Posts Tagged ‘CMS’

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.


CMS Signature Requirements – A Reminder for Compliant Records

In Uncategorized on August 22, 2013 at 6:24 pm

As we all know, there are certain signature requirements imposed by CMS and other payers.  The purpose of a rendering/treating/ordering practitioner’s signature in patients’ medical records, operative reports, orders, test findings, etc., is to demonstrate that services submitted to Medicare have been accurately and fully documented, reviewed and authenticated.  Furthermore, it confirms the provider has certified the medical necessity and reasonableness for the service(s) submitted to the Medicare program for payment consideration.   Such signature must be legible and should include the practitioner’s first and last name.  For clarification purposes, it is recommended that providers include their applicable credentials (e.g., P.A., D.O., or M.D.).

These signatures can be electronic or written – both of which have a set of acceptable formats.  Examples of acceptable written signatures are:  legible fill signature, legible first initial and last name, illegible signature over a typed or printed name, illegible signature on letterhead that otherwise identifies the signatory (if multiple providers on letterhead, the signatory’s name must be circled), etc….[1]  Conversely, an illegible signature with no accompanying typed or printed name or letterhead is unacceptable absent an attestation statement. 

Occasionally we have seen situations in which a carrier seeks additional information in the form of notes, which are deemed illegible.  In this case, it is advisable for your billing company to have on file an attestation statement confirming the nature of that illegible signature.  This is key because once your billing company has been asked for this attestation statement, you are only allowed 20 calendar days in which to provide it.  Such statement must include the following components:

  • the full printed name of the provider
  • sufficient information to identify the beneficiary
  • date of service
  • signature and date by the author of the medical record entry (i.e., generally the provider)

In order to expedite the submission of such requests, it behooves you to provide your billing company with an executed blank signature attestation statement that the billing company can keep on file for future use.



CMS Published Proposed Rules on Reporting of Overpayments

In Uncategorized on August 22, 2013 at 6:05 pm

Reminder to be mindful of proper management of overpayments!

In spring 2012, CMS released a Notice of Proposed Rulemaking (NPRM) that would, if finalized, require providers and suppliers to report and return self-identified overpayments either within 60 days of the incorrect payment being identified or on the date when a corresponding cost report is due, whichever is later.

In addition to the 60-day reporting requirement, CMS is also proposing that providers retain medical records for at least 10 years in order to allow for a look-back for the identification of billing errors that may have occurred in previous years. 

The announcement is one part in a series of steps Medicare is taking to “protect taxpayer dollars.” In addition to the overpayment reporting requirements, CMS is: using private auditors to identify so-called wasteful spending before it happens; expanding the use of Recovery Audit Contractors to the Medicaid program; testing changes to hospital billing systems to help prevent over-billing; and, changing the process for approving payments for durable medical equipment with historically high payment error rates.

The Proposed Rule identifies a Medicare overpayment as “funds that a person receives or retains under Medicare to which the person is not entitled.”  The NPRM provides examples of overpayments in Medicare to include:

  • Duplicate submission of the same service or claim
  • Payment to the incorrect payee
  • Payment for excluded or medically-unnecessary services
  • Payment for non-covered services

Any failure to report and return the overpayment within the applicable time frame could be a violation of the False Claims Act.  Providers also could be subject to civil monetary penalties or excluded from participating in federal healthcare programs for failure to report and return an overpayment.

The Medicare Over Payment Proposed Rule ( is available for public inspection.  The link also provides instructions for how to submit comments.

Happy Valentine’s Day – CMS’ Present To Providers: Potential Delay in ICD-10 Timeline

In Uncategorized on February 14, 2012 at 7:49 pm
The acting head of the CMS on Tuesday signaled that the agency will extend the timeline on ICD-10 implementation.
Over the past few months, the American Medical Association has been actively working toward delaying the implementation of ICD-10.  In mid-January, a letter from AMA Executive Vice President and CEO James L. Madara, M.D. to House Speaker John Boehner (R, Ohio) stated that, “[r]equiring doctors to use ICD-10 would offer no direct benefit to patient care.”  That letter further stated that “requiring all physician practices to use new diagnosis codes starting Oct. 1, 2013, also would interfere with concurrent efforts by doctors to implement electronic medical records and satisfy other Medicare quality improvement requirements.”
After recently speaking to attendees at the American Medical Association Advocacy Conference in Washington, acting CMS Administrator Marilyn Tavenner told reporters that the CMS will “re-examine the timeframe” through a rulemaking process. She did not say when that rulemaking process will begin but said the CMS would send details about the process in the coming days. “There’s concern that folks cannot get their work done around meaningful use, their work around ICD-10 implementation and be ready for exchanges,” Tavenner said. “So we’re trying to listen to that and be responsive.” Separately, Tavenner said she the CMS has had “good results” with accountable care organization applications and expects to make an announcement about selected applicants “at the beginning of the second quarter of this year.”
For more information on ICD-10, please see The Centers for Medicare & Medicaid Services’s webpage, at

Resolve To Use The New CMS ABN In 2012!

In Uncategorized on December 21, 2011 at 4:52 pm

The Advanced Beneficiary Notice of Noncoverage (“ABN”) is a form that is used by health care providers, including physicians, when they expect Medicare to deny payment.  More specifically, each and every time that you, the provider, believe that Medicare will deny a charge, you must have the patient complete the ABN (which is linked to a specific date of sesrvice), acknowledging that he/she has been advised that Medicare may not pay for the service, but that he/she wants the service regardless, and agrees to be financially responsible for it.  An example might be a Medicare patient seeking a complete physical (as distinguished from the annual wellness visit!) – a service that Medicare will not cover.  Having this date-of-service-specific ABN is the only way that a provider can legitimately transfer a charge that was denied by Medicare as a non-covered service to the patient for payment.

The Centers for Medicare and Medicaid Services (CMS) has revised the ABN, Form CMS-R-131. The revised form replaces ABN-G (Form CMS-R-131G), ABN-L (Form CMS-R-131L), and NEMB (Form CMS-20007).   The CMS website has links to the new form and instructions for use of the new ABN form, respectively: 

Use of the revised ABN form (which has a release date of 3/2011 printed in the lower left hand corner) will be mandatory starting January 1, 2012, however it is certainly available for current use as well.   Any ABNs submitted after 1/1/2012 which have a release date of 3/2008 printed in the lower left hand corner will be deemed invalid, and the patient will NOT be deemed liable for any charges that remain denied as non-covered by Medicare.

Slight 5010-Compliance Reprieve

In Uncategorized on November 17, 2011 at 6:16 pm

CMS has announced that it will NOT enforce 5010 non-compliance until March 31, 2012.  This is a slight reprieve, but all HIPAA covered entities should be actively in testing mode, and continually “working with their trading partners to become compliant with the new HIPAA standards, and to determine their readiness to accept the new standards as of January 1, 2012.”

For the full text of the CMS statement, please see:

Government Incentivizes EMR Adoption

In Uncategorized on April 1, 2011 at 6:05 pm

Reposted from, October 2009

On February 17, 2009, the American Recovery and Reinvestment Act (ARRA) was signed into law, committing $19.2 billion to healthcare information technology (HIT) to promote the use of HIT for all providers of healthcare. A whopping $17.2 billion has been allocated as incentive payments to eligible healthcare professionals for EMR adoption. More specifically, providers using a certified EMR will be eligible for substantial government cash incentives in the years 2011 through 2014. While the law does not yet specify what constitutes a “certified” EMR, industry leaders agree that CCHIT will likely be selected as the standard. Providers who have not adopted a certified EMR by 2015 may be penalized.

As the chart below reflects, those providers adopting a certified EMR system in 2011 & 2012 will receive the greatest benefit, for they will be eligible for incentive payment for 5 years and at a higher rate.

Feel free to contact M.E.D.I.C., Inc. if you would like to discuss EMR options and issues as you prepare to foray into this new technology!

CMS Comment Regarding Physical Therapy Cap Exceptions Process

In Uncategorized on April 8, 2010 at 7:25 pm

On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act, which extends the exceptions process for outpatient therapy caps (see Section 3103).  Outpatient therapy service providers may continue to submit claims with the KX modifier, when an exception is appropriate, for services furnished on or after January 1, 2010, through December 31, 2010.  

The therapy caps are determined on a calendar year basis, so all patients began a new cap year on January 1, 2010.  For physical therapy and speech language pathology services combined, the limit on incurred expenses is $1,860.  For occupational therapy services, the limit is $1,860.  Deductible and coinsurance amounts applied to therapy services count toward the amount accrued before a cap is reached.