Articles Posted in Medicare

President Obama signed the “Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010.” The law includes a provision that clarifies Medicare’s position for payment of hospital outpatient services provided on either the day of or the three days prior to an inpatient admission. The 3-day payment window policy is effective for services provided on or after June 25, 2010. Medicare may not reopen claims submitted prior to June 25, 2010 to require a separate bill for outpatient non-diagnostic services.

The 3-day payment window, which has been unofficially followed by Medicare since 1991, allows a hospital to charge for all diagnostic services and non-diagnostic services “related” to the inpatient stay that are provided during the 3-day payment window.

The law defines “other services related to the admission” as including services that are not diagnostic services (other than ambulance and maintenance renal dialysis services) for which payment may be made by Medicare that are provided to a patient by a hospital: (1) on the date of the patient’s inpatient admission; (2) during the 3 days immediately prior to the date of admission, unless the hospital shows that the services provided were not related to the admission.

The U.S. Department of Health and Human Services Office of Inspector General (OIG) issued Advisory Opinion 10-08 to address the provision of dietitian and social worker services at a freestanding radiation oncology center (Center) at no extra charge to the beneficiaries. The OIG determined that the proposed arrangement would not violate the Federal Anti-Kickback Statute and thus, the OIG would not impose administrative sanctions.

The proposed arrangement involved patients at the Center receiving dietitian and social worker services at no additional charge. The OIG addressed the arrangement as it affected Medicare beneficiaries. The services would not be advertised as “free” or “at no charge.” Patients would receive the dietitian services after being identified for risk of nutritional complications and social worker services would be provided during the patient’s treatment. Under the proposed arrangement, the services would not be separately billed, and the applicable cost sharing amounts for the Medicare beneficiaries would not be routinely waived.

The Centers for Medicare and Medicaid Services (CMS) informed the OIG that the dietitian and social worker services provided at the Center would fall within the reimbursement the Center received for the patients. Thus, the amounts that the Medicare beneficiaries pay to share the costs would be partially attributable to the costs of the dietitian and social worker services and the Center would not be provided the services free because of this reimbursement. If this form of reimbursement had not been factored into the proposed arrangement, then the services would not be part of the reimbursement and could implicate the Anti-Kickbac Statute.

On June 18 the U.S. Senate passed a six-month plan to prevent the Medicare physician 21 percent payment cut. The measure, which will cost $6.4 billion, was pushed through with the concern that the steep payment cut would raise the possibility that medical providers would turn away patients covered by Medicare. It will delay the cuts until November 30, 2010 while Congress tries to create a long-term plan. The plan was passed unanimously and lawmakers attribute its passage to the efforts to offset its attributed costs.

Almost immediately after the U.S. Senate announced the passage of the plan, Medicare announced that it would process Medicare claims received for June at the lower rate. This is because the U.S. House of Representatives will not be able to consider the plan until next week. However, there are indications that the bill’s success in the House may be complicated. House Speaker Nancy Pelosi announced that the House will not pass the Senate bill until the Senate agrees to act on job-creation legislation. If the bill does pass in the House, Medicare providers will have the burden to resubmit their claims to be made whole.

For more information on Medicare payments or the physician fee cut, please visit www.wachler.com or contact a Wachler & Associates attorney at 248-544-0888.

On May 14, 2010, the Centers for Medicare and Medicaid Services (CMS) released an MLN Matters article explaining Change Request (CR) 6954. CR 6954 adds Section 3.14 to the Medicare Program Integrity Manual. This section clarifies language regarding clinical review judgments. It requires Medicare claim review contractors to instruct their clinical review staffs to use the clinical review judgment process when making complex review determinations about a claim. The clinical review judgment involves two steps:

(1) The synthesis of all medical record information to create a longitudinal clinical picture of the patient; and

(2) The application of the clinical picture to the review criterial to determine whether the clinical requirements in the relevant policy are met.

The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 6698 to clarify how Medicare claim review contractors review claims and medical documentation submitted by providers. This clarification included an outline of new rules for signatures and added language for e-prescribing.

The previous language in the Program Integrity Manual (PIM) required a “legible identifier” in the form of a handwritten or electronic signature for every service provided or ordered. CR 6698 updates these requirements to require that every service provided or ordered be “authenticated by the author” by handwritten or electronic signature; stamp signatures are generally unacceptable.

CR 6698 also provides some exceptions to the signature requirement. First, facsimiles of original written or electronic signatures are acceptable for certifications of terminal illness for hospice. Second, there are other circumstances for which an order does not need to be signed. For example, orders for clinical diagnostic tests are not required to be signed, but there must be medical documentation by the treating physician that s/he intended the clinical diagnostic test to be performed. The documentation showing intent must be authenticated by the author with a handwritten or electronic signature. Finally, other regulations and CMS instructions regarding signatures take precedence. For example, if the NCD, LCD, and CMS manuals have specific signature requirements, those signature requirements take precedence. However, if these are silent as to signature requirements, the reviewer should follow the guidelines set forth in CR 6698.

Last month the Centers for Medicare and Medicaid Services (CMS) published an MLN Matters Article regarding changes to remittance advice coding. The article is directed towards Home Health Agencies that submit claims to a Regional Home Health Intermediary (RHHI) or to the Home Health Medicare Administrative Contractor (HH MAC – National Heritage Insurance Corporation (J14 only)) for services provided to Medicare beneficiaries.

The article explains that CMS released Change Request (CR) 6897 to instruct Medicare RHHIs and the J14 HH MAC to use a new Remittance Advice Remark Code (RARC) and a changed Claims Adjustment Reason Code (CARC) for home health agencies (HHAs) that are subject to the Home Health Prospective Payment System (HH PPS) outlier limitation. Up to CR 6897, the code “CARC 45” had been used to alert HHAs that an outlier payment, which would be eligible for payment, was not eligible because the HHA’s outlier limitation had been met. CMS found that CARC 45 did not adequately explain the reasoning for the denial of the payment, and therefore created a new remittance advice remark code (RARC) to be used in situations where the outlier limitation has been met. Then new RARC is N523. In addition to N523, HHAs can expect to see the claim adjustment reason code B5 (CARC B5).

The new RARC and updated CARC are effective for claims with dates of service on or after March 1, 2010. Therefore, if a calculated outlier amount is not paid because the HHA has reached the outlier limitation, HHAs can expect to see the following on their remittance advice: (1) Group Code CO: “Contractual Obligation,” (2) Claim adjustment reason code B5 (CARC B5); (3) RARC N523.

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) Home Health Care Survey is designed to measure the experiences of individuals receiving home health care from Medicare-certified home health care providers. The CAHPS has three broad goals: (1) to produce comparable data on the patient’s perspective that allows objective and meaningful comparisons between home health agencies on domains that are important to consumers; (2) public reporting of survey results so as to create incentives for agencies to improve their quality of care; and (3) public reporting to enhance public accountability in health care by increasing the transparency of the quality of care provided in return for public investment.

The home health care CAHPS (HHCAHPS) survey began in October 2009 with agencies that wished to implement the survey on a voluntary basis. The data collected during the voluntary period will be posted in Spring 2011. Agencies will have the option to suppress the reporting of their data collected during the voluntary period.

However, the Home Health Prospective Payment System (HHPPS) Final Rule (November 10, 2009) stated that HHCAHPS will be linked to the quality reporting requirement for the CY 2012 annual payment update (APU). The Centers for Medicare & Medicaid Services (CMS) strongly encourages that the designated quality staff in all Medicare-certified home health agencies (HHAs) read the Final Rule.