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Posts Tagged ‘Medicare Billing’

HME News Interviews Andrea Stark on Face-to-Face

Friday, March 6th, 2015

Angela Hayden

Andrea Stark talks with HME News correspondent Anna McDevitt about the Face-to-Face rule in this exclusive interview. The Face-to-Face (FTF) rule affects a total of 166 HCPCS and requires that a physician document the face-to-face encounter with the beneficiary and sign off on evaluations performed by nurse practitioners, physician assistants or clinical nurse specialists. The evaluation of the beneficiary must have taken place within the six months prior to the detailed written order. Additional requirements handed down for those 166 codes disqualify the use of verbal orders to dispense equipment and instead subject these HCPCS to the detailed written order prior to delivery (WOPD) requirements as outlined in the Program Integrity Manual.  These provisions are broken into two phases of implementation: Phase 1 – the requirement for the detailed written order prior to delivery and Phase II- the requirement for the face-to-face notes to be the supplier’s possession prior to delivery.  Phase I began enforcement January 1, 2014, and we currently have an undetermined delay in enforcement of Phase II.


Andrea will be partnering with Healthcare Attorney Jeff Baird and Liz Beaulieu of HME News to discuss the newest developments in the Face-to-Face in the March 11th webcast “A Look Ahead: Legal and Reimbursement Headliners and Guidance for 2015”, click here for additional details on this event. Despite the delay in enforcement of Phase II, Andrea Stark recommends an early adoption approach to this rule as discussed in her interview.  Click on the image below to view:




Executing ABNs Not in Person

Tuesday, March 3rd, 2015

Andrea Stark


As a general rule, Medicare expects that Advanced Beneficiary Notices (ABNs) will be issued in-person. However, there are exception protocols for delivery “other than in-person” prescribed in Chapter 30 of the Claims Processing Manual 50.7.2 – Options for Delivery Other Than In Person.(http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c30.pdf)


Per the CMS manual, ABNs can be issued via mail, telephone and even via email, BUT the linchpin is that the delivery cannot be disputed by the beneficiary to be considered valid. Having a system that enables you to affirmatively document the notification (and avoid dispute) is the most important component of this protocol. Utilization of tracking mechanisms and/or requiring signature confirmation for mailed notices, delivery confirmation receipts for emailed notices, and recordings of phone conversations can all be reliable tools where appropriate. (Just be mindful that you do this in accordance with state and federal laws as you do not want to run awry of wiretapping regulations).  However, independent data collection will lessen the likelihood that your patient will successfully dispute the delivery of the ABN.


Beyond the delivery of the ABN, the CMS guidance further instructs suppliers to make follow-up attempts to collect a beneficiary signature on the ABN.  These follow-up attempts need to also be documented as part of this protocol.  While not required, we also recommend including a notification that they are responsible for the equipment as long as it remains in their possession; however, if they do not wish to continue accruing future monthly liabilities, they may arrange to return the equipment to avoid any new charges.


When these protocols are followed, the GA modifier should be added to claims for billing purposes once the delivery of information is confirmed (where knowledge is viably transferred and the customer is considered in possession of the information).  Always maintain the documentation of both the initial delivery and follow-up attempts at collecting a signature in the patient’s file should the DME MAC request it. If theses protocols are followed you are not required to have a signed ABN to invoke the protections; however, this protocol is not effective and does not offer protections in scenarios where a supplier cannot confirm the equipment is in use, or cannot make identified contact with the beneficiary. Ultimately, in order to benefit from the ABN protections, the supplier must satisfy the burden of “informing the beneficiary” of their financial responsibility in terms that the patient can understand.


For more details about ABN protections and proper use of the ABN, please join us for an in-depth webinar: “Unraveling the Mystery of the Advance Beneficiary Notice: Harness the Protections and Profit Generating Potential of this Multi-Faceted Form” to be hosted on April 28.


The End of April Brings Big Changes: PECOS Delay & MPP

Friday, May 3rd, 2013

Angela Hayden & Andrea Stark


Originally set to go into effect on May 1st, 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 24th, 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 22-23rd 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


Training Capable Medical Billers

Friday, January 25th, 2013

Derrick B. Stark, CPA


When you close your eyes, you can picture a qualified medical biller. He or she is a labyrinth of useful knowledge about modifiers, diagnosis codes, and the cute quirks of every insurance company on the planet. They can even pitch in when you forget the lyrics to the third verse of “Who Let the Dogs Out.” As long as we set up equipment, they can get payments… until they can’t. They can do it all… until they won’t. We cannot live without them… until we must.


In spite of these challenges, you can structure your organization to produce more capable billers.  Here are the 3 steps to training a capable medical biller.




Medical billing is a process, not a person. There is no single person that knows everything. And even if there was, everything changes. As of yesterday, that knowledge is obsolete. In reality, there are four primary positions in medical billing:

  • Intake and data entry – You know these individuals as customer service representatives, but make no mistake, the billing process starts as soon as the fax machine starts warming up its toner cockles.
  • Transmission – These individuals are responsible for reviewing claims before submission, resolving rejection reports, and printing paper claims and patient statements.
  • Payment posting – These guys do what they say they are going to do…post payments.
  • AR clerks or collectors – AR clerks resolve denials and pursue insurance companies like they stole your grandma’s purse.

These positions are split between two general types: those who move large volumes of data and information quickly and efficiently according to a prescribed logical plan, and those who investigate to solve unique problems based on broad experience. It is very difficult for one person to switch between these categories, so it is important to segregate duties accordingly.




While I am not a proponent of all-day lecturing and self-study, inexperienced medical billers need a point of reference. That is, they need to understand the concepts of medical billing and the prime research sources for the specific questions they will encounter. Develop a curriculum of articles, videos, and/or lectures that cover the following topics:

  • General overview of the company, its history, and its major departments and components
  • Basic billing workshop
  • Research
  • Using the billing software and other significant applications

These educational bits should be broken up over multiple days and interspersed with on-the-job-training.




After the educational genesis, “newbs” should be assigned to an experienced staff member with expertise. This trainer should not be a territorial wildebeest with fangs and an insecurity complex. The habits and attitude of the trainer will very likely transfer to the trainee.


First the trainee should simply observe the work. The trainer should explain what she is doing as she does it and why each task is necessary. As the trainer encounters unusual items, she should walk through the specific steps of determining how to handle the abnormality. Afterwards, switch seats and let the trainee get his hands dirty with the trainer looking over his shoulder. Rinse and repeat.




Once the budding medical billing expert gets traction, they should begin working independently, but the trainer should not dive into a complex project immediately. Prioritize the questions the trainee has and help him discover the answer as opposed to simply giving it to him so the trainer can return to her very important work. Audible huffing sounds are not helpful. It is also important to review the trainee’s work product very closely until it meets standards.


These basic steps, reasonable intelligence, and practice will usually make an inexperienced biller a competent biller within 4-8 weeks.


When Beneficiaries Opt Not to Use Medicare Benefits

Friday, January 4th, 2013

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!


It’s deductible season… Do you have a plan?

Thursday, December 27th, 2012

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:

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. 

Don’t Put Anything in Item 29 Just Yet!

Friday, March 30th, 2012

The DME MACs have released a list serve that has been picked up by several media outlets regarding the information suppliers should include in Item 29 of the claim form. The list serve indicates that: any beneficiary payment collected for the specific covered service, (i.e., coinsurance and deductible) should be reflected with the claim submission. However, we strongly recommend that suppliers refrain from following this guidance, specifically as it relates to coinsurance and deductible amounts, while we seek additional clarification from the DME MACs.


Suppliers have historically been told not to put any dollar amounts in Item 29, unless the patient has remitted payment up front for a non-assigned claim. The reason for this is that when the claims processing system sees a dollar amount in Item 29, it is generally assumed that the patient paid for a covered service and that the patient, not the supplier, should be sent a check for reimbursement.


MiraVista is actively seeking a clarification from the DME MACs regarding this guidance and will provide an update as soon additional information becomes available.

Payment Flaw Found with Competitive Bidding; Temporary Fix Problematic

Wednesday, January 5th, 2011

While testing the Medicare claims processing system under Competitive Bidding, CMS discovered a flaw in the payments allotted to grandfathered suppliers. According to a recent release from Palmetto GBA there is a “possible problem” with the way the system handles claims for certain accessories purchased for use with grandfathered equipment.


Under Competitive Bidding, non-contract suppliers should be able to submit claims for supplies and accessories billed with rented, grandfathered equipment, regardless of whether the supply itself is rented or purchased (Note: Only contracted suppliers may bill for supplies when the base equipment has capped). However, testing has found that the Medicare payment system is denying accessories associated with hospital beds, walkers, CPAPs and RADs when billed by grandfathered, non-contracted suppliers.


To resolve the issue, CMS has created a quick fix that will temporarily enable grandfathered suppliers to submit claims for HCPCS affected by the processing error. Effective January 1, 2011 suppliers must append the KY modifier to claims for the following HCPCS when billed as a purchase for a covered, grandfathered item currently under rental (not capped):  

  • Continuous Positive Airway Pressure Devices, Respiratory Assistive Devices, and Related Supplies and Accessories: A4604, A7030, A7031, A7032, A7033, A7034, A7035, A7036, A7037, A7038, A7039, A7044, A7045, A7046, E0561, E0562
  • Hospital Beds and Related Accessories: E0271, E0272, E0280, E0310
  • Walkers and Related Accessories: E0154, E0156, E0157, E0158

This solution is not perfect. By appending the KY modifier, the system will incorrectly pay for the aforementioned HCPCS at Medicare’s standard fee schedule amount, rather than at the appropriately reduced single payment amount. This will result in grandfathered suppliers receiving higher payments than is allotted under Competitive Bidding.


At this time,­­ it is unclear whether CMS plans to go back and adjust these claims at a later date. According to the release, suppliers may mitigate the need for future claim adjustments by submitting the single payment amount (Competitive Bidding price in the patient’s home state) as their submitted charge for each affected accessory or supply on the claim.


We will keep you apprised of any updates as they are released.

Costs to Increase for Medicare Claim Submissions; CEDI to Shut Down Free Network Access

Thursday, September 9th, 2010

By: Andrea Stark, DMEPOS Consultant, MiraVista LLC


There may soon be an increased cost to submit claims to Medicare. Suppliers, clearinghouses, third party billers and software vendors are currently able to connect and transmit information directly to Medicare via several free modem and FTP network connections.  However, during a vendor call on September 8, 2010, CEDI announced that all direct connections to their gateway will be shut down over the next several months, and all electronic Medicare transactions will need to be transmitted through one of six select network service vendors: ECC Technologies, IVANS, McKesson CareBridge, MedXpress, VisionShare or Nebo Systems, Inc


Effective November 1, 2010, all new vendors and suppliers who aren’t actively submitting claims to CEDI will need to go through one of the above network service vendors, or through a clearinghouse that provides this service. All free connections to CEDI will be shut down for everyone else effective April 30, 2011.


The premise behind the service change is driven by CMS’ security concerns. National Government Services currently operates the Common Electronic Data Interchange (CEDI) contract, which is the entity responsible for the front-end editing of all claims traffic and transactions with the DME MAC contractors. NGS is closing all free modem and FTP connections to the CEDI gateway in order to meet requirements put forth in the Medicare Claims Processing Manual, Chapter 24 and the Internet Only Manual, Pub 100-17.  The six network vendors mentioned above will be the only vendors allowed to transmit data between suppliers and CEDI via secure AT&T Global Network Service (AGNS) lines.


If you connect directly to the CEDI gateway to upload your claims, retrieve response reports, download Medicare ERNs or send claim status inquiries, you will likely be affected by the upcoming change in service. However, if you are already transmitting claims and other transactions to Medicare through a clearinghouse or one of the network service vendors above, you may not be affected by the transition.  Suppliers who are currently using free network connections can typically expect to pay a per claim fee to a clearinghouse, or pay monthly fees for bandwidth time through one of the approved network service vendors once the transition takes place.


It will still be possible to secure a direct line to CEDI by becoming a direct network service vendor, but this option will be cost prohibitive for most.  IVANS and McKesson also serve as CMS’ authorized AT&T resellers. 


On September 9, 2010, CEDI released a list serve announcement confirming the coming transition. A copy of the announcement and a list of vendor FAQs is available at: http://www.ngscedi.com/news/newsindex.htm. Contact information for CEDI’s select network vendors is available at: http://www.ngscedi.com/telecomm/teleindex.htm.

Using Excel to Harness the Power of Data Management and Revitalize Your AR

Thursday, June 17th, 2010

By Andrea Stark, MiraVista, LLC


As a consultant working in the reimbursement sector of the DME industry, I routinely visit clients to perform assessments of their accounts receivable (AR) departments. Like most business owners, these DME suppliers are looking for ways to create a more targeted workflow and improve billing efficiencies. While each case is unique and each client faces their own individual challenges, the one thing I’ve consistently found is that the majority of DME suppliers are underutilizing a valuable tool almost every one of them has at their disposal: Microsoft Excel.


I can’t tell you how many times I’ve met with a client frustrated with the limitations of their current billing software. True, most commercially available software can create standard AR reports (i.e. an Accounts Receivable By Payor report), which aggregate tens-of-thousands of records and provide an agreeable snapshot of current AR standings. However, these reports give little guidance on the type of information many business owners and billing managers base decisions on, such as quality of sales, effectiveness of collections or the cause of recurring problems. But with Microsoft Excel, this is exactly the type of information you can extract. 


With a little know-how, suppliers can use Excel to: export and manipulate large quantities of raw data, analyze data to evaluate performance and problem areas, and easily map information that would otherwise have to be manually looked up and entered. 


In just a moment, I will provide a few examples of how our DME billing company, ClaraVista, utilizes Excel to produce targeted results with little effort. However, I know it will not do any good if you are unable to take this information and apply it to your own business. That’s why we’d like to go beyond just telling you what you should be doing and actually show you how to do it.


On Wednesday, June 23, 2010, MiraVista will be holding a live Excel webinar tutorial, entitled: Maximizing AR Efficiencies through Excel: Your Receptionist or Delivery Tech Could be Your Best Data Analysts and we encourage you to come! The webinar will start at 2pm EST for Excel 2003 users and 4pm EST for Excel 2007 users.


During our Excel Webinar, Derrick Stark CPA, CVA, will use sample reports relevant to the DME industry to show you how to fully utilize the program to strategically analyze, sort and format data in your own sales, collections and AR reports. Attendance is being offered at a discounted rate of just $49 and seats are limited to the first 50 participants. For registration and payment information, please call: 803.462.9959 x 252.


With that said, let’s move on to some examples of how we use Excel at ClaraVista:


Average Age of Claims By Procedure Code

As our account managers are combing through vast amounts of AR data, it is helpful for them to analyze collection trends in regards to certain procedure codes.  For example, if we see average times increasing, it may indicate: a problem with a specific client’s procedures for providing the service, a processing issue with a specific insurance company, or an increased level of scrutiny by the payor.  We also use this analysis as a monitoring component to our own quality control protocol. 


We start, by exporting our data to Excel and sorting it by procedure code. We then use Excel to quickly calculate the average age of claims by each procedure code. By running this query over subsequent months and comparing the results, we are able to identify the trends which our staff should focus on to perpetually improve collection results.



Another great feature of Excel is that it allows you to easily map information that would otherwise have to be manually looked up and entered.  For example, based on standard prefixes associated with Blue Cross/Blue Shield policy numbers, Excel can determine the appropriate Blue payor (e.g. Blue Cross of Alabama, Blue Shield, etc).


At ClaraVista, we maintain a spreadsheet in Excel that correlates standard policy number prefixes to specific payors, and input all of our transactional data, including policy numbers, in a separate spreadsheet. We then have Excel lookup the proper payor based on our Prefixes spreadsheet and identify any records where an incorrect payor is being billed (based on the policy number). The results allow our billing staff to quickly identify any claims that are not paying due to data entry errors related to the payor information.


Missing/Expired Authorization Analysis

We also use Excel is to avoid denials related to missing or expired authorizations. Through a series of simple formulas, we can quickly create custom reports that identify those patients for which there is no authorization at all or the expiration date expires within the next 90 days. This data allows us to generate quick work lists for maintaining current authorizations.


You Too Can Benefit From Excel!

With fee schedule cuts across the board, tighter payment regulations and ever changing policies, you have to maximize your resources and harness the power of data management.  All billing software programs are built on database platforms, and most allow for some level of data export.  By understanding how to organize exported raw data and manipulate it in Excel, you can produce strong returns on a modest effort.

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