Archive for August, 2013|Monthly archive page

HIPAA/HITECH Omnibus Final Rule – Last Few Weeks To Comply!

In Uncategorized on August 27, 2013 at 6:38 pm

On January 17, 2013, the U.S. Department of Health and Human Services (“HHS”) issued a final rule (“Omnibus Rule”) affecting multiple aspects of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and the HITECH Act.  

The Omnibus Rule, commonly referred to by this name because of its sweeping scope, is comprised of four final rules that (in general and succinct terms):

  • modify aspects of HIPAA and its implementing regulations including the privacy standards located at 45 C.F.R. parts 160 and 164, subparts A and E (the “Privacy Rule”), the security standards located at 45 C.F.R. parts 160, 162 and 164, subpart C (the “Security Rule”), and enforcement standards located at 45 CFR part 160, subparts C, D, and E (the “Enforcement Rule”);
  • implement statutory amendments, including an increased and tiered civil money penalty structure, under the Health Information Technology for Economic and Clinical Health Act (“HITECH”);
  • modify the interim final rule for Breach Notification for Unsecured Protected Health Information located at 45 C.F.R. part 164, subpart D (the “Breach Notification Rule”), including replacing its harm threshold for breach notification requirements with a default presumption that an acquisition, access, use, or disclosure of PHI that violates the Privacy Rule is a breach, and supplant the Breach Notification Rule as of the Compliance Date (covered entities and business associates must continue to comply with the interim rule in the meantime); and
  • modify the HIPAA Privacy Rule by implementing section 105 of Title I of the Genetic Information Nondiscrimination Act of 2008 (“GINA”), clarify that genetic information is health information, and prohibit health plans, including group health plans, health insurance issuers (including HMOs), and issuers of Medicare supplemental policies, from using or disclosing genetic information for underwriting purposes.

The Omnibus Rule went into effect on March 26, 2013, and, except with respect to certain grandfathered business associate agreements, HIPAA covered entities and business associates must comply with its requirements by September 23, 2013.   The Business Associate’s Agreement between you and youe billing company – if entered into prior to March 26, 2013 – is in fact one of those that has been grandfathered in, and allowed a one-year extension in which to comply. 

The AMA summarized more fully the portions of the Omnibus Rule that impact the medical provider community.  Please be sure to review this carefully to ensure compliance.  Additionally, I have attached a sample HIPAA/Omnibus Notice of Privacy Practices, which, once modified to include specific data points pertaining to your practice, may be used by your practice going forward.  This sample was taken largely (but modestly adapted) from the sample Omnibus Notice published by MGMA. sample HIPAA Omnibus Notice of Privacy Practices-adapted from MGMA

As always, please do not hesitate to contact M.E.D.I.C., Inc. with any questions that you may have about this.


SGR Update — Fix Remains High Priority for 113th Congress

In Uncategorized on August 27, 2013 at 6:28 pm

Congressional leaders remain committed to finding a permanent solution to the SGR problem that has plagued the Medicare program and provider payments for over a decade.  Although there has long been bi-partisan agreement that the SGR formula developed during the Clinton Administration was seriously flawed, a permanent fix has remained elusive. 

Although an SGR fix is not imminent, due to a convergence of factors, a permanent fix appears achievable in 2013.  All of the Congressional Committees (Senate Finance, House Ways and Means and House Energy and Commerce) that share jurisdiction over Medicare Physician Payment reforms have held hearings and solicited feedback from stakeholders on possible permanent solutions.  Democratic and Republican leaders in both the House and Senate remain committed to finding a permanent solution whereas in years past, the level of commitment to finding a permanent fix has not been as strong. 

Draft proposals have been circulated amongst the various physician and other healthcare organizations, and industry feedback and reaction have been sought. 

If Congress should fail to come up with a permanent fix before the end of 2013, current estimates are that a cut of approximately 24% in provider payments will be necessary to comply with the SGR law. 

Some of the common themes that are emerging as part of the SGR discussions center around the following concepts:

Repeal SGR and replace with statutory increases (possibly 1 – 2 % per year but still to be determined) for a period of time (possibly 3 – 5 years but still to be determined). This would eliminate the 24 % cut slated for January 1, 2014.

  1. Incorporate Specialty Specific Quality Measures as part of the payment formula (aka Update Incentive Program).
  2. Provider payments would be a combination of a “base rate” plus a variable rate tied to quality/performance (Specialty Specific Quality Measures).
  3. Score on Quality would be based upon a comparison against peers (risk adjusted) AND compared to the individual provider’s prior year scores AND provider participation in specialty specific clinical improvement initiatives.
  4. Each provider would “self-identify” with a peer cohort (i.e. providers of the same specialty); and provide information on each of the following:

*             Identifies the peer group the provider wants to be compared to; and
*             Provides information on each quality measure applicable to such peer group to which the provider shall be assessed.

The Secretary of HHS will be responsible for developing the methodology for assessing the performance of providers with respect to the measures and with developing the methods for collecting information needed for such assessments.  The Secretary is directed to establish these processes in a way that minimizes the “… amount of administrative burden needed to ensure reliable results.”

In reviewing the proposals, several administrative/operational questions have arisen.  These include: 

  • Auditing/data retention requirements
  • Claims reporting requirements
  • Administrative complexity of process
  • How/when will payments be made
  • What will be necessary to support provider participation in this type of payment model
  • Predictability of payment


Clearly, much still needs to be done to address and hopefully to resolve this ever-pressing matter.

reprinted with permission, Healthcare Business & Management Association (HBMA)

OIG Releases Revised Provider Self-Disclosure Protocol

In Uncategorized on August 27, 2013 at 6:18 pm

The Department of Health and Human Services, Office of Inspector General (OIG) recently released a revised  Provider Self-Disclosure Protocol, updating the earlier version originally released in 1998 (see the following link:

Providers who wish to voluntarily disclose “self-discovered evidence of potential fraud to OIG may do so under the Provider Self-Disclosure Protocol (SDP).”  Self-disclosure does not absolve a provider of responsibility for potential fraud, but it does provide the opportunity for health professionals to avoid some of the costs associated with civil or administrative litigation.

In releasing the update, the OIG stated, “OIG endeavors to work cooperatively with providers who are forthcoming, thorough, and transparent in their disclosures in resolving these matters. While OIG does not speak for the Department of Justice or other agencies, OIG consults with those agencies, as appropriate, regarding the resolution of SDP matters.”

In 1998, the OIG published the original Provider Self-Disclosure Protocol to establish a process for health care providers to voluntarily identify, disclose, and resolve instances of potential fraud involving the Federal health care programs. The SDP was crafted to provide guidance on how to investigate this conduct, quantify damages, and report the conduct to OIG to resolve the provider’s liability under civil monetary penalty (CMP) authority.

Since the original Self-Disclosure Protocol was published, the OIG has identified several areas where additional guidance would be beneficial and could improve the efficient resolution of SDP matters. On the basis of the agencies experience and comments received from the public over the years, the OIG decided to revise the SDP in its entirety.

The new Protocol supersedes and replaces the 1998 Federal Register Notice and the associated “Open Letters” that have served to provide additional guidance to providers.

CMS Will Deny Enrollment Applications When Outstanding Overpayment Exists

In Uncategorized on August 23, 2013 at 7:16 pm

Effective October 1, 2013, any providers or owners of provider-entities having an existing or delinquent overpayment that has not been repaid in full at the time of the enrollment application or change of ownership filing may be denied that new enrollment or change of ownership until that overpayment has been addressed. 

Upon receipt of the CMS enrollment forms (855A, 855B or 855S application), the Medicare Contractor will determine – whether any of the owners listed in Section 5 or 6 of the application has an existing or delinquent Medicare overpayment.  Upon receipt of a CMS-855I application, the Medicare Contractor will determine whether the physician or non-physician practitioner has an existing or delinquent Medicare overpayment.

If an owner, physician, or non-physician practitioner has such an overpayment, the contractor shall deny the application, using 42 CFR 424.530(a)(6) as the basis. The denial shall be issued regardless of:

  • Whether the person or entity is on a Medicare-approved plan of repayment or payments are currently being offset:
    • Whether the overpayment is currently being appealed
    • The reason for the overpayment

For now this rule applies only to initial enrollments and new owners in a CHOW, not revalidations or updates to current enrollments.  Note also that if the Medicare Contractor determines that the overpayment existed at the time the application was filed, but the debt was paid in full by the time the contractor performed its review, the contractor will not deny the application because of that overpayment.

Multiple Fee Schedules – Good or Bad?

In Uncategorized on August 23, 2013 at 6:37 pm

A client recently asked M.E.D.I.C., Inc. about the legality and viability of implementing multiple fee schedules – each tailored to a specific carrier allowable, so as to reduce the appearance uncollectible AR in reports.  I thought that perhaps other clients and non-client providers may have considered this as well, and would thus be interested in this information.  For the reasons outlined below, I believe that it is preferable for a medical practice to maintain only one fee schedule.

As an initial matter, it is fairly common knowledge that a practice cannot bill Medicare a fee that is more than the fee billed to other carriers.  Medicare’s guidance on this is not crystal clear, however the rules do say are that a providers’ fee may not be “substantially in excess” of their “regular fee” (or “usual and customary” fee) for the same service(s).  Translation: if a providers’ fees to Medicare exceed their fee for the same service more than some unstated amount, or more often than ‘occasionally’, then that practice would be violating Medicare’s rule.  The premise is that if a provider charges less to other carriers, then that provider’s regular or usual and customary fee is in fact that lower fee.

So, if Medicare is your best payer, then it is moot to even entertain the idea of tailoring fee schedules to the carrier allowables, for you will run afoul of this regular/usual and customary fee rule.

Conversely, if Medicare is the lowest fee schedule, and you are wanting to charge other carriers higher fees because they may allow (and thus, pay) more, you will be safe with regard to Medicare’s rules.  BUT, while not running afoul of Medicare rules, this practice may be in violation of your participation agreements with those other carriers.  Those participation agreements may contain “most favored rate” or “most favored nation” clauses which provide that that carrier receives the best (i.e., lowest) fee schedule rate that you have.  In a case in which Medicare is the lowest fee schedule, then any carrier possessing such a “most favored rate/nation” clause must only be charged the Medicare (i.e., lowest) fee, and again the discussion of tailoring fee schedules is moot.

The key question to ask is why a practice may want to use multiple fee schedules – each tailored to the specifics of the various carriers with which the practice participates.  Often, the rationale is to avoid posting contractual adjustments…  if the fee that a provider charges is equivalent to the carrier allowable, then there will be no contractual adjustment.  However, the time saved by not posting contractual adjustments will be lost in the constant management and updating of that fee schedule to accommodate the constantly changing allowable.   And, if those fees are not constantly managed and updated, then the provider will undoubtedly leave some money on the table.  Also, keep in mind that this is a code-by-code analysis, not a schedule-by-schedule one…  for example, Medicare may pay more for some CPTs but not others – so now you have to worry about not only capturing all moneys to which you are entitled on an ever-changing code-by-code analysis, but you also have to remember not to violate Medicare’s regular and customary fee rule on a code-by-code basis!  This is undeniably an administrative nightmare!

Another rationale that is often asserted is that using one “overinflated” fee schedule will result in overstated AR, while tailoring the fee schedule to the carrier allowable will result in an accurate depiction of the truly owed and collectible AR.  That may be true, however, there are several elements that must be factored into this equation:

  • The contractual adjustments that are logged (and thus, which can be reported on) when using a single fee-schedule provide practices with a complete depiction of the amount of income that that practice has foregone by virtue of its participation agreements – i.e., the amount contractually written-off versus collected as the full fee.  This is important to a practice’s ability to analyze the value of participation with a particular carrier.  For example, when deciding whether to continue participating with ABC Insurance Company, a practice with a single fee schedule can take its most frequently billed procedure codes and analyze the collection rate across various carriers – they are all being charged the same fee, so the amount paid vs. write-off is patently obvious, and comparable.  This analysis is impossible with multiple fee schedules.
  • Absent a constant review and analysis of fee schedules and carrier allowables, a practice employing multiple fee schedules is bound to lose some money by underbilling for charges whose allowables have changed, or using the lower fee based on the allowable of one carrier when filing to another carrier that would have allowed and paid more.
  • Finally, there is the problematic conundrum of billing for patients with multiple coverage.  A practice cannot charge two different fees for one service on the same claim form.  So, although a practice may have established multiple fee schedules for each carrier, how does determine which fee to use for a claim for a patient having secondary (and perhaps tertiary) insurance coverage?  One fee must be selected, and in doing so, that practice is clearly going to either lose some amount of income (if the fee is less than one of the carriers’ allowable), or it is going to have a contractual write-off (the thing that it was trying to avoid in the first place).

All things considered, while the single-fee schedule approach may indeed lead to inflated AR figures, the benefits of that system appear to far outweigh the negatives, and in the long-run is much more efficient than the multi-fee-schedule approach.

As always, please do not hesitate to contact M.E.D.I.C., Inc. at any time to discuss these – or any matters – further.

Cigna Has Imposed A Single Appeal Process As Of 7/1/13

In Uncategorized on August 23, 2013 at 6:30 pm

Per Cigna’s announcement (emphasis added):

Historically, for certain business units and types of appeals, we have offered second-level appeals to health care professionals who were not satisfied with the resolution of a first-level review.  Please be aware that beginning July 1, 2013, we will no longer offer second-level appeals.  All appeals will follow a thorough single appeal review process and will be completed within 60 days. This change establishes a consistent approach for health care professionals across Cigna’s network.

As a reminder, all appeals should be initiated in writing within 180 calendar days of the date of the initial payment or denial decision. If the appeal relates to a payment that we adjusted, the appeal should be initiated within 180 calendar days of the date of the last payment adjustment.

This new policy impacts medical billing clients only in that when you receive a request for information from your billing partner, you need to be sure to provide complete information in a timely manner, as that biller has only one chance to appeal denials going forward!

2013/2014 Flu Vaccine Information

In Uncategorized on August 23, 2013 at 6:05 pm

The Centers for Disease Control has announced the following information regarding ordering the 2013-2014 flu vaccine:

The 2013-2014 influenza vaccine can be ordered at this time from manufacturers and distributors.

As the 2012-2013 flu season has shown, it is important to pre-book vaccine as soon as it is available. Most of the flu vaccine offered for the 2013-2014 season will be trivalent (three component).

  • Trivalent vaccine offers important protection from flu.
  • Some quadrivalent (four-component) vaccine will be available as well according to manufacturers; however, supplies are expected to be limited.
  • All nasal spray vaccine is expected to be quadrivalent, however, this makes up only a small portion of total vaccine availability.
  • Ordering flu vaccine should not be delayed if quadrivalent flu vaccine is not available.

More information is available on the CDC website.

PECOS/Ordering & Referring Issue Redux

In Uncategorized on August 23, 2013 at 6:03 pm

As some of you may recall, there was a flurry of activity a couple of years ago regarding PECOS – CMS’s online provider enrollment system – and the need for all providers to be enrolled in PECOS.  CMS’s incentive (or, “stick”), if you will, for getting all providers on board was to deny any claims related to providers not enrolled in PECOS, and identified in the PECOS “ordering and referring” list.  That deadline for compliance, and the subsequent enforcement was slated to be May 1, 2013 – as of that date, any claim relating to an ordering/referring provider not enrolled in PECOS was going to be summarily denied.  However, just prior to that enforcement date, CMS announced that:

Due to technical issues, implementation of the Phase 2 ordering and referring denial edits is being delayed. These edits would have checked the following claims for an approved or validly opted-out physician or non-physician who is an eligible specialty type with a valid individual National Provider Identifier (NPI). If either of these were missing or incorrect, claims would deny.  

  • Medicare Part B claims from laboratories, imaging centers and Durable Medical Equipment, Orthotics, and Supplies (DMEPOS) that have an ordering or referring physician/non-physician provider; and
  • Part A Home Health Agency (HHA) claims that require an attending physician provider. 

CMS will advise you of the new implementation date in the near future. In the interim, informational messages will continue to be sent for those claims that would have been denied had the edits been in place.

You may be questioned by any facilities, labs, or DME providers to which you refer patients regarding your PECOS status….  This is what they are talking about, and the potential for their claims to be denied if you are not in PECOS is the root of their concern.

CMS Issued A Vaccine Update 3/21/13

In Uncategorized on August 23, 2013 at 5:57 pm

Recall my discussion in a prior post of CMS’ refusal to cover tetanus (or other vaccines, other than the annual influenza vaccine, the once per lifetime pneumococcal vaccine, and the high-risk patient’s hepatitis-B vaccine) as a medically necessary vaccination absent an incident of exposure?  Well, in spring of 2013, CMS clarified their position.

To report the tetanus vaccine administered for the treatment of an injury or direct exposure to a disease or condition, append modifier AT (acute treatment) to the code for the vaccine.  Claims submitted without modifier AT will be denied.

 Note: The medical record must support the need for the service and the use of modifier AT.

Vaccinations or inoculations are excluded as immunizations unless they are directly related to the treatment of an injury or direct exposure to a disease or condition, such as anti-rabies treatment, tetanus antitoxin or booster vaccine, botulin antitoxin, antivenin sera, or immune globulin. In the absence of injury or direct exposure, preventive immunization is not covered. However, pneumococcal, hepatitis B, and influenza virus vaccines are exceptions to this rule.  See, The Centers for Medicare and Medicaid Services Benefit Policy Manual, 100-02, Chapter 15, Section

Remember, patients demanding a vaccine absesnt an acute incident or exposure need to be presented with and execute a valid Advanced Beneficiary Notice (ABN) in order for the practice to be able to bill that patient once Medicare denies the claim.

Report Surgical H&P With Caution

In Uncategorized on August 23, 2013 at 5:36 pm

History and physicals before surgery can be potholes in the road for reimbursement if reported incorrectly.  Carefully review the circumstances under which the physical is performed to prevent claim denials.

In most cases, if the surgeon performs a history and physical (H&P) to clear a patient for a scheduled surgery, you should not report a separate service.  An H&P is a routine, standard procedure prior to surgery, and is separately reimbursable only if the service satisfies your payer’s medical-necessity requirements.  In practical terms, a pre-surgical H&P is a bundled, global service, unless the patient presents with a new chief complaint that requires work above and beyond that normally required for such a service.

For example, a patient may develop a new problem or otherwise have had a significant change of status in the days before his surgery, which would require the surgeon to perform a more extensive evaluation.  In such a circumstance, you may report the appropriate E/M service level, as supported by the key components of history, exam, and medical decision-making.  Any new diagnosis or patient problems must be documented to establish medical necessity for the visit.  Also, remember that pre-surgical visits (related to the surgery) that occur within 24-hours of the surgery are generally encompassed in the surgical global period, and are not separately compensable.

The rules change for services provided within 24 hours of an unscheduled and/or emergency procedure.  In these cases, a surgeon making the decision for surgery during the visit would report an appropriate E/M service code with modifier 57 Decision for surgery appended.

As always, please contact us at any time with questions regarding this, or other matters.