Angela Hayden & Andrea Stark

Originally set to go into effect on May 1^st, PECOS Phase 2 has been delayed…again. CMS issued word of the delay via their website citing technical issues with the claim processing side for correctly applying the PECOS edits that would have caused erroneous rejections.  Specific information was not released regarding a timeframe for when the new deadline would be set.  So for now, providers have an opportunity to complete their internal review process and avoid immediate claim denials.

Providers are familiar with the many delays that have affected the PECOS project.  Due to repeated delays, Phase 1 has essentially been in effect for 3.5 years in one form or another;  represented to providers via GEN response rejections (pre-5010) then as N544 remark codes on remittance advices (post-5010).

In March 2013, CMS announced that May 1st would be the Phase 2 implementation date.   Yet five days prior to implementation, we have another delay.  What does that mean to providers?  At MiraVista we are advising providers “Don’t get too comfortable”.  The delay is due to a technical issue and is not intended to offer providers a substantial break.  We have no way to officially determine when a resolution will occur, but these types of minor issues can be fixed in as little as 30 days. As such, providers should continue to review their records and ensure accuracy to be prepared for implementation.

Another important announcement took place on April 24^th, which was the introduction of HR 1717 by Congressman Tom Price of Georgia.  Price kept to his word and introduced new legislation to repeal and replace the current Competitive Bidding Program with the Market Pricing Program (MPP).  The bill text was released by Congressman Price’s office and proposes an end to Round 1 pricing effective December 31, 2013.  The legislation also calls for an immediate cease to both Round 2 implementation and National Mail Order, suggesting the termination of any awarded contracts under these programs.  These are hefty requests that are accompanied by a detailed plan of action for the transitional period between the termination of Competitive Bidding and the implementation of MPP.  This transitional plan is an important part of the legislation in order to gain a budget neutral score by the Congressional Budget Office (CBO).  We will keep you up-to-date as we continue to review the legislation and monitor its progress.

Providers are encouraged to reach out to their Representatives to gather support for the new legislation. AAHomecare has provided a template letter to assist in this process which can be accessed here: http://action.aahomecare.org/9244/stop-medicare-bidding-program-home-medical-equipment/.   The bill was introduced with a total of 25 co-sponsors, so be sure to reach out and thank those congressional members who are in support of this pivotal piece of legislation.  Providers can also show their support by joining AAHomecare on Capitol Hill for the Washington Legislative Conference on May 22-23^rd to lobby on behalf of the DME industry (Register here: https://www.aahomecare.org/events/2013/5/washington-legislative-conference)

Bill Text: http://tomprice.house.gov/sites/tomprice.house.gov/files/HR%201717.pdf

Andrea Stark

MiraVista, in collaboration with providers of Group 3 products, successfully initiated discussions with the Jurisdiction C RAC, Connolly Healthcare, to secure modifications to a disruptive automated review.  The implications of the exercise should bring hope to all suppliers that auditing contractors can be rational and make responsive changes when merited.

Providers of Group 3 air-fluidized beds in Jurisdiction C started getting bombarded with automated recoupments from Connolly Healthcare in December, and could not figure out why the claims were being recouped without development.

When researching a RAC audit, the first step is to visit the RAC website and locate the CMS approved audit issues.  We discovered that the websites post a shortened version of the audit issues, and with automated reviews providers do not get development letters that contain the full version of the audit issue direct from the RAC.  Therefore, they do not get an opportunity to view the full description of the audit logic.  Attempts to figure out the true root of the audit logic were elusive until a dialogue began with senior RAC officials.

Connolly officials directed us to a very helpful, but widely unknown, resource.  Connolly has a Provider Portal in place that provides access to audit activity for a given provider.  This portal is the only place where providers can find the detailed description of auditing logic on automated reviews.  If you service Jurisdiction C beneficiaries, you can log in yourself and view the provider-specific data the RAC maintains for your company using your PTAN, State, and a CCN that has been pulled for RAC review by visiting the following link: https://cmsprovider.connollyhealthcare.com/.  When you log into the portal, you can see the history of all the claims audited by this contractor, dollar amounts, service dates, status of the review, and a detailed rationale for the edit.  This data can also be exported to Excel.  Through the portal, providers can see other detailed elements, such as the maximum number of complex reviews the RAC can pull for your company in a 45-day period (as this is provider-specific; limited to 10% of your annual volume of claims submission in a year).

Upon viewing the detailed rationale, we discovered that the claims were being recouped based on a provision in the LCD that requires the USE of a Group 2 support surface 30 days prior to initiation of therapy with a Group 3 bed.  We dug in a little deeper and researched claims from the audited sample and found that most fell into two categories: 1) either the patient had a Group 2 in their history that had capped out and was no longer actively billing, or 2) the patient obtained a Group 2 from another insurer.  In all cases, the patients had used a Group 2 support surface prior to the Group 3, but the problem was that none of the claims had a PAYMENT for a Group 2 immediately before the first service date for the Group 3.

Connolly was receptive to meeting with us to discuss our concerns that the logic structure was targeting too broad a sample.  There are a number of logical reasons that there will be no payment history immediately preceding the Group 3 delivery.  In our dialogue with Connolly, we pointed out that many patients will be on Group 2 therapy for extended periods of time prior to initiation of Group 3 therapy.  The Group 2 products are capped rentals and they convert to purchases after 13 months of rental.  Connolly officials actively listened to our concerns and agreed the logic should be modified.  As a result, the audit was converted from a fully automated review to a semi-automated review.  Connolly additionally modified the logic so that if they find any history of a Group 2 in the data they have available, the claim will NOT be targeted for recoupment or further review.  However, when these provisions cannot be established, the claims will be developed for a complex review/response from the provider to prove the patient had used the Group 2 prior to the Group 3.  This is a HUGE win for providers in this product space!

We are very pleased to report that the logic has already been corrected as of our March conversation and will not affect claims going forward.  However, any appeals in the works for previously targeted claims will have to be resolved through normal channels.  Separate from this audit issue, Connolly has another complex review that is targeting Group 3 claims for development and this audit will require providers to establish documentation that fully complies with all aspects of the LCD to support medical necessity.  When claims are developed for complex review, providers are given 45 days to send in a response to the request.

Audits aren’t going anywhere, and in the course of an increasing number of audits, mistakes will be made by contractors and providers alike.  The key take-away here is that it is possible to establish a reasonable dialogue with contractors.  These dialogues can lead to a meaningful modification of audits with unintended consequences.

Andrea Stark

On March 5th, the National Supplier Clearing House (NSC) posted an article on their website regarding a new extension for DME providers to update their participation agreements with Medicare.  While the original deadline to make this change was 12/31/2012, we were given an extension through 02/15/2013 which was prompted by the “Doc Fix” bill.  Now, DME providers specifically are being granted an even longer extension through 04/15/2013.  So we have a new opportunity to get the word out.  MiraVista originally reported this on our blog to alert providers of the first extension and because this caught us by surprise so late in the game, it sounds like we stirred up enough dust that CMS found the rationale justifiable for an extension.

Here is the source notification:

http://www.palmettogba.com/palmetto/providers.nsf/vMasterDID/95HKSA6855?opendocument

Non-participating providers are already in good shape.  However, providers that are listed as participating are the ones that will want to consider whether or not they want to remain that way.  This decision will not affect contracted providers under competitive bidding as they are obligated per the terms of their contract to accept assignment for contracted services.  However, it does make a difference to any provider selling Medicare covered products where the Medicare fee schedule reimbursement is not viable.  It is unlikely that a lot of retail pharmacies selling diabetic testing supplies can afford to accept assignment and sell test strips for $10 per box of strips.  A lot of ostomy providers opted out of the participation game ages ago for the same reason.

If a provider is non-participating they can choose to not accept assignment on services rendered, file the claim and let the patient get reimbursed their 80%.  Filing non-assigned is NOT an option available to participating providers.  Additionally, it should be noted that once a provider is designated as non-participating they can still accept assignment and get paid by Medicare for cases they choose to file on an assigned claim basis.  However, there are several nuances to filing non-assigned claims appropriately.  Filing non-assigned does not alleviate the burden of collecting documentation or claim filing, nor does it automatically mitigate risk associated with a claim… it simply does not tie a provider to a fee schedule amount.  Providers will want to consider these and other factors as they contemplate the decision to change from participating to non-participating or vice versa.

Here is some of the information we posted with our earlier alert that still remains relevant:

…if you have multiple lines of business, such as a hospital-owned DME, the participation status must be the same for all entities… if the hospital is participating; the DME line of business must also remain participating.

To quickly see if you are listed as a participating supplier, visit this link, and enter the zip code where you are located along with a product you sell, then hit search. If you see a green “P” next to your business, you are registered as a participating provider and must accept Medicare fee schedule rates on any covered product you sell to Medicare beneficiaries (unless you file the paperwork to change your participation status). If there is no green “P” next to your business, there is no need to worry about the deadline and you already have the flexibility to choose assignment on a case-by-case basis. Your final decision to participate or not should be heavily weighted on your product mix and the Medicare fee schedule viability as it relates to your business.

MiraVista does not expect this deadline to be extended again, so providers should take this opportunity to weigh their options and make a decision.  If you have questions, or would like to consult with an expert in the field, you can arrange to speak with Reimbursement Consultant Andrea Stark at 803-462-9959 ext. 246.

Andrea Stark & Angela Hayden

Almost four years after the public implementation of the PECOS project, CMS started the clock on the countdown to Phase 2.  This second phase will implement edits to deny claims dated on or after May 1, 2013 for claims with physician data that does not link to a valid PECOS record.  Claims for DME, Home Health and Part B lab and similar services prescribed by a referring physician will be affected by the new edits.  This has been in the works for quite some time; however, because of the repeated delays to implementation, the call to action has waned.  With larger scale issues on the docket such as Competitive Bidding, PECOS seems to have been all but forgotten.  As previously reported on our blog and in several editions of our signature Vista Notes publication, we believed it to be imminent that suppliers would be given a 60 day window, for the Phase 2 announcement. Now that we are proceeding to implementation, suppliers must ensure that physician records match the PECOS database before the edits go into place. Don’t expect any more delays… the official countdown has begun.

Phase 1 (the informational messaging phase) began in October of 2009 using claim rejection, warning messages to communicate that the ordering/referring provider submitted on a given claim was not PECOS certified.  This front-end warning system was used until the implementation of Version 5010 when these claims were allowed to proceed past the front-end system and warnings are now reflected in the form of a remark code N544 on Medicare remittance advices.  Until now, these N544 remark codes have served only as a warning to providers of denials to come if action is not taken on these flagged physicians. Beginning May 1, under Phase 2, these remittance warnings will become actual denials on future EOBs.

Providers need to act swiftly to identify which physicians in their billing system are problematic and cannot be validated in the PECOS database.  Affected claims will be denied and cannot be reprocessed until the data is corrected or the physician has been certified.   At this stage of the game, most of the N544 remark codes are likely tied to typographical errors, transposed NPI numbers, or incorrect use of group NPI numbers instead of individual practitioner NPI numbers.  There are still a select number of practitioners that are either new or not linked to PECOS, and these will be a bit more difficult to resolve.

Here are a few steps to help you identify which records can be fixed in your billing software and which physicians will require contact:

1. Start by verifying that the NPI from the physician record in your billing system ties back to the individual physician and not a group practice or facility by looking up the NPI in your system on the NPPES website. Make sure there are no spelling errors in the first or last name and that the NPI is correct for the doctor.
2. Next, compare your physician record to the PECOS database located here (in the Downloads section click the CSV version of the Medicare Ordering and Referring File) to verify that this physician is confirmed as PECOS certified.
3. When you do find a match (based on NPI), ensure that the first letter of the first name and the first four letters of the last name match exactly to the PECOS record.  If your record does not match the PECOS file, claims will be denied.
4. Identify and parse out those physicians that do not have a match in the PECOS database and begin contacting them to encourage the completion of the enrollment process.  In the case of long standing physicians they may need to send in a renewal of their Medicare enrollment information, so the PECOS record can be created.  Remind the doctor that none of their referrals for DME, Home Health or lab referrals will be payable after May 1 until this issue is resolved.

While it is in the hands of the physician to complete the enrollment process, there are some resources that providers can use to explain what PECOS is and why this update or enrollment is necessary. The most recent piece of information is provided in an MLN Matters article released by CMS (#SE1305), which is a consolidation of previous instruction and can be found here: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1305.pdf. Physicians should also be reminded that the PECOS database is used to populate the www.medicare.gov website and without enrollment, Medicare beneficiaries will not be able to validate or locate them for new business.

The bottom line is that real revenue is at stake if providers are not mindful of this deadline. By taking these steps and utilizing the resources available, PECOS Phase 2 Implementation can be a smooth transition for providers, but action must be taken now.  For additional guidance on navigating through this process you can attend our webinar on April 10th @2pm EST (registration details here) or contact our office to schedule a consult with reimbursement consultant, Andrea Stark at 803-462-9959 ext.246.

Andrea Stark

**This is a snippet from an article in the February 2013 edition of Vista Notes**

See: http://tinyurl.com/NSCOpenEnrollment

The most substantial provision affecting DME providers in the American Tax Payer Relief Act of 2012 (ATRA) is the provision to reduce all diabetic supplies (including strips, lancets and control solution sold in retail stores) to mail order rates effective 4/1/2013.  This equates to a 14% cut in the upcoming months.  More devastating than this is the next provision to subject retail diabetic supplies to national mail order rates as soon as that program goes into effect on 07/01/2013.  We know now that this will equate to a 72% cut across the board even if you did not participate in the bid program.

Medicare providers that are enrolled as ”participating providers” will most likely have to take the supplies off the shelf and cease selling them in their stores because the prices are not sustainable.  “Non-participating providers” will be left with no choice but to file claims non-assigned.  While non-participating providers can CHOOSE to accept assignment on a case-by-case basis, they also have the right to file claims on a non-assigned basis.  Non-assigned claims allow providers to collect the retail price up front and, after the claim is filed, Medicare remits payment to the beneficiary directly.  Beneficiaries will likely come out of pocket only a few times before they switch to a much cheaper, contracted, mail-order provider that will be forced to accept the cuts.

Because of the doc-fix provisions in ATRA and ensuing fee schedule changes for physicians, Medicare did extend the deadline to change participation status through 02/15/2013.  If you intend to change your participation status with Medicare, you must submit a letter signed by the Authorized Official to the National Supplier Clearinghouse and have it postmarked no later than today 02/15/2013.  Normally the Open Enrollment deadline would have already been closed effective 12/31/2012.  If you are a participating provider selling retail diabetic supplies and you do not want to accept assignment on these products, you may want to consider changing your status.  However, if you have multiple lines of business, such as a hospital-owned DME, the participation status must be the same for all entities… if the hospital is participating; the DME line of business must also remain participating.  To quickly see if you are listed as a participating supplier, visit this link, and enter the zip code where you are located along with a product you sell, then hit search.  If you see a green “P” next to your business, you are registered as a participating provider and must accept Medicare fee schedule rates on any covered product you sell to Medicare beneficiaries (unless you file the paperwork to change your participation status).  If there is no green “P” next to your business, there is no need to worry about the deadline and you already have the flexibility to choose assignment on a case-by-case basis. Your final decision to participate or not should be heavily weighted on your product mix and the Medicare fee schedule viability as it relates to your business.  For additional questions, arrange to speak with Reimbursement Consultant Andrea Stark at (803)-462-9959 ext. 246.

Andrea Stark

*Update on 02/07 corrects a typographical error regarding the number of payments made to contracted suppliers for transitioning beneficiaries with previously rented equipment.

Competitive Bid Prices are officially real and the cuts are deep.  With the announcement of Single Payment Amounts (SPAs) on January 30, the supplier community was stunned.  If you sell diabetic supplies anywhere in the country, or if you are in any of the Round 2 MSAs, you have big questions that need to be answered.  We outline below several considerations that each of you will need to contemplate in some form or other…

Contract Offers:  The first round of contract offers started to arrive on February 1 and gave business owners two weeks to determine what the next three and a half years will hold for the future of the business.  Acceptance is not an easy decision and should not be made lightly.

With hard, fast numbers in hand, you will want to ensure that you can be profitable with the margins you’ll be getting.  Consider variable costs that can wreak havoc on those margins such as wages, overhead expenses, and fuel prices to service what will equate to a much larger area.  Give consideration to the Medicare weight assigned to the HCPCs at the time of bid submission.  Weight was assigned by CMS to HCPCs based on Medicare historic utilization data (which is not always consistent with the most expensive item in a product category).  For example in the CPAP product category there were 23 HCPCs up for bid, Disposable filters was the top product with an overall weight of 35.5% of your bid submission.  The CPAP ranked #11 with an overall weight of 2%. This should guide you with where Medicare highlights the relative market importance.

Consider what contracts you are being offered.  Where will the referrals come from:  Hospitals? Nursing homes? Private Practices?  Sleep Labs?  Wound Care Clinics? Your product mix offerings will play a large role in whether or not you can expect any increases in new referrals.  If you expect to get your referrals from local hospitals, do you have enough contracts to make it worth the discharge planner’s referral?  If you won hospital beds and a competitor won beds, walkers, wheelchairs, and oxygen, chances are they will not split the referral to send you a bed when the patient needs multiple items.

What will life look like after the bid starts?  Do you have the resources to pull through the initial wave of new patients?  Many of the products like oxygen and CPAP setups for example will be documentation heavy.  Heavy documentation requirements will directly impact your DSO.  Remember, you’ll have to get your own supporting documentation for new customers that are switching from a non-contracted supplier (CMNs, orders, chart notes, compliance documentation, etc.).  Can you float the new inventory needs to accomplish these setups while you track down doctors for old documentation and wait 30-60-90 days for orders to get confirmed and reach a billable status?

Switching to a contracted supplier will be treated just like a traditional change in supplier today.  There will be no free passes, and you shouldn’t expect much cooperation from your former competitors that are losing their patients.  Keep in mind however, for every patient that switches from an existing DME capped rental product, you are entitled to start a new capped rental cycle as a newly contracted supplier (regardless of how many rental payments were made previously).  If the patient is an existing oxygen customer that switches from a non-contracted supplier, you are entitled to at least 10 months of rental payments (unless they have more than 10 payments left on their CMN for payment).

But on the flip side, contracted providers are not exempt from audit activity.  In fact, audit activity is traditionally based on increases in volume and billing concentrations… so expect to have a portion of your funds and resources tied up in pre-pay reviews.

Diabetic Suppliers:  With the SPA announcement we also learned that 15 suppliers would be offered a contract to handle the entire nation’s home delivery of diabetic supply needs.  Rates were cut by 72% in this category, and that really stings.  What is worse is that this newly contracted rate will be EVERYONE’s new fee schedule for diabetic supplies beginning July 1, 2013 thanks to the American Taxpayer Relief Act (ATRA).  ATRA is the same legislation that prevented the rest of the nation from falling off the infamous “fiscal cliff”.  A sleeper provision in this bill will force all retail operations to accept this new lower rate when they sell diabetic supplies to Medicare beneficiaries directly.  Another provision in ATRA will help you to slide into this cut by forcing an approximate 14% reduction on diabetic testing supplies sold after April 1, 2013.  The fee schedule updates apply to diabetic testing supplies like strips, lancets, control solution, etc.  They do not affect the glucose monitor purchase price.

Grandfathering: Let’s face it.  If 18,000 suppliers put their name into the round 2 hat and 867 got contracts, there will be more suppliers contemplating what life looks like without a contract.  Suppliers included in this multitude will be contemplating the grandfathering provision that applies to rented equipment.  For traditional capped rental items, like beds, CPAPs and manual wheelchairs, grandfathering will allow you to finish up the rental cycle for any setup that began prior to 7/1/2013.  You’ll still be paid at the rate you started out with (not the newly published SPA amounts).  You will not be allowed to setup any new customers after 7/1/2013… those patients will have to seek out service from a contracted supplier.  Additionally, if the item you are billing requires supplies (e.g. CPAP equipment), then you can bill the accessories for as long as the item is actively billing rental.  After 13 payments are made and the item caps the patient must get their supplies from a contracted supplier.  You will also retain the liability for capped equipment to ensure it is free from defect for the remainder of the useful lifetime of the equipment (5 years from the initial date).

These changes force suppliers to make tough decisions and while we cannot make the final decision for you, MiraVista will partner with you in asking the right questions and contemplating the unforeseen. As you have questions, MiraVista will help direct you to the answers that make the difference between just surviving and thriving.  Arrange to speak with Reimbursement Consultant Andrea Stark  or Operations and Analytical Expert Derrick Stark to discuss your concerns at (803) 462-9959 ext. 246.

Just as a reminder, if you sell an item to a beneficiary that wants to pay you cash and not use their Medicare benefits, you must procure an Advance Beneficiary Notice (ABN) where the beneficiary selects the option to waive their rights.  But it is not as simple as just getting a signature and checking the right box… you must also disclose any reasons you believe the claim would likely deny IF you were to file the claim.  Waiving benefits doesn’t give you a pass on documentation collection or medical necessity verification.

The reason you must go this extra step is because the waiver of Medicare benefits is a revocable designation.  At any time in the future if the beneficiary changes their mind and wants you to file a claim (or if the caretakers get involved and insist you file), you will be obligated to do so.  In the event that the claim is filed and then denies for medical necessity reasons (that were NOT disclosed to the beneficiary in writing), you will be back on the hook to refund monies you collected.  So, do the leg work… make sure that the protections you intended to have at setup are still there waiting for you in the eventual case you have to file that claim.

While there can be profit in the retail market, there are still pitfalls to be mindful of.  This is just one of the can’t miss topics to be discussed in our upcoming webinar with Andrea Stark and healthcare attorney Jeff Baird on Jan 15.  For the last three years, HME News has had Andrea and Jeff present a candid and practical update for the coming year.  In this webinar they’ll tackle entry into cash and internet sales market place, what you should, can and cannot do with regards to patient collections, and common sense protections to ensure you are not left in the wake of the technology revolution.

You can register for this event or reserve a digital recording through our website using the Seminars and Webinars link. Seats are limited so register today!

Andrea Stark and Angela Hayden

It’s that time of year again; deductible season will soon be in full swing. The Medicare deductible is up $7.00 from last year bringing it to $147.00. The first approved claims of the year will be passed to the patients’ deductible and forwarded to the secondary insurance/patient until the deductible is met. Both DME claims and Part B services share the same deductible. While state Medicaid programs will cover the Medicare deductible, most commercial insurance payers pass the cost on to their own deductibles leaving you to pursue the patient.

Providers can utilize real-time eligibility to determine the amount of the beneficiaries’ unmet deductible before processing claims. Beneficiaries with recurring rentals should be notified in advance that they will be required to cover the deductible. Providers do have the right to collect the patient deductible upfront prior to submitting claims.

Some billing software vendors have a built-in feature for deductible holds that will run eligibility automatically to notify you of cases where the deductible has not been met to allow you to proactively attempt collections. In this process claims are held until the deductible has been met.  Contact your billing software vendor to find out what options are offered. If your software does not have this feature, eligibility can also be accessed via the online portals provided by the jurisdictions below:

• NHIC – PSP (Provider Services Portal)
• National Government Services – Connex
• CIGNA Government Services – (Provider Portal is not yet active)
• Noridian Administrative Services – Endeavor

Additionally, providers can take advantage of Claim Status Inquiry (CSI) services through Ivans, Ability or another approved Network Service Vendor (NSV). Search for the term “CSI” on your Jurisdiction’s website for additional details and enrollment information.

Beneficiaries with setups during deductible season and those beneficiaries with recurring rentals or supplies should be educated regarding the deductible. Beneficiaries are responsible for the unpaid deductible as well as the Medicare premium and 20% co-insurance. Notifying patients will likely reduce call volume for those with questions concerning deductibles as it comes across in EOBs. 

Andrea Stark

The DME MACs continue to push buttons and create uncertainty for providers that provide consumable supplies on a regular basis. A recent bulletin takes a pretty swift shot at providers that utilize automated Voice Recognition software and technology to efficiently process refill requests for consumable supplies such as ostomy, urological supplies, surgical dressings, diabetic testing supplies, etc.

Prior to sending out refills suppliers must determine the quantity of each item the beneficiary has on hand.

In the educational articles posted by the MACs (see links below) they have taken a position that questions that result in a Yes or No response will not be accepted as meeting the documentation burden. Questions that spoon feed beneficiaries and only capture an amount of supplies the beneficiary is requesting or responses to questions stating the beneficiary has less than “X” number of days remaining are all considered vague and non-specific, and the contractors will not justify reimbursement based on this captured data. The article further stipulates that the MACs prefer (although they do not require) an actual count of supplies remaining. Basically if your questions produce an identical response from multiple beneficiaries it is likely to be discounted.

So can we continue to use IVRs without risk of incurring audit risk? That is a good question! We are requesting additional dialogue with CMS on these directives and hope to procure a more liberal take on what can and cannot satisfy this requirement. While we maintain the MACs are taking an overly restrictive position beyond the scope of what SHOULD be required to meet this burden, they have put their cards on the table and providers have to adapt accordingly. In light of the directives, MiraVista recommends that scripts be modified to require a unique response from beneficiaries by asking open ended questions. We believe that if the provider asks “How many days of supply do you have remaining?” or “When do you expect that you will run out of your current supply?”, that CMS will have to accept the answer as a unique response. If using an IVR system it is preferred that you collect an individual, open response from the beneficiary to establish compliance with the current CMS requirements. You could model your question along the lines of the following:

“Please take a moment and assess how much supply you have remaining, and then answer the following question: How many days’ worth of supplies do you have left? Enter a two-digit representation for the number of days remaining: 1 day should be entered as 0-1, 14 days as 1-4.”

In cases where the response indicates the beneficiary has more than 10 days worth of supply remaining, your shipment should be delayed or the beneficiary should be personally contacted to verify the response.

This is a featured article from the December 2012 edition of VistaNotes.

Links:

http://www.medicarenhic.com/dme/medical_review/mr_bulletins/

 http://www.cgsmedicare.com/jc/pubs/news/2012/1012/cope20351.html

Angela Hayden

While CMS has not given us a definitive date for the next phase of PECOS implementation, it is coming soon. Once we receive an official notice providers will have 60 days to update their systems before claims will begin to deny. Considering that a portion of the process may include action on behalf of referring and ordering physician, providers should be taking proactive steps now to ensure that internal records are correct.

Some billing software systems are making an effort to assist providers with this cleanup process by completing back end updates based on Medicare’s data. However, because these update processes may not be scrubbing for all criteria to avoid denials, providers are encouraged to complete a manual review of their physician records to screen for missing or invalid data.

In order to pass Medicare edits, a physician record must match exactly with what is on file in the PECOS system. For example, if a physician is registered in PECOS as Dr. Robert Smith and a provider’s billing software record has the same physician on file as Dr. Bob Smith the claim will deny. Name misspellings, transposed numbers and misplaced information are small errors that can cause big delays in claim payment.

When analyzing data, providers should be comparing their records to the PECOS list which can be downloaded here. All suppliers should make an effort to correct inconsistent data within their own billing software and also isolate data for those physicians that are not PECOS certified.

While it is up to the physician to enroll with PECOS, providers can contact non-certified physicians to encourage them to register. Accepting referrals from a non-certified physician could cause claim denials and delays in reprocessing of those claims. Claims that deny for not having a PECOS certified physician cannot be reprocessed until the physician has been certified. Ultimately both providers and to a lesser degree physicians will be affected by this update and it is imperative to take action now rather than waiting to ensure a smooth transition.