As discussed in yesterday’s blog, the Jurisdiction A DME MAC, NHIC, will no longer be issuing paper Acknowledgement Letters for redetermination requests effective April 1, 2012 – a trend that seems to be catching on. In another list serve released by the Jurisdiction D DME MAC, NAS announced that it too plans to eventually eliminate mailing paper Acknowledgement Letters as suppliers begin to utilize its Endeavor (a web-based alternative to calling the Jurisdiction D IVR) and IVR systems to verify the receipt and status of appeals.

Note: This change does not impact decision letters, only the acknowledgement letters sent to confirm your appeal was received.

Beginning yesterday, February 29^th, suppliers in Jurisdiction D may obtain the status of an appeal by calling the MAC’s IVR and selecting the appeals menu option. You must wait at least 10 days from date your appeal is received for it to be uploaded into the IVR system and will need the following information to access the status of your appeal:

1. Your National Provider Identifier (NPI)
2. Your Provider Transaction Access Number (PTAN)
3. The last five digits of your Tax Identification Number (TIN)
4. The patient’s Medicare number
5. The patient’s name as it appears on their Medicare card
6. The 14-digit claim control number (CCN). This can be found on your remittance advice in the Internal Control Number (ICN) field.

NAS has not specified the exact date it plans to discontinue mailing Acknowledgement Letters; however, we don’t expect it to be too far down the road. Information on how to use the IVR to check on the status of an appeal is available on the NAS website here.

On January 20, 2012, CMS released change request (CR) 7167, which provides the DME MACs with instructions on how to obtain payment from a DME supplier’s surety bond. Effective February 21, 2012, if a supplier has not made at least partial payment towards an identified overpayment within 101 days of the date on the payment demand letter, the DME MACs are to request payment from the supplier’s surety.

Preventing Debits to Your Bond:

It’s important to note that the new instructions do not alter your appeal rights and your surety bond will be tapped as a last resort. Suppliers will still be able to have payments offset from their pending claims to settle a debt. As long as you are actively billing Medicare (defined as at least once per year) and an offset is actively taking place for any overpayments for which you do not appeal timely or lose your appeal, this will satisfy the partial payment requirement. In the case of most overpayments, providers typically will see automatic offsets if full payment is not received timely.  While interest does begin to accrue and you end up paying more money in the end, this process will actually keep most suppliers from facing the threat of having their surety bonds tapped into.

However, if your cash flow dries up and you are unable to remit payment in full or offset claims to make good on an overpayment, you will want to contact your MAC and request an extended repayment plan (ERP) immediately. To be considered for an ERP, you must submit your request in writing and explain your current situation. ERP requests must reference the specific overpayment, the number of months requested for repayment, the monthly payment amount, and must include the first month’s payment. In addition, you must provide specific documentation to support your financial hardship. For more detailed information on what must be included in an ERP request, see the Overpayments and Refunds chapter of your DME MAC’s Supplier Manual.

The whole intent behind surety bonds is to ensure Medicare has a way to retrieve owed debts from suppliers who may otherwise just pack up and walk away. By providing a bond, the surety is agreeing to repay Medicare any debts owed by the bonded supplier (up to the amount of the bond) in the event attempts to collect money from the supplier prove unsuccessful. The surety is only liable for overpayments incurred during the term of the bond.

Collection Procedures:

The following procedures have been laid out in CR7167 for collecting overpayments from a DME supplier’s surety:

1. An electronic list of bonded suppliers will be sent to the DME MACs by the Provider Enrollment Operations Group on a monthly basis.
2. The DME MACs will review the list monthly and identify any suppliers who have not remitted full or partial payment for an overpaid claim within 101 days of a demand letter being sent.
3. The DME MAC will send the supplier’s surety a letter informing them that they must remit payment for the amount owed within 30 days. The surety will be responsible for any debt incurred under the term of the bond, up to the amount of the supplier’s bond, including any accrued interest.
4. The DME MAC will provide the surety with sufficient evidence that the supplier owes the delinquent debt. The MACs are given significant discretion to determine what constitutes “sufficient” evidence.
5. Once payment is received from the surety, the DME MAC will send a letter to both the supplier and the NSC within 15 days, notifying them that the debt has been paid. 

If the bond ends up being reduced, suppliers must obtain additional coverage to maintain the required $50,000 bond minimum within 30 days of being notified that their bond has been debited by the DME MAC. If just a portion of your bond is debited and you do not wish to obtain a new $50,000 bond, your only option is to obtain the additional amount needed to meet the minimum $50,000 bond requirement through your current surety and have it added to your current bond. CMS will not allow suppliers to obtain any new bonds in amounts less than $50,000. If you are unhappy with your surety and do not want to purchase additional coverage from them (or they refuse to sell you additional coverage), you have two options:

1. Cancel the remaining bond and obtain a new $50,000 bond with another surety. In this scenario you will be losing any money you have paid on the current term of the bond
2. Keep the remaining amount with your current surety in addition to purchasing a new $50,000 bond from another surety. In this scenario, you will have a total coverage of greater than $50,000. With this option, you will be able to ride out the term of your current bond, having it serve as backup coverage.

Although obtaining surety bonds became a mandatory part of enrollment into the Medicare program in 2009, up until now there have been no procedures in place for how to retrieve owed monies from a supplier’s surety. As a consequence of the new regulations, suppliers may see an increase in the fees paid to obtain or renew bonds once sureties begin to feel the sting of repaying monies owed by their bonded suppliers. Additionally, suppliers who have had their credibility damaged by a debit from their bond may find it challenging to obtain additional coverage with their current surety, or a new surety, in order to maintain the required minimum bond amount of $50,000.

The Appeals Process:

While not specifically discussed in the change request, we do not expect bond debits to impact the appeals process. Under current guidelines, suppliers may stave off recoupment attempts by entering into an appeal at the first level, redeterminations, within 40 days of the date on the demand letter. If the final determination is unfavorable, you then have an additional 60 days from the date of the determination to enter into an appeal at the second level, reconsiderations, before CMS may begin recoupment attempts. In this scenario, it will be greater than 101 days before a final determination is made at the second level. However, it is our expectation that if a supplier staves off recoupment by entering into a timely appeal at the first and second levels, the supplier will not be required to remit payment until the final determination is received (even if 101 days passes).  Again, you have the option of remitting a check or voluntarily offsetting claims once it comes time to pay the piper.  As a reminder, there are no additional protections to prevent recoupments after the second level of appeals. If your appeal comes back as unfavorable recoupment will resume with interest.  Pursuit of an Administrative Law Judge Hearing (third level of appeals) in and of itself will not prevent recoupments until you procure a favorable response.

A new pilot program, scheduled to begin in September 2011, will allow providers and suppliers to respond to documentation requests from most audit contractors electronically. Per CMS, the primary goal of Medicare’s Electronic Submission of Medical Documentation (esMD) pilot project is to reduce costs and cycle time by minimizing and eventually eliminating the mailing of paper documentation to medical review contractors.

The esMD program will be implemented in two phases. Beginning in September of this year, suppliers will have the option to respond to documentation request letters electronically. By 2012, CMS will expand esMD to allow review contractors to also send electronic documentation requests, rather than mailing paper letters.

Participation in the esMD program is completely voluntary. Physicians, hospitals and suppliers who wish to participate will need to obtain access to a special internet gateway, known as a CONNECT-compatible gateway, that meets the security standards established by the Nationwide Health Information Network (NHIN). Much like the network service vendors charged with providing connectivity to the CEDI gateway, suppliers will need to go through an authorized Health Information Handler (HIH) to obtain access to the esMD system. A total of 27 HIH’s will ultimately offer access to a CONNECT-compatible gateway; however, only the following 5 are expected to be ready to handle transmissions by September 2011: 

• HealthPort (http://www.healthport.com/)
• IVANS (http://www.ivans.com/)
• MRO (http://www.mrocorp.com/)
• NaviNet (http://www.navinet.net/)
• RISARC (http://www.risarc.com/)

Suppliers should take the following into consideration when deciding whether to participate in esMD:

1. Just like with the CEDI network vendors, the HIHs will likely charge suppliers a fee to submit documentation through their gateways. Fees are set independently by each HIH and are not regulated by CMS, so be sure to shop around.
2. The esMD system will only accept documents in a portable document format (PDF). Paper documents will need to be scanned and converted into PDF files before being transmitted. If you have an electronic health record system or program that is able to export information in PDF format, such as Adobe Acrobat, this should not be an issue. Also, some HIHs may also offer scanning and conversion services in addition to their esMD services.
3. Not all audit contractors are accepting electronic submissions at this time. While all DME MACs are expected to eventually participate, not all RAC and ZPIC contractors have jumped on board. Suppliers who do not wish to participate in esMD or who are submitting responses to non-participating medical review contractors may continue to mail or fax documentation for review.

Medical review contractors planning to participate in the esMD program and accept electronic submissions include:

Beginning September 2011:

• The CERT Contractor
• RAC A (DCS)
• RAC B (CGI)
• DME MAC A (NHIC)
• DME MAC D (NAS)

Beginning November 2011:

• RAC D (HelathDataInsights)
• DME MAC B (NGS)
• ZPIC for  Zones 1 and 7 (SafeGaurd Services)

Beginning January 2012:

• DME MAC C (CGS)

Although the Jurisdiction C RAC (Connolly Healthcare) has not confirmed participation in esMD, CMS expects the RAC to begin accepting electronic transactions within the next 12 months. At this time, there is no word on whether the remaining ZPIC contractors will participate.

For more information, including a complete list of providers who plan to offer esMD gateway access, visit: http://www.cms.gov/esMD and http://www.qssinc.com/esmd.

The DME MACs have released a universal redetermination request form for DMEPOS suppliers, according to an NHIC, DME MAC A list serve issued earlier today.

“The new form is designed so that you can easily include all of the basic information needed to submit a redetermination request and will be valid in all four DME MAC Jurisdictions, meaning that suppliers who submit claims across multiple jurisdictions will only need to deal with one Redetermination Request Form regardless of which DME MAC to whom they are submitting their request.”

A copy of the new form may be downloaded at:

 http://www.medicarenhic.com/dme/forms/DME_Redetermination_Request_Form.pdf.

Good news for DME suppliers struggling to get physicians enrolled in PECOS! CMS has instructed the Part A and Part B MACs to perform a one-time mailing of a PECOS solicitation letter to every physician in their jurisdiction who is enrolled in Medicare, but who isn’t found in the PECOS system. Those physicians who need to establish an enrollment record in PECOS will soon receive a letter directly from their MAC, which provides them with instructions on how to enroll in the system and informs them of the consequences of non-enrollment (i.e. the inability to order or refer services for Medicare beneficiaries).

All solicitation letters must be sent to physicians no later than June 28, 1010. In the event that a letter is returned as undeliverable, CMS has instructed the MAC to place the letter in the physician’s file, but to take no further action otherwise.

A copy of the letter has been pasted below. The full instruction issued to the MACs is located at: http://www.cms.gov/transmittals/downloads/R712OTN.pdf.

Dear Physician/Non-Physician Practitioner:

 

Our records indicate that you do not have an enrollment record in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) because you enrolled in Medicare prior to the implementation of PECOS and you have not submitted any updates to your Medicare enrollment information in the past 6 (or more) years. PECOS is the enrollment system for Medicare providers and suppliers.

 

There are three important reasons why you should take the necessary action to establish an enrollment record in PECOS as soon as possible. First, updating your Medicare enrollment record will assist us in ensuring payment accuracy for the services you furnish to Medicare beneficiaries. Second, you will need an approved enrollment record in PECOS to continue to order or refer items or services for Medicare beneficiaries. Finally, in accordance with the American Recovery and Reinvestment Act of 2009, Title XIII, known as the “HITECH Act,” incentive payments may be made by Medicare and Medicaid to enrolled “eligible professionals” and certain hospitals that meet the HITECH requirements. More information on Medicare HITECH incentive payments can be found at http://www.cms.hhs.gov/Recovery/11_HealthIT.asp under “Related Links Outside CMS” on the CMS web site. The Centers for Medicare & Medicaid Services (CMS) will use the PECOS enrollment records to verify Medicare enrollment for HITECH incentive payments. Therefore, you will not be eligible to receive incentive payments from Medicare for meaningful use of certified electronic health records if your enrollment information is not maintained in PECOS by CMS.

 

Since you do not have a current Medicare enrollment record, it is imperative that you immediately begin the process to establish your enrollment record in PECOS. CMS expects you to do this as soon as possible after receiving this letter. If you have already submitted an enrollment application within the last 60 days, and your enrollment application has been accepted for processing by the carrier or A/B MAC, you need not take any additional actions based on this letter.

 

You can submit your enrollment application in one of two ways:

 

(1) Use Internet-based PECOS  

 

Step 1. Before you begin, be sure you have a National Provider Identifier (NPI) and have created a User ID and password in the National Plan and Provider Enumeration System (NPPES). You will need the NPPES User ID and password in order to access Internet-based PECOS. If you need help creating an NPPES User ID and password, or if you are not sure you ever created them or cannot remember what they are, you may contact the NPI Enumerator for assistance at 1-800-465-3203.

 

Step 2. Read the documents that are available about Internet-based PECOS on the CMS Provider/Supplier Enrollment web page (www.cms.hhs.gov/MedicareProviderSupEnroll).

 

Step 3. Once you have completed and submitted your enrollment application using Internet-based PECOS, be sure to print the Certification Statement, sign and date it, and mail it, along with any required supporting documentation, to the carrier or A/B MAC whose name and mailing address will be displayed to you by the system.  

 

Note: If you reassign some or all of your Medicare benefits to a group practice, there will be two Certification Statements to print, sign and date, and one of them will also need to be signed and dated by an Authorized Official of the group practice. The carrier or A/B MAC cannot process your web-submitted enrollment application without having the signed and dated Certification Statement(s) in hand.

 

(2) Complete the paper Medicare enrollment application (CMS-855I) as an initial application. 

 

Step 1. Complete the CMS-855I (if you reassign benefits to a clinic or group practice other than your own, complete a CMS-855R as well), sign and date (blue ink recommended) and mail the application(s), along with any required additional supporting documentation, to the Medicare carrier or A/B MAC. These forms are downloadable from the CMS Provider/Supplier Enrollment web page (shown above) or the CMS forms page www.cms.hhs.gov/cmsforms, or you may request the necessary forms from the carrier or A/B MAC. 

 

Step 2. Once the paper application has been received by the carrier or A/B MAC, the carrier or A/B MAC will begin to process your enrollment application. If additional information is needed by the carrier or A/B MAC to complete the processing of your enrollment application, they will contact you. 

 

You are strongly urged not to delay in establishing your Medicare enrollment record within PECOS, especially if you plan on applying for incentive payments under the HITECH program. 

 

The carriers and A/B MACs are expected to process your enrollment application within 60 days as long as you submit your enrollment application before September 1, 2010.

 

If you need information about Medicare enrollment or how to use Internet-based PECOS, visit the CMS Provider/Supplier Enrollment web page at:

 www.cms.hhs.gov/MedicareProviderSupEnroll.

 

If you need assistance with your NPPES User ID and password, contact the NPI Enumerator at 1-800-465-3203.

 

If you have questions about this letter, contact [carrier or A/B MAC phone number/contact person].

 

Sincerely,

[Name of carrier or A/B MAC]

 

By: Andrea Stark, Medicare Consultant & Reimbursement Specialist

CMS is expanding the claims editing process for DME MACs to include a new defense against claims containing missing, improper or fraudulent physician orders. The new edits require the verification of a referral source’s Medicare enrollment and were designed to ensure that medical equipment is ordered only by those individuals authorized to do so. However, as an unintended consequence, providers now risk having legitimate claims rejected if their referral sources are not properly registered with the Provider Enrollment Chain and Ownership System (PECOS).

The expanded editing process is supposed to allow the DME MACs to verify whether a claim’s ordering physician/practitioner is actively enrolled in the Medicare program by comparing the NPI on your claim to a national list of NPIs in the PECOS database. However, the process is deeply flawed, as registration in PECOS has only recently become a requirement and the database is incomplete.

As you might expect, physicians are required to enroll with their A/B MAC or Local Carrier to submit their own claims for patient encounters, just like DME suppliers have to enroll with the National Supplier Clearinghouse. Traditionally, this meant the practitioner submitted a paper 855-I or 855-R application package. That is, until 2008 when the PECOS system was developed as a way for physicians to enroll online and update their applications via the internet. The online system was first made available to individual practitioners in December, 2008 and was opened to group practices /organizational providers in April, 2009. (Eventually, PECOS will be expanded to allow DME Providers to update their 855-S applications via the internet as well. However, this is not expected to happen anytime soon.).

Until recently, this internet based approach has been voluntary, and many physicians never setup an online PECOS account. The PECOS database feeds into, but is separate from, the carrier maintained file of approved physicians. The local Medicare contractors have been internally updating the PECOS database when paper applications were received with physician enrollments and changes.  But even that process only goes back to November 2003. That means physicians who have been enrolled in the Medicare program in excess of five years and who haven’t made recent updates or changes to their enrollment are not likely to be in the PECOS system. Notwithstanding, CMS has instructed CEDI and the MACs to use this developmental, online database to determine if claims should be processed.

The new editing process is being implemented in two phases.

Phase I:

Effective October 5, 2009, PECOS began providing CEDI and VMS with a list of all Medicare approved physicians/practitioners who are eligible to order and refer beneficiary services as reported in the PECOS database. This list is updated on a daily basis.

During Phase I, claims are being reviewed for the requirement of a Medicare enrolled physician/practitioner by comparing the ordering physician’s NPI on the claim to the list of physician/practitioner’s NPIs in the PECOS database. If a valid NPI number is found, further verification will be made by comparing the first letter of the physician’s first name and the first four characters of the physician’s last name (and these characters must be capital letters to pass the editing process).

Initially, if a name or NPI is found to be invalid, the claim will still be processed and the provider will receive a warning message on their GenResponse report (for electronic claims).

Phase II:

Effective April 5, 2010, claims will be rejected if the ordering physician/practitioner’s NPI is not provided on the claim, not found in the PECOS list, or found to be inactive.  Also effective April 4, 2010, providers will no longer be permitted to utilize their own NPI in place of an ordering physician/practitioner’s NPI.

Rejection Messages:

If a claim is flagged for a warning message or eventually rejected, providers will receive a C200, C201 or C202 error code with a “Referring Provider Not Authorized” rejection message on their GenResponse report (for electronic claims) or Remittance Advice (for paper claims).

Most providers are already receiving these error codes on their GenResponse reports, but don’t know what to do with them. Currently, claims with these errors are still being processed; however, they will begin rejecting on April 5, 2010.

Preventing Rejections:

The first step to preventing rejections is to ensure that you are monitoring your GenResponse Reports and capturing all instances where referral sources are rejecting as not registered in the PECOS system.

To help providers quickly identify which physicians need to register or update their information in PECOS, MiraVista, LLC in collaboration with ClaraVista, LLC (a sister company specializing in outsourced DME billing solutions) has developed a free and simple tool known as the PECOS Warning Extractor (available for download at http://www.starkvistagroup.com. The PECOS Warning Extractor takes the complexity out of filtering through technical GenResponse reports by finding the Phase I rejection warnings on your report and identifying which physician NPIs are related to those warnings.  Once you have this list of NPIs you can quickly notify those physicians that need to begin the PECOS process.

Unfortunately, the PECOS database is not accessible to DMEPOS providers in a downloadable format at this time, but the PECOS database is used to populate the “Find A Physician” search tool on the www.medicare.gov website. However, there are several steps you can take:

1. Identify all physicians with NPIs resulting in warning messages (visit http://www.starkvistagroup.com to download a free tool to help parse out this data).
2. Make sure the physician information contained in your billing software reflects the same NPI and spelling of the physician’s name as reported on the publically available NPPES system: https://nppes.cms.hhs.gov/NPPES/NPIRegistrySearch.do?subAction=reset&searchType=ind. Claims must be billed using the physician’s legal name (i.e. Robert, instead of Bob) and individual billing number, not the NPI for the group practice, and must be reported in all CAPS.
3. Once your software record is verified to be accurate, contact those physicians and practitioners for which you are receiving rejection warnings, and:

a. Refer them to MedLearn Matters publication SE0194 (page 3) for insight on how to enroll in PECOS and the documentation needed to get started. (http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0914.pdf.)

b. Provide them with contact information for the CMS External User Services (EUS) Help Desk for general questions about accessing and using the PECOS enrollment system. The Help Desk’s toll-free number is 1-866-484-8049 and their e-mail address is eussupport@cgi.com.

c. Ask them to enroll in PECOS at: https://pecos.cms.hhs.gov/pecos/login.do using the same user ID and password established with NPPES (the NPI contractor).

d. Provide the NPI Enumerator’s phone number and e-mail address for questions about their NPPES user ID and password. The NPI Enumerator may be reached, at 1-800-465-3203 or via email at: customerservice@npienumerator.com.

At this point many referral sources have obtained an NPI (through the NPPES system), but they may or may not have registered with the PECOS system.  To make matters worse, many physicians remain unaware of the recent requirement to enroll in PECOS, as their claims are not likely to be affected by these new DME specific edits. This enrollment process appears to go more quickly for individual practitioners, but can be a lengthy process taking up to 60 days for organizational/group practices.  In addition to ensuring claims for DME will be processed, physicians should also know that the PECOS database is used to populate the www.medicare.gov website. If they are not currently in the PECOS database, patients that search for a provider on the www.medicare.gov website will not be able to find them.  By taking an aggressive, proactive approach to educating your referral sources you can lessen the impact of possible rejections at the first of the year.

By: Michelle Duncan

Effective February 02, 2009, suppliers enrolling in Medicare who are notified by their DME-MAC (or NSC-MAC) of missing documentation in their enrollment applications will be given 30-days to submit the missing documentation.

The 30-day window begins on the date the initial request for information (pre-screening letter) is sent by the DME-MAC. Although not required to do so, a DME-MAC’s future attempts to contact the supplier regarding the same missing documentation does NOT constitute a new 30-day period.

DME contractors may reject the application of any supplier who does not furnish all requested documentation or supporting information within 30 calendar days.

Should a provider’s Medicare enrollment be revoked by CMS or their DME-MAC (including NSC-MAC), the revocation will be effective 30 calendar days AFTER the initial notice of determination is sent. However, revocations due to debarment and Federal exclusion are effective the date of debarment or exclusion. Also, if the revocation is a result of a lapse in licenseure or certification, the revocation can be retroactive to the date of expiration. 

More information may be found in MLN Matters Article MM6282.