​In our August edition of (K)notes, we reported the OIG tagged PAP resupply as one of the agency’s top 25 perceived vulnerabilities. In October, the agency updated its Work Plan, indicating PAP resupply is an audit issue with priority. Both the top 25 report and recent Work Plan addition stem from a June 2018 report where the OIG audited 110 resupply claims (out of 7 million) and found 86 errors from 82 different suppliers. By extrapolating the error rate to the universe of paid claims, the OIG suggested CMS overpaid $631 million over the two-year period.

Wait. What?

A Dangerous Precedent: The Six-Year Lookback

Based on the OIG’s recommendation, CMS asked the 82 suppliers involved in the OIG audit to refund $13,414 in overpayments and then perform a six year self-audit under the authority imposed by the 60-day rule. MiraVista challenged the appropriateness of this application. The audit simply cannot be statistically relevant to the larger claim population, and the 60-day rule requires “credible evidence of an overpayment”. We do not believe such a small sample can possibly yield credible evidence, especially given that CMS mandated the self-audit before suppliers had an opportunity to review or challenge the OIG findings. In following the OIG guidance, CMS set a dangerous precedent by engaging such a material consequence for what amounts to immaterial evidence.

Suppliers Can Protect Resupply Claims

Despite challenges to the basis of the 60-day rule application, resupply claims are not difficult to support when suppliers maintain appropriate processes. Suppliers should consider the following before releasing resupply claims:
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• Do not add the KX modifier to claims for resupply in between failed PAP trials (see previous write up on the MiraVista blog).
• Secure an annual prescription for all billable accessories to satisfy evidence of continued medical need:
  • Ensure prescriptions are dated within 12 months of the service date.
  • Refuse delivery or write off supplies during any gap between prescriptions.
• To comply with continued use requirements, collect signed delivery tickets when customers pick up product from a retail location or maintain requests for refill logs for shipped product:
  • Suppliers should not initiate customer contact any sooner than 14 days before delivery.
  • Suppliers must ensure refill logs include a reason to replace each accessory.
• Ensure proof of delivery documents list all billable items and quantities. Log delivery confirmations in the beneficiary’s chart before the delivery service purges the data.
• Collect sufficiently detailed, compliant orders with quantities and frequency of replacement:
  • Confirm the order does not contain conflicting accessories that cannot be used simultaneously (e.g. full-face mask and nasal mask).
  • Affix a document preparation date to orders where the prescriber does not create the order.
  • When orders have corrections, ensure the author strikes through the original text, signs and dates the change.

When a resupply program is in lock step with Medicare requirements, suppliers can avoid recoupments, denials, and mandates to perform extensive self-audits. 

SOURCE LINKS
https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000405.asp
https://oig.hhs.gov/oas/reports/region4/41704056.asp

During Medicare’s open enrollment period from October 15 to December 7, beneficiaries can switch from traditional fee-for-service Medicare to a Medicare Advantage plan and vice-versa. Many of them do, causing revenue gaps while suppliers scramble to comply with new insurance requirements for existing customers. Proactive companies can, however, take advantage of this time with two important steps.

1. Engage Customers

It is important for customers to notify their suppliers when changing insurance. New insurance plans may require prior authorization, re-testing, office visits, or even a supplier change. During open enrollment, suppliers should proactively communicate with customers while they are weighing options. For example, suppliers can insert colored flyers with patient statements to remind customers to call about changes in insurance. With a simple phone call, customers can avoid disruption in service and increased financial responsibility.

2. Evaluate Plans

As beneficiaries weigh their options, suppliers should also take stock of which plans they intend to accept. Suppliers can use the find-a-plan tool on the Medicare website to identify which Medicare Advantage plans are offered in their area by following these instructions:

• Click [Continue without logging in].
• What type of coverage are you looking for? Click [Medicare Advantage Plan].
• Enter your zip code [Enter a five-digit zip code].
• Click [Continue].
• Do you get help with your costs from one of these programs? Click [I’m not sure].
• Click [Continue without logging in].
• Do you want to see drug costs? Click [No].
• Click [Next].

​Suppliers should scan the list for any new plans coming to their market and contract with those offering tolerable reimbursement rates. Furthermore, suppliers should proactively educate customers about which local plans they accept.

Engaging with customers now will prevent revenue headaches later.

SOURCE LINKS
www.medicare.gov/plan-compare

CareCentrix recently announced plans, effective January 1, 2020, to deny PAP rental and resupply claims for delinquent policyholders. The change affects beneficiaries with Cigna and Blue Cross of Florida plans where CareCentrix processes DME claims. The company published the controversial notice on the heels of a recent meeting with AAHomecare about DME supplier complaints, including authorization and reconsideration inconsistencies.

The new policy suspends non-life sustaining services for all policyholders who:

1. Have aged cost share balances payable to CareCentrix in excess of six months,
2. Are in the deductible phase of coverage, and
3. Failed to pay, or establish a payment plan with, CareCentrix.

Policyholders who are current on their cost shares or who have met their deductible are not affected.

Strangely, only PAP rental and resupply claims are affected or deemed non-life-sustaining. No other services are affected by the policy.

How does the deductible status affect suspension?

One of the three criteria for payment suspension requires an active, unmet deductible. Once the beneficiary meets their deductible, the company will resume paying for PAP rentals and resupply claims. Notwithstanding, we expect CareCentrix will require new authorizations anytime the policyholder resolves a suspended status.

How can suppliers find out which customers are affected?

Suppliers can query patient status individually or download a list of all suspended patients via the CareCentrix secure portal. We recommend suppliers first download the master spreadsheet with all suspended policyholders, then compare the list to active PAP rental and resupply customers in their billing software. From the patient tab in the portal, a comprehensive list of affected policyholders is available by clicking “Download Suspension List.”

Additionally, suppliers should receive a 60-day email notification from CareCentrix with details about payment suspensions before they take effect. CareCentrix will also send email notifications to suppliers with recent PAP activity when the suspended status changes.

Carecentrix will use email addresses linked to the portal for branches with recent claims activity for affected policyholders. Because the reimbursement policy takes effect on January 1, 2020, we expect the first notifications to arrive on or after November 1, 2019.

How will the policy impact claim processing?

If suppliers submit PAP claims while a customer is suspended, the claims will deny CO-256, service not payable per managed care contract. EOBs will also contain an A1 denial with N59 remark code which basically redirects suppliers back to the provider manual. Because A1 and N59 are nondescript denial codes, suppliers should watch for the CO-256 denials from Carecentrix to identify these claims.

What happens to claims before and after a suspension date?

Claims with service dates prior to a suspension date are not affected. Suppliers can continue sending supplies and billing rentals up to the suspension date. Likewise, claims with service dates after a suspension ends are eligible for payment. When the plan sends notification of reinstatement, however, suppliers must secure a new authorization to resume covered services.

Do suppliers have recourse for denied claims?

Not really. The plan allows suppliers to refuse service, even if an approved authorization is on file. Per the published policy and FAQ, however, suppliers are prohibited from collecting directly from customers for these services … so as far as CareCentrix is concerned, mamma’s gotta get paid first, right?

Later, if the customer ultimately resolves their past due balance, suppliers can appeal denied claims through the reconsideration process. CareCentrix will deny resubmitted claims as duplicates, and again the plan prohibits passing balances to customers while they are suspended.

Encourage customers to make arrangements with the plan. Customers should call 866-441-4169 to negotiate a resolution and resume PAP services. CareCentrix claims to offer customers an interest-free payment plan with terms up to 18 months, depending on the amount of outstanding balance.

Guys, just make sure this payer is worth it.  The collection rate needs to be pretty fantastical to justify the hoops and the hassle. And if you need help evaluating performance, we will help.

SOURCE LINKS
https://ha2.edelivery-view.com/Public/CCX1000/Change%20Impacting%20Certain%20Cigna%20and%20FLBL%20Members%20-%201210(a)(e).pdf

Welcome back to the final article in our short series on resolving Medicare denials.  If you missed the previous posts on reopening claims or resubmissions and appeals, you may want to go back and read those first.  Otherwise, let’s wrap it up with a practical discussion about the strategy of making a choice in the context of procedural differences unique to each resolution option.

Engagement Time (shortest to longest)

Suppliers have a limited amount of time to engage each of the escalation options. After a certain point, the age will limit the available options. For example, if a post payment review recoups a two-year-old claim, the date of service will be too old to resubmit, but the denial breathes new life into the appeal and reopen pathways. Some denials can only be appealed, and if suppliers fail to escalate the appeal within 120 days of the denial, they must write off the balance.

Engagement times are as follows:

• Appeal – Suppliers only have 120 days from the denial date to engage a formal appeal.
• Resubmit – Suppliers have one year from the date of service to resubmit a claim.
• Reopen – Suppliers have one year from the last denial date to request either a telephone or written reopening (even if the date of service is now past timely filing).

Processing Time (shortest to longest)

In terms of processing time, telephone reopenings and claim resubmissions offer clear advantages when compared to written reopenings and appeals. Preparing any written document just takes longer in most cases.

General processing times are as follows:

• Telephone reopening – The MACs often process requests in as few as five days.
• Resubmit – Electronic claims often process in 14 days.
• Written reopening – The MACs often process requests within 15-30 days.
• Appeal – The MACs often process requests in 30-45 days.

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The nature of the denial, however, may narrow the field of available options. Some denials can only be appealed (See Denial Types below).

Supplier Preparation Time (shortest to longest)

Preparation time is a finite resource, and as such, suppliers should consider it thoughtfully. Clearly, we should keep prep time minimal, but suppliers cannot afford to pursue an option that doesn’t fix the problem. Appeals take the most time to prepare, but they may be the only means to resolve the denial, if not the best means to get the point across.

Typical preparation times are as follows:

• Resubmit – 1-2 minutes to fix the error in the billing system.
• Telephone reopening – 10 minutes to engage the customer service representative and make the change.
• Written reopening – 15 minutes to prepare the document and fax the request.
• Appeal – 20-30 minutes to assemble documentation, make the case, and fax the request.

Denial Types

Sometimes the characteristics of the denial itself can limit escalation options.

Rejected claims do not have appeal or reopen rights. They must be resubmitted. These claims typically present on EOBs with a MA130 remark code.

Medical necessity denials, on the other hand, cannot be reopened or resubmitted. They must be appealed. Examples of medical necessity denials include CO-50 (medical necessity), CO-150 (level of service), and CO-151 (frequency of service). If the supplier doesn’t appeal the denial within 120 days of the EOB notification, they must write off the open balance.

And so, a basic understanding of each option … the situations in which it applies, the effort required to execute … goes a long way toward an efficient billing operation. At the risk of sounding clichéd, work smarter, not harder.
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