OIG Compliance

The OIG operating through the DHHS works to ensure that covered entities act within the confines of privacy and security laws established in HIPAA and related federal healthcare legislation. One of the OIG’s main duties relative to the medical billing and coding industry is the prevention of fraudulent activity among covered entities. As a medical billing and coding specialist you must be vigilant about potential activity that may be viewed as fraudulent by the OIG.

Some of the most common fraudulent practices that the OIG deals with include:

• Unbundling codes: Unbundling is a fraudulent practice of submitting separate claims to an insurance provider for services that could fit on a single bill. Providers send separate claims so that the various CPT/ICD-9 codes on each claim are “unbundled” from one another thereby maximizing their payment from insurance companies.
• Upcoding: Upcoding occurs when providers assign higher CPT/ICD-9 codes than necessary to explain a patient’s condition or services they received. For instance, a provider might upcode for extra tests that weren’t performed on a patient just to get more money from an insurance company.
• Undercoding: Undercoding is the opposite of upcoding, when a provider intentionally leaves out codes for healthcare services rendered. Providers may undercode in an attempt to avoid investigation by the OIG.
• Falsifying medical records: Falsifying medical records is perhaps the most egregious fraudulent activity committed by a healthcare provider. In this case, providers falsify a patient’s medical records, including histories of their conditions, descriptions of treatment, and payment histories for self gain. Providers and any staff guilty of falsifying medical records will be subject to prosecution by the OIG and other parties that may want to press charges.

If the OIG suspects that a provider or an insurance company is committing fraud on their claims, they may conduct an audit. The OIG has the authority as an acting party of the DHHS to enforce laws found to be broken by any covered entity. As a medical billing specialist it is in your utmost interest to adhere to the federal healthcare laws and regulations to avoid getting in trouble with the OIG. Check out the DHHS for more information about OIG compliance.

Understanding the Healthcare Reform Act of 2010

The most important aspect of the Healthcare Reform Act of 2010 for medical billing and coding purposes is its overall expansion of the healthcare system and its attempt to cover more Americans. These efforts to extend coverage will require many more people to become skilled medical billing and coding professionals simply to keep up with healthcare demands. Specifically, the law is estimated to enroll an additional 30 million Americans in various healthcare programs. As healthcare eligibility increases among the American populace, so too will the number of healthcare claims needed to be filed and processed. The most relevant effects of the bill are listed below.

Increased Protections for People Enrolled in Medicare

The Healthcare Reform Act is designed to increase healthcare access, including to those people who should already have access to care under current federal healthcare laws. The new law makes many preventive care services covered under Medicare at little to no cost to enrollees. Preventative services such as annual wellness visits and preventive screenings for conditions like cancer, diabetes, and HIV will now be covered for Medicare enrollees.

These increased protections and available services will help millions of Americans to receive necessary healthcare, but it will also result in many more claims per year to be filed with Medicare administrative contractors (MACs) across the country.

Mandatory Electronic Medical Records and Transactions

The most important component of the Healthcare Reform Act for medical billing specialists is the requirement that all providers use EHR systems by the end of 2015. This means that providers who deal with mostly paper claim forms will need to reorganize their billing department to handle electronic transactions. Those electronic transactions will need to meet the security and privacy standards required by HIPAA (like those established with the privacy and security rules) and other healthcare legislation.

The push towards EHR is also designed to minimize administrative burdens for medical billing coding specialists and other provider staff who deal with medical information. The Healthcare Reform Act of 2010 includes a number of suggestions for reducing this administrative burden aside from mandatory EHR, including the implementation of new recordkeeping software. These practices will ultimately make your job as a medical billing and coding specialist much easier and optimize the healthcare experience for all parties involved.

Healthcare administrative technologies change all the time, and providers can no longer delay learning how to work with them. The Healthcare Act of 2010 merely expedited the process of bringing all providers, insurance companies, and other covered entities into the healthcare digital age. There will be a huge demand for trained medical billing and coding specialists who can assist in this transition from paper claims filing to claims filed exclusively over digital networks.

Code Descriptor

POS 19 Off campusoutpatient hospital

A portion of an off-campus hospital provider based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

POS 22 On campusoutpatient  hospital

A portion of a hospital’s main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons

who do not require hospitalization or institutionalization.

Additional information related to POS codes 19 and 22

**  Payments for services provided to outpatients who are later admitted as inpatients within three days (or, in the case of non-IPPS hospitals, one day) are bundled when the patient is seen in a wholly-owned or whollyoperated physician practice. The three-day payment window applies to diagnostic and nondiagnostic

services that are clinically related to the reason for the patient’s inpatient admission, regardless of whether the inpatient and outpatient diagnoses are the same.

The three-day payment rule will also apply to services billed with POS code 19.

**  Claims for covered services rendered in an off campus-outpatient hospital setting (or in an on campus-outpatient hospital setting, if payable by Medicare) will be paid at the facility rate. The payment  policies that currently apply to POS 22 will continue to apply to this POS, and will now also apply to POS 19

unless otherwise stated.

POS 19 - When should we use

New and revised place of service codes for outpatient hospitals

Note: This article was revised December 9, 2015, to clarify the effective date of place of service (POS) 19. POS 19 will be accepted for any claims processed on or after January 1, 2016. That is, POS code 19 is valid for any claim, regardless of the date of service, when it is processed on or after January 1, 2016. The title of the table was also changed for clarification. All other information is unchanged.

**  Revising the current place of service (POS) code set by adding new POS code 19 for “off campus-outpatient hospital” and revising POS code 22 from “outpatient

hospital” to “on campus-outpatient hospital;” and

**  Making minor corrections to POS codes 17 (walk-in retail health clinic) and 26 (military treatment facility).

You should ensure that your billing staffs are aware of these POS code change

Therefore, in response to the discussion in the 2015 physician fee schedule (PFS) final rule with comment period published November 13, 2014 (79 FR 67572); in order to differentiate between on-campus and off-campus provider-based hospital departments, CMS is creating a new POS code (POS 19) and revising the current POS code description for outpatient hospital (POS 22).

CR 9231, from which this article is taken, provides this POS code update, effective January 1, 2016. Specifically, CR 9231 updates the current POS code set by adding

new POS code 19 for “off campus-outpatient hospital” and revising POS code 22 from “outpatient hospital” to “on campus-outpatient hospital” as described in the   following table.

Can we appeal while using GA modifier -Medicare

ABN modifiers

When a patient is notified in advance that a service or item may be denied as not medically necessary, the provider must annotate this information on the claim (for both paper and electronic claims) by reporting modifier GA (waiver of liability statement on file) or GZ (item or service expected to be denied as not reasonable and necessary) with the service or item.

Failure to report modifier GA in cases where an appropriate advance notice was given to the patient may result in the provider having to assume financial responsibility for the denied service or item.

Modifier GZ may be used in cases where a signed ABN is not obtained from the patient; however, when modifier GZ is billed, the provider assumes financial responsibility if the service or item is denied.

Note: Line items submitted with the modifier GZ will be automatically denied and will not be subject to complex medical review.

When provider need to notify Medicare - change in address, ownership, business, legal name, banking arrangements

Q: What does Medicare consider to be “reportable event” (with regard to the provider/supplier’s enrollment record)? How long does a provider/supplier have to notify their Medicare administrative contractor (MAC) of the event?

A: Since providers and suppliers are responsible for maintaining and reporting changes to their enrollment information, a “reportable event” is one that requires an update to that record. The required timeframe for notifying the provider/supplier’s Medicare administrative contractor (MAC) of the change is based upon the type of “reportable event” that occurred

The following types of “reportable events” must be reported no later than 30 days after the event has occurred:

• Change in location/address -- occurs when a provider/supplier establishes, moves, or closes a practice or facility. It may also occur if the address is changed in any way.

• Change in final adverse action -- occurs when a physician is debarred or excluded by any federal or state health care program, has his/her medical license suspended or revoked by a state licensing authority, was convicted of a felony within the last 10 years, has his/her Medicare billing privileges revoked by a Medicare contractor, or has a revocation or suspension by an accreditation organization.

• Change in ownership -- occurs when there is a change in authorized officials or delegated officials for the organization.

The following types of “reportable events” must be reported no later than 90 days after the event has occurred:

• Change in business structure -- occurs when a provider or supplier changes the business structure of the practice (e.g., sole proprietorship to sole incorporated owner).

Can we request Medicare early or immediate offset of a demanded debt?

A. Yes. When you receive an overpayment demand letter indicating a refund is due, you can request immediate offset of the debt in writing.

The immediate recoupment process allows providers to request that recoupment begin prior to day 41. Providers who elect this option may avoid paying interest if the overpayment is recouped in full prior to day 31. The immediate recoupment process does not terminate appeal rights.

An immediate offset is considered a voluntary repayment. Keep in mind a request for an immediate offset will occur only as funds become available. Providers who choose immediate recoupment must do so in writing. However, a provider can terminate the immediate recoupment process at any time.

The advantages of utilizing this new process include:

• Avoiding the possibility of checks “crossing in the mail”

• Cost savings associated with check fees and postage

• Avoiding potential interest accrual due to late receipt of refund

To request immediate offset of demanded debt, complete the Medicare Debt Recovery: Request for Immediate Offset form  and fax the form to:

Part A Debt Recovery (904) 361-0320 or Part B Debt Recovery (904) 361-0444.

Note: The fax numbers indicated are for immediate offsets of a demanded debt only. Any other financial concerns should be sent in writing to the appropriate Part A or Part B Medicare department.

To ensure your request is handled promptly, all requests must include:

• Date of Request

• Which option the provider is requesting?

• One-time request for immediate recoupment of a current overpayment letter (All ARs in the overpayment letter will be placed on immediate offset)

• Request for immediate recoupment of a current overpayment letter and all future overpayments (Future immediate offset requests must include a request for immediate offset of a current overpayment letter.)

All things you need to know about LCD, - FAQ

What is the difference between LCDs and NCDs?

A. Local coverage determinations (LCDs) for a specific jurisdiction are developed by the Medicare Administrative Contractor (MAC) assigned to that jurisdiction. First Coast Service Options Inc. is the MAC for Florida, Puerto Rico, and the U.S. Virgin Islands. Although the majority of coverage determinations are local, in certain cases, Medicare may develop a national coverage determination (NCD) that is applicable to all jurisdictions.

: Where can I find LCDs on Fist Coast Service Options Inc.’s Medicare provider website?

A. Although the Centers for Medicare & Medicaid Services’ (CMS) Medicare coverage database (MCD) still holds the “official versions” of local coverage determinations (LCD), identical copies are now hosted in First Coast’s own coverage database, which may be accessed through First Coast’s LCD lookup.

The LCD lookup tool helps you find the coverage information you need quickly and easily by utilizing the preferences (line of business and geographic location) that you indicated upon entry onto First Coast’s Medicare provider website. Its intuitive “form interface” also makes it easy to use. Just enter a procedure code or “L number,” click the corresponding button, and the application will automatically display links to any LCDs applicable to the parameters specified.

Click the link, and you can view the entire LCD (except attachments) and quickly find the information you need. Best of all, depending upon the speed of your Internet connection, the LCD search process can be completed in less than 10 seconds. And if you’re looking for fee schedule information as well as coverage information, you can search for both simultaneously by using of First Coast’s fee schedule lookup.

List of Preventive Services and Screenings Covered by Medicare

•    Abdominal Aortic Aneurysm Screening

•    Alcohol Misuse Screening and Behavioral counseling Intervention in Primary Care

•    Annual Wellness Visit (Including Personalized Prevention Plan Services)

•    Bone Mass Measurements

•    Cancer Screenings 

•    Breast Cancer (mammograms and clinical breast exam)

•    Cervical and Vaginal Cancer (pap test and pelvic exam [includes the clinical breast exam])

•    Colorectal Cancer 

                 o    Fecal Occult Blood Test

                 o    Flexible Sigmoidoscopy

                 o    Colonoscopy

                 o    Barium Enema

•    Prostate (PSA blood test and Digital Rectal Exam)

•    Cardiovascular Disease Screening

•    Depression Screening in Adults

•    Diabetes Screening

•    Diabetes Self-Management Training

•    Glaucoma Screening

•    Hepatitis C Screening

•    Human Immunodeficiency Virus (HIV) Screening

•    Immunizations (Seasonal Influenza, Pneumococcal, and Hepatitis B)

•    Initial Preventive Physical Examination (IPPE) (also commonly referred to as the “Welcome to Medicare” Preventive Visit)

•    Intensive Behavioral Therapy for Cardiovascular Disease

•    Intensive Behavioral Therapy for Obesity

•    Medical Nutrition Therapy (for beneficiaries with diabetes or renal disease)

•    Sexually Transmitted Infections (STIs) Screening and High-Intensity Behavioral Counseling (HIBC) to prevent STIs

•    Tobacco-Use Cessation Counseling

As a result of the Affordable Care Act, Medicare now covers many of these services without cost to patients, including the Annual Wellness Visit that was created under the Affordable Care Act.

Railroad Medicare Coverage of Supplies if You Have Diabetes

Railroad Medicare covers certain supplies if you have Medicare Part B and have diabetes. These supplies include:

• Blood glucose self-testing equipment and supplies

• Therapeutic shoes and inserts

• Insulin pumps and the insulin used in the pumps

Blood Glucose Self-testing Equipment and Supplies 

Blood glucose self-testing equipment and supplies are covered for all people with Medicare Part B who have diabetes. This includes those who use insulin and those who do not use insulin. These supplies include:

• Blood glucose monitors

• Blood glucose test strips

• Lancet devices and lancets

• Glucose control solutions for checking the accuracy of testing equipment and test strips

Railroad Medicare covers the same type of blood glucose testing supplies for people with diabetes whether or not they use insulin. However, the amount of supplies that are covered varies.

If you:

1. Use insulin, you may be able to get up to 100 test strips and lancets every month, and 1 lancet device every 6 months

2. Do not use insulin, you may be able to get 100 test strips and lancets every 3 months, and 1 lancet device every 6 months

If your doctor documents why it is medically necessary, Railroad Medicare will cover additional test strips and lancets for you.

Medicare and Railroad Medicare will only cover blood glucose self-testing equipment and supplies if you get a prescription from your doctor which includes:

• That you have diabetes

• What kind of blood glucose monitor you need and why

• Whether or not you use insulin

• How often you need to test your blood glucose

Medicare will not pay for any supplies not asked for, or for any supplies that were sent to a beneficiary automatically from suppliers. This includes blood glucose monitors, test strips, and lancets. Also, if a beneficiary goes to a pharmacy or supplier that is not enrolled in Medicare, Medicare will not pay. The beneficiary will have to pay the entire bill for any supplies from non-enrolled pharmacies or non-enrolled suppliers.

The Annual Wellness Visit (AWV) Exam: Understanding Your Coverage

The Affordable Care Act of 2010 brought new covered services, as well as changes to existing services regarding copayments and deductibles. The addition of the Annual Wellness Visit (AWV) exam is meant to help you maintain good health through a yearly visit with your primary care doctor.

Before the AWV exam, the ‘Welcome To Medicare’ exam (also called your Initial Preventive Physical Exam, or IPPE) benefit was available to you during the first twelve months of your Railroad Medicare eligibility. This initial exam established your health baseline from which the doctor could measure changes.

The new Annual Wellness Visit is the next step towards using all the information gathered in your 'Welcome to Medicare' exam. In addition, there is no co-pay, and it is not charged toward your Railroad Medicare deductible.

Your Annual Wellness Visit will:

• Update medical and family history

• Update measurement of height, weight, body-mass index and blood pressure

• Document changes you made in using other health care professionals

• Document changes other health care professionals may have made, like medications

• Look for any cognitive changes or impairments

Observation Care: Are You ‘Inpatient’ or ‘Outpatient’? It Makes a Difference

If you are in the hospital, occupying a bed, are you an inpatient of the hospital, or not? You probably think you are, but that may not necessarily be true. Here’s why:

Being ‘inpatient’ means you have been formally admitted to the hospital with a doctor’s order. Being ‘outpatient’ means that you are getting emergency department services, observation services, or having outpatient surgery, tests, etc., at the hospital, but a doctor has not written an order to admit you into the hospital. The amount of time you spend in the hospital, even if it is overnight, does not determine your hospital status. You are not an inpatient until you are admitted to the hospital formally on a doctor’s order.

Outpatient observation services are performed in a hospital on the hospital’s premises, including use of a bed and at least occasional monitoring by a hospital’s nursing or other staff, to help your doctor determine if it’s necessary to admit you formally to the hospital as an inpatient, or if you can be discharged. Generally, patients are not kept in outpatient observation status for more than 48 hours.

Why does your hospital status matter? Your status, inpatient or outpatient, has an effect on how Medicare pays the hospital, and how much you may have to pay for the hospital services. You can pay more for services received when you are in outpatient hospital observation status because instead of being responsible for one Part A deductible for all of your hospital services, you are instead responsible for a separate copayment for each outpatient hospital service. The total of your copayments for outpatient services, including tests, procedures and observation, can be more than your Part A deductible would be as an inpatient. Also, Medicare Part B does not cover self-administered drugs, including your prescription drugs and over-the-counter drugs that you may receive as an outpatient.

What determines whether you are admitted as an inpatient? Generally, you will not be admitted as an inpatient if you are not expected to need medically necessary hospital care for two of more midnights.

what is bone density or Bone Mass measurment

Bone Density: Time to Get It Tested

Bone Mass Measurement (BMM), or bone density screening is a test that identifies bone mass, detects bone loss, and may determine bone quality. BMM can be performed with a bone 'densitometer' or an approved bone 'sonometer system.' Bone densitometry uses an X-ray or some other form of radiation, and the test will determine your bone density according to the rate at which this radiation is absorbed by your bones. There are usually three methods of testing: a stationary machine kept in one location, such as your doctor’s office or a hospital; a mobile unit, such as you see with mammography units, or with a portable machine. Bone sonometers are ultrasound machines and do not use radiation. You often see these machines in doctors’ offices. This is the same ultrasound technique used for gallbladders, bladders, etc.

Medicare may cover BMM screening once every two years (at least 23 months have passed since the month the last covered BMM was performed) or more often when medically necessary for persons who are at risk for osteoporosis and meet other conditions. This test is free (deductible and coinsurance/copayment are waived) if your doctor or health care provider accepts assignment. To 'accept assignment' means your doctor or health care provider or suppler has a signed agreement to be paid directly by Medicare and to accept the Medicare approved amount. They cannot bill you for any more than the Medicare deductible and coinsurance.

Medicare covers bone mass measurement when:

• It is ordered by a physician or qualified health care practitioner who is treating you, following an evaluation of the need for the BMM

Medicare Payment Floor Standards detailed review

The “payment floor” establishes a waiting period during which time the contractor may not pay, issue, mail, or otherwise finalize the initial determination on a clean claim. The “payment floor date” is the earliest day after receipt of the clean claim that payment may be made.

The payment floor date is determined by counting the number of days since the day the claim was received, i.e., the count begins the day after the day of receipt.

There are different waiting periods, and thus different payment floor dates, for electronic claims and paper claims. The waiting periods are 13 days for electronic claims and 26 days for paper claims. For the purpose of implementing the payment floor, the following definitions apply:

An “electronic claim” is a claim submitted via central processing unit (CPU) to CPU transmission, tape, direct data entry, direct wire, or personal computer upload or download. A claim that is submitted via digital FAX/OCR, diskette, or touch-tone telephone is not considered as an electronic claim.

A “paper claim” is submitted and received on paper, including fax print-outs. This also includes a claim that the contractor receives on paper and then reads electronically with OCR technology

Also, for the purpose of implementing the payment floor, effective 7/1/04 and for the duration of the HIPAA contingency plan implementation, an electronic claim that does not conform to the requirements of the standard implementation guides adopted for national use under HIPAA, including electronic claims submitted electronically using pre-HIPAA formats supported by Medicare, is considered to be a paper claim.

Based on the waiting periods, the payment floor dates are as follows:

Claim Receipt Date                     Payment Floor Date

10-01-93 through 6/30/04       14th day for EMC 27th day for paper claims

07-01-04 and later                  14th day for HIPAA-compliant EMC

                    27th day for paper and non-HIPAA EMC

01/01/2006 and later  29th day for paper

Except as noted below, the payment floor applies to all claims. The payment floor does not apply to: “no-payment claims, RAPs submitted by Home Health Agencies, and claims for PIP payments.

What is Other Claims (other than clean) and Data Element matrix

Claims that do not meet the definition of “clean” claims are “other” claims. “Other” claims require investigation or development external to the carrier or FI’s Medicare operation on a prepayment basis. “Other” claims are those that are not approved by CWF for payment that the FI identifies as requiring outside development. Examples are claims on which the provider’s FI/carrier:

• Requests additional information from the provider or another external source. This includes routine data omitted from the bill, medical information, or information to resolve discrepancies;

• Requests information or assistance from another contractor. This includes requests for charge data from the carrier, or any other request for information from the carrier;

• Develops Medicare Secondary Payer (MSP) information;

• Requests information necessary for a coverage determination;

• Performs sequential processing when an earlier claim is in development; and

• Performs outside development as a result of a CWF edit.

How Medicare Determining and Paying Interest

The contractor must pay interest on clean, non-PIP (FIs) claims for which it does not make payment within the payment ceiling specified in § 80.2.1.1, provided payment is due on such claim. The interest rate and formula for calculation are shown above. The interest rate is determined by the rate applicable on the carrier or FI’s payment date.

The contractor applies interest to the net payment amount after all applicable deductions are determined (e.g., deductible, copayment, and/or MSP). Interest is rounded to the nearest penny.

A. Reporting Interest Payment on Remittance Record

See 100-22 for remittance advice completion instructions

B. Payment Made to Beneficiary

If interest is paid on a claim for which payment is made directly to the beneficiary, the contractor adds the following messages on the beneficiary notice:

“Your payment includes interest since we were unable to process your claim timely.”

C. Claims Paid Upon Appeal

Interest payments are not payable on clean claims initially processed to denial and on which payment is made subsequent to the initial decision as a result of an appeal request. This applies to appeals where more than the applicable number of days elapsed before an initial denial, but the claim was later paid upon appeal. Where an appeal of a previously paid claim results in increased payment FIs follow the following section.

Medicare provider Enrollment time frame - How to make it quicker

How you can expedite your enrollment application process

As the Medicare administrative contractor (MAC) for jurisdiction N (JN), First Coast Service Options Inc. (First Coast) is not only responsible for processing Medicare claims but also for processing enrollment applications for providers and suppliers located in Florida, Puerto Rico, and the U.S. Virgin Islands.

The Centers for Medicare & Medicaid Services (CMS) has established the following timeliness standards for contractors responsible for processing enrollment applications within their assigned jurisdictions:

• PECOS Web applications (initial enrollment with no site visit) -- 80% must be processed within 45 days

• Paper-based applications (initial enrollment with no site visit) -- 80% must be processed within 60 days

• Paper-based applications (initial enrollment with site visit) -- 80% must be processed within 80 days

• Paper-based applications (changes to enrollment record or reassignment) -- 80% must be processed within 60 days

First Coast Provider Enrollment Average YTD Processing Times

(Through August 31)

 

PECOS Web Applications

Part A                Part B

 

No development 23 days 31 days

With development 83 days 60 days

Paper Applications

 

No development 36 days 26 days

With development 91 days 57 days

Factors affecting total processing times

Although First Coast processes each enrollment application as quickly as possible, the following key factors may affect the total processing time needed:

• Provider type:

• Part A -- institutional providers

• Part B -- physicians, non-physician practitioners, clinics, and group practices

Shortest processing times: Enrollment applications for Part B providers and suppliers

Medicare deductible, coins - can we collect from patient when patient have secondary insurance

The Medicare Program

The Original Medicare Program, also known as Fee-For-Service (FFS) Medicare, consists of:

• Part A, hospital insurance; and

• Part B, medical insurance.

Under FFS Medicare, eligible individuals may enroll in Part A, Part B, or both Part A and Part B. Most individuals choose to enroll in both Part A and Part B.

FFS Medicare was expanded in 1973 to include:

• Individuals who are under age 65 with certain disabilities; and

• Individuals with End-Stage Renal Disease.

Two parts were added to the Medicare Program in 1997 and 2006, respectively:

• Part C, Medicare Advantage (MA) (first known as Medicare+Choice); and

• Part D, the Prescription Drug Benefit.

MA is another health plan choice available to beneficiaries. It is a program run by Medicare-approved private insurance companies. Most MA organizations arrange for or directly provide health care items or services to the beneficiary who:

• Is entitled to Part A and enrolled in Part B;

• Permanently resides in the service area of the MA Plan; and

• Elects to enroll in a MA Plan.

The Prescription Drug Benefit provides prescription drug coverage to all beneficiaries enrolled in Part A and/or Part B who elect to enroll in a Medicare Prescription Drug Plan (PDP) or a MA Prescription Drug Plan. Insurance companies or other companies approved by Medicare provide prescription drug coverage to such individuals who live in the Plan’s service area. Medicare beneficiaries who meet certain income and resource limits may qualify for the Extra Help Program, which helps pay for PDP costs.

The Medicaid Program

The Medicaid Program is a cooperative venture funded by Federal and State governments that pays for medical assistance for certain individuals and families with low incomes and limited resources. Within broad national guidelines established by Federal statutes, regulations, and policies, each State:

Medicare - Payment Ceiling Standards - Payment days

Payment ceilings were implemented for clean claims received by the carrier or FI on or after April 1, 1987. “Clean” claims must be paid or denied within the applicable number of days from their receipt date as follows:

Time Period for Claims Received  Applicable Number of Calendar Days

01-01-93 through 09-30-93   24 for EMC and

                             27 for paper claims

10-01-93 and later   30

All claims (i.e., paid claims, partial and complete denials, no payment bills) including PIP and EMC claims are subject to the above requirements.

Interest must be paid on claims that are not paid within the ceiling period.

The count starts on the day after the receipt date and it ends on the date payment is made. For example, for clean claims received October 1, 1993, and later, if this span is 30 days or less, the requirement is met.

Procedure codes with modifier 22 - Medicare internal issue

An internal system processing issue has caused some surgical procedure codes billed with modifier 22 processed on/after January 1, 2014, to not allow any additional money above the fee schedule. First Coast Service Options (First Coast) is currently identifying the impacted claims and will begin to initiate adjustment action on all impacted claims within the next two weeks. Note: only claims previously reviewed by our medical staff having met medical necessity requirements to allow above the fee schedule will be adjusted. Providers are asked not to file appeals or call the First Coast call center regarding this internal issue. First Coast apologizes for any inconvenience this issue has caused.

Issue

An internal system processing issue has caused some surgical procedure codes billed with modifier 22 processed on/after January 1, 2014, to not allow any additional money above the fee schedule.

Resolution

First Coast is currently identifying the impacted claims and will begin to initiate adjustments on all impacted claims within the next two weeks. Claims having met medical necessity requirements will be changed to an unlisted surgical procedure code (modifier 22 will be appended to the related unlisted surgical procedure) to allow payment above the Medicare physician fee schedule. First Coast began utilizing this process July 11, 2014, for all surgical procedure billed with the 22 modifier that met medical necessity requirements for additional payment.

Receipt Date - Medicare definition

The receipt date of a claim is the date the contractor receives the claim (provided the filing is in a format and contains data sufficiently complete so that the filing qualifies as a claim). The receipt date is used to: determine if the claim was timely filed , determine the “payment floor” for the claim , determine the “payment ceiling” on the claim  and, when applicable, to calculate interest payment due for a clean claim that is not timely processed, and to report to CMS statistical data on claims, such as in workload reports.

A paper claim that is received by 5:00 p.m. on a business day, or by closing time if the contractor routinely ends its public business day between 4:00 p.m. and 5:00 p.m., must be considered as received on that date, even if the contractor does not open the envelope which contains the claim or does not enter the claims data into the claims processing system until a later date. A paper claim that is received after 5:00 p.m., or after the contractor’s routine close of business between 4:00 p.m. and 5:00 p.m., is considered as received on the next business day.

A paper claim is considered as received if it is delivered to the contractor’s place of business by the U.S. Postal Service, picked up from a P.O. box, or is otherwise delivered to the contractor’s place of business by its routine close of business time. If the contractor uses a P.O. box for receipt of mailed claims, it must have its mail picked up from its box at least once per business day unless precluded on a particular day by the emergency closing of its place of business or that of its postal box site.