.

MEDICARE ADVANTAGE PLANS (replacement for traditional Medicare)

On average, Medicare Advantage premiums will be 4 percent lower in 2012 than in 2011, and plans project enrollment to increase by 10 percent.
Of people with Medicare, 99.7 percent continue to enjoy access to a Medicare Advantage plan, and benefits remain consistent with those offered in 2011.
Those who enroll in Medicare Advantage plans may have different cost-sharing arrangements. On average Medicare Advantage premiums will be 4 percent lower in 2012 than in 2011, and plans project enrollment will increase

Medicare Physician Revalidation Extended Two Years to March 2015 and a Sample Revalidation Letter

2011-11-08T09:55:00.001-06:00

The Centers for Medicare & Medicaid Services (CMS) has extended the revalidation period for another 2 years. This will allow for a smoother process for provider and contractors. Revalidation notices will now be sent through March of 2015.

IMPORTANT: This does not affect those providers which have already received a revalidation notice. If you have received a revalidation notice from your contractor, respond to the request by completing the application either through internet-based PECOS or completing the appropriate 855 application form.

The first set of revalidation notices went to providers who are billing, but are not currently in the Provider Enrollment, Chain and Ownership System (PECOS). To identify these providers, contractors searched their local systems and if a Provider Transaction Access Number (PTAN) for a physician was not in PECOS, a revalidation request for that physician was sent. CMS asks all providers who receive a request for revalidation to respond to that request.
For providers NOT in PECOS – the revalidation letter will be sent to the special payments or primary practice address because CMS doesn’t have a correspondence address. For providers in PECOS – the revalidation letter will be sent to the special payments and correspondence addresses simultaneously; if these are the same it will also be mailed to the primary practice address. If you believe you are not in PECOS and have not yet received a revalidation letter, contact your Medicare contractor. Contact information may be found here.
Institutional providers (i.e., all providers except physicians, non-physician practitioners, physician group practices and non-physician practitioner group practices) must submit the application fee with their revalidation. In mid-September, CMS revised the revalidation letter that contractors sent to providers to clarify who must pay the fee.
CMS plans to post a list of providers who were sent requests to revalidate. They will make an announcement via CMS listservs when this information is posted.
See sample revalidation letter below.
THIS IS A REVALIDATION REQUEST IMMEDIATELY SUBMIT AN UPDATED PROVIDER ENROLLMENT PAPER APPLICATION 855 FORM OR REVIEW, UPDATE AND CERTIFY YOUR INFORMATION VIA THE INTERNET-BASED PECOS SYSTEM
PROVIDER/SUPPLIER NAME
ADDRESS 1,
ADDRESS 2
CITY STATE ZIP CODE
NPI:
PTAN:
Dear Provider/Supplier Name:
In accordance with the Patient Protection and Affordable Care Act, Section 6401 (a), all new and existing providers must be reevaluated under the new screening guidelines in Section 6028. Medicare requires all enrolled providers & suppliers to revalidate enrollment information every five years (reference 42 CFR § 424.57(e)). To ensure compliance with these requirements, existing regulations at 42 CFR § 424.515(d) provide that CMS is permitted to conduct off-cycle revalidations for certain program integrity purposes. Upon the CMS request to revalidate its enrollment, the provider/supplier has 60 days from the date of this letter to submit complete enrollment information using one of the following methods:
Providers and suppliers can enroll in the Medicare program using either the:
(1) Internet-based Provider Enrollment, Chain, and Ownership System (PECOS).
To revalidate via the Internet-based PECOS, go to https://pecos.cms.hhs.gov. This system allows you to review information currently on file, update and submit your revalidation via the internet. Once submitted, be sure to print, sign, date, and mail the certification statement along with all required supporting documentation. In order for us to process the revalidation, the original signature and documentation must be received within 15 days of internet submission.
Physicians and non-physician practitioners will access Internet-based PECOS with the same User ID and password that they use for NPPES. For assistance in establishing an NPPES User ID and password, or if you have forgotten your ID or password or wish to change your NPPES password, contact the NPI Enumerator at 1-800-465-3203 or TTY 1- 800-692-2326, or send an e-mail to customerservice@npienumerator.com
For provider/supplier organizations, your Authorized Official must register with the PECOS Identification and Authentication system. If you have not registered, do so now by going to (https://pecos.cms.hhs.gov). This registration process can take up to three (3)weeks. If additional time is required to complete the revalidation, you may request one 60-day extension, which will begin on the date of the request.
To avoid any registration issues, review the internet-based PECOS related documents available on the CMS Web site (www.cms.hhs.gov/MedicareProviderSupEnroll).
(2) Paper Application Process
To revalidate by paper, download the appropriate and current CMS-855 Medicare Enrollment application from the CMS Web site at www.cms.hhs.gov/cmsforms. Mail your completed application and all required supporting documentation to the [insert contractor name], at the address below.
[Insert application return address]
With the exception of physicians, non-physicians practitioners, physician group practices and non-group practices, providers and suppliers that are revalidating their enrollment information must submit with their application an application fee.
The 2011 application fee of $505 or a request for hardship exception must be included with the provider enrollment application. Submit the enrollment fee via Pay.Gov prior to submitting the application (reference 42 CFR 424.514). You can submit your application fee by electronic check, debit or credit card. If you feel you qualify for a hardship exception waiver, submit a letter and financial statements to request a waiver in lieu of the enrollment fee along with your application or certification statement. Revalidations are processed only when fees have cleared or the hardship waiver has been granted. You will be notified by mail if your waiver request has been granted or if a fee is required.
For more information on the application fees and other screening requirements under the PPACA view the MLN Matters Article at http://www.cms.gov/MLNMattersArticles/downloads/MM7350.pdf.
You are required by regulations found at 42 CFR 424.516 to submit updates and changes to your enrollment information in accordance with specified timeframes. Reportable changes include, but are not limited to changes in: (1) legal business name (LBN)/tax identification number (TIN), (2) practice location, (3) ownership, (4) authorized/delegated officials, (5) changes in payment information such as changes in electronic funds transfer information and (6) final adverse legal actions, including felony convictions, license suspensions or revocations of a health care license, an exclusion or debarment from participation in Federal or State health care program, or a Medicare revocation by a different Medicare contractor.
Failure to submit complete enrollment application(s) and all supporting documentation within 60 calendar days of the postmark date of this letter may result in your Medicare billing privileges being deactivated.
If you have any questions regarding this letter, please call [contractor telephone number will be inserted here] between the hours of [contractor telephone hours will be inserted here] or visit our Web site at [insert Web site] for additional information regarding the enrollment process or the [insert application type].
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Your Guide to the 2012 OIG Work Plan: Does Anything on This List Worry You?

2011-11-01T13:36:00.000-05:00

Here are some highlights from the new OIG Work Plan for FY 2012. There are more items that apply to practices, as well as items for hospitals, nursing facilities, home health, and medical equipment and supplies. The link to the complete plan is at the end of the article.

Compliance With Assignment Rules

If you accept assignment with Medicare (i.e. you accept what Medicare allows as payment for a service), the OIG wants to know if you are adhering to the allowable and not collecting more than the patient’s deductible and co-insurance.

Physicians-Owned Distributors of Spinal Implants (New)

Do physician-owned distributors (PODs) of spinal implants have a conflict of interest when they sell implants to hospitals? The OIG will investigate.

Place-of-Service Errors

Because there is a payment differential between a service provided in a hospital outpatient department or ASC and the same service provided in the physician’s office, the OIG wants to know if you provided the service where you claimed you did.

Physicians: Incident-To-Services (New)

Incident-to services are reported on the honor system – the claim does not reflect that a mid-level provider performed the service under the supervision of a physician. The OIG will dig under the claims to see if practices really understand and follow the incident-to rules.

Physicians: Impact of Opting Out of Medicare (New)

The OIG will be checking that physicians who opted out of Medicare are not filing claims for services, and also monitor disruption of service to Medicare patients due to opt-outs.

Evaluation and Management Services: Trends in Coding of Claims

If you provided E/M services in 2009, you received part of the $32 billion paid out as 19% of all part B payments. Did you pick a code and hope your documentation was up to the task, or did you review your documentation and choose the code that reflected what was there?

Evaluation and Management Services: Provided During Global Surgery Periods

Are physicians correctly ascertaining which services are part of the global surgery period or are they mistakenly charging for services that are wrapped into the procedure or surgery? The OIG knows.

Evaluation and Management Services: Use of Modifiers During the Global Surgery Periods (New)

Check those modifiers used during the global period. This item refers to services provided during the global period that were unrelated to the original service and thereby billable.

Evaluation and Management Services: Potentially Inappropriate Payments

This is the review we’ve all been talking about. The OIG will be inspecting electronic records to see if identical documentation appears serialized in the records.
The original work plan can be found here.

DataPlus Blog

:::Holiday Hours:::

Stark, False Claims and Anti-Kickback Laws: Easy Ways to Stay Compliant with the Big Three in Healthcare

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False Claims Act

Anti-Kickback Statute

Put It All Together: Your Compliance Plan

Common Sense Billing and Coding Compliance

101 Ideas for Increasing Revenue and Decreasing Expenses in Your Medical Practice

Ten Golden Rules for Your Medical Office Staff

Steve Jobs, Social Media and iPad enabled voting: A look at what’s next in technology and healthcare.

Steve Jobs thought iCloud had the potential to store Medical Data

Researchers using Social Media to study attitudes about Public Health

Interesting EHR/EMR data from the Soliant Health Blog

HealthWorks Collective predicts changes in healthcare communications after ACA

Oregon to help disabled voters cast ballots using iPads

2012 Medicare Deductibles and Premiums: Is This the Year You’ll Collect Deductibles at Time of Service?

MEDICARE PART B (covers a portion of the cost of physicians’ services, outpatient hospital services, certain home health services, durable medical equipment, and other items)

MEDICARE PART A (inpatient hospital, skilled nursing facility, and some home health care)

MEDICARE PART D (medications)

MEDICARE ADVANTAGE PLANS (replacement for traditional Medicare)

Medicare Physician Revalidation Extended Two Years to March 2015 and a Sample Revalidation Letter

Your Guide to the 2012 OIG Work Plan: Does Anything on This List Worry You?

Compliance With Assignment Rules

Physicians-Owned Distributors of Spinal Implants (New)

Place-of-Service Errors

Physicians: Incident-To-Services (New)

Physicians: Impact of Opting Out of Medicare (New)

Evaluation and Management Services: Trends in Coding of Claims

Evaluation and Management Services: Provided During Global Surgery Periods

Evaluation and Management Services: Use of Modifiers During the Global Surgery Periods (New)

Evaluation and Management Services: Potentially Inappropriate Payments