Medicare Update

Homecare Association Raises Concern about Impact of CMS Verification Process

On November 20, 2009, the American Association for Homecare (AAHomecare) sent a letter to the Centers for Medicare & Medicaid Services (CMS) requesting that CMS delay the implementation of rules/instructions providing for the rejection of claims for DMEPOS based on ordering/referring physician enrollment in the Provider Enrollment, Chain and Ownership System (PECOS).

According to the AAHomecare letter, the Association is concerned about the slow pace of physician enrollment in PECOS and how claim rejections may affect patient access to care and provider payments. For information about the facts and circumstances surrounding AAHomecare's concerns, see the letter. 

On April 24, 2009, CMS issued Transmittal 480 (Change Request 6421). Transmittal 480 is intended to address concerns about DMEPOS ordered/referred by physician and non-physician practitioners (ordering/referring provider) that may not be permitted by the Medicare program to do so.

As a first step, CMS is verifying that the ordering/referring provider on a DMEPOS claim:

• Has a current enrollment record in Medicare (i.e., the ordering/referring provider enrolled or updated his/her enrollment record within the past 5 years and the NPI is in the record); and
• Is of a specialty that is eligible to order and refer.

CMS intends to implement this verification in 2 phases:

• Phase 1 (October 5, 2009 - January 3, 2010) - DMEPOS suppliers that report ordering/referring providers who do not pass both edits will receive an informational message on their remittance. CMS reports that paper billers will not receive an informational message.
• Phase 2 (January 4, 2010 and thereafter) - DMEPOS suppliers that report ordering/referring providers who do not pass both edits will have their claims rejected.

For more information on this verification process, see:

• Transmittal 480/Change Request 6421
• MLN Matters Article Number MM6421
• Provider Inquiry Assistance Article - JA6421
• Message for Providers/Suppliers Concerning CR 6421

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OIG Work Plan Reveals Possible Risk Areas for Medicare Providers and Suppliers

On October 1, 2009, the Department of Health and Human Services' Office of Inspector General (OIG) released its Work Plan for fiscal year 2010 (Work Plan).

The Work Plan addresses the areas and issues the OIG intends to audit, evaluate and inspect during fiscal year 2010.  The Work Plan also provides some insight into the areas and issues that may evolve into future OIG enforcement activities. Therefore, health care providers and suppliers should consider the Work Plan in relation to their operations.

This post briefly highlights some of the Work Plan priorities for hospitals, physicians and other health care providers with respect to Medicare Parts A and B. Work Plan priorities for Medicare provider and supplier types not addressed in this post (e.g., home health agencies) will be covered in subsequent posts.

CMS Targets Top Medicare Part B Billers in Revalidation Efforts

The Centers for Medicare & Medicaid Services (CMS) recently issued 2 change requests (CR) directing Medicare carriers and Part A/B administrative contractors (MAC) to undertake certain revalidation efforts.

Specifically, CR 6574 (Transmittal 557) directs Medicare carriers and MACs to begin revalidating the top 50 billing (in terms of the dollar value of submitted claims) Medicare Part B individual practitioner suppliers within each state (for each of their contractor identification numbers) that do not have an established record in the Provider Enrollment, Chain and Ownership System (PECOS). 

CR 6485 (Transmittal 556) has similar instructions for the top 50 billing (based on the amount billed within the prior quarter or calendar year) Medicare Part B organizational suppliers (including groups/clinics).

According to the CRs, Medicare carriers and MACs are expected to mail the initial revalidation letters within 30 days of the issuance of the CRs.  CR 6574 and 6485 were issued on September 14, 2009 and rescinded and replaced CRs that were issued on August 21, 2009. The CRs also have an effective and implementation date of October 23, 2009.

CR 6574 and 6485 instruct Medicare carriers and MACs to follow the revalidation instructions found in Section 9 of Chapter 10 of the Medicare Program Integrity Manual. 

Medicare Part B suppliers should note that those instructions provide for the revocation of Medicare billing privileges if a revalidation request is not responded to within a designated time period.

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OIG Releases Compendium of Unimplemented Recommendations

On May 29, 2009, the Department of Health and Human Services' (HHS) Office of Inspector General (OIG) released its Compendium of Unimplemented Office of Inspector General Recommendations (May 2009).

The Compendium includes information about OIG recommendations that had not been fully implemented as of December 31, 2008.  The Compendium also includes a list of "priority recommendations," which the OIG believes represent the most significant opportunities to positively impact HHS programs.

The list of "priority recommendations" includes a number of recommendations for the Medicare program. In brief, those recommendations (and any estimated savings) include:

• Ensure accurate Medicare Part D sponsors bids and prospective payments
• Implement safeguards to prevent and detect fraud and abuse in Medicare prescription drug plans
• Ensure durable medical equipment suppliers' compliance with Medicare standards
• Modify payment policy for Medicare hospital bad debts (estimated savings $340 million)
• Reduce the rental period for Medicare home oxygen equipment (estimated savings $3.2 billion)
• Modify payments to managed care organizations (estimated savings $1.97 billion)
• Place a ceiling on administration costs included in managed care organizations' rate proposals
• Improve Centers for Medicare & Medicaid Services performance evaluation process for program safeguard contractors
• Ensure the appropriate processing of denial of Medicare payment remedies for noncompliant nursing homes
• Improve oversight of Medicare hospices

The Compendium also includes other unimplemented OIG recommendations pertaining to the Medicare program, including (but not limited to):

• Identify duplicate Medicaid and Medicare home health payments
• Require physician examination before ordering home health services
• Revise graduate medical education payment methodology
• Reduce Medicare end stage renal disease payment rates
• Improve quality oversight of ambulatory surgical centers in the Medicare program

See the Compendium for more detailed information (including background information, OIG findings, recommendations, status and any estimated savings). 

Senator Grassley Inquires about Medicare Overpayments to DMEPOS Suppliers

In a April 17, 2009 letter to the Centers for Medicare & Medicaid Services (CMS), Senator Charles Grassley urged CMS to respond to an Office of Inspector General (OIG) memorandum, revealing that DMEPOS suppliers had $352 million in debt deemed "currently not collectible" (CNC) in 2005 (and $402 million in debt deemed CNC in 2006).

According to the OIG memorandum, the OIG selected a random sample of 10 DMEPOS suppliers in Texas with Medicare debt of at least $50,000 deemed CNC (i.e., a Medicare overpayment that remains uncollectable 210 days after the date of the first demand letter).

CMS then attempted to identify all of the owners and managers of the 10 DMEPOS suppliers, cross reference such information against other DMEPOS supplier and home health agency (HHA) enrollment applications, and Medicare claims. 

In doing so, the OIG sought to determine whether any of the sample DMEPOS suppliers were associated with other businesses that received Medicare payments during 2002-2007 through shared ownership or management, family relationship, address or telephone number. In brief, the OIG found that:

• 6 out of 10 DMEPOS suppliers reviewed were associated with 15 other suppliers and HHAs that received Medicare payments of $58 million during 2002-2007.
• Most associated DMEPOS suppliers lost billing privileges by January 2005 and accumulated their own CNC debt, although most associated HHAs received payments as recently as December 2007.
• Most sample DMEPOS suppliers were connected to associated businesses through shared ownership/management (e.g., the owner/manager of the sample DMEPOS supplier also owned/managed the associated DMEPOS supplier or HHA).
• 11 associated supplier and HHA enrollment applications did not include the name of at least one owner or manager listed in Accurint.

According to Senator Grassley's letter, the OIG memorandum suggests that, without better oversight, individuals with unpaid Medicare debt could submit new DMEPOS or HHA applications with intentionally omitted owner/manager information resulting in inappropriate Medicare payments.

In the letter, Senator Grassley requests that CMS provided detailed answers to the following questions:

• When a potential DMEPOS supplier or HHA applies to participate in the Medicare Program, are they required to disclose any relationship with other companies currently in default to the Medicare program?
• What policies are in place to recoup losses after a default, and if so please provide copies?
• What enhanced authorities does CMS require to protect the program?

CMS to Host Special Open Door Forum on Medicare Provider & Supplier Enrollment

The Centers for Medicare & Medicaid Services (CMS) recently announced that it will hold a Special Open Door Forum to discuss the Internet based Provider Enrollment, Chain and Ownership System (PECOS) and the implementation of regulatory provisions.

CMS reports that, during this Special Open Door Forum, CMS will discuss:

• Internet based PECOS for physicians, non-physician practitioners and provider and supplier organizations
• Provider and supplier reporting responsibilities, including:
  • Final adverse actions
  • Change of practice locations
  • Change of ownership
  • Other reportable events
• Effective date of Medicare billing privileges and retrospective billing for physicians, certain non-physician practitioners, and physician and non-physician practitioner organizations
• Revalidation efforts

According to CMS, there will also be an opportunity for participants to ask questions.

To participate in this Special Open Door Forum, one must dial 1-800-837-1935 and reference conference ID 94109369.  On May 11, 2009, CMS will also post an audio recording of this Open Door Forum on the Special Open Door Forum page of the CMS website, which will be available for 30 days.

CMS Revises Fact Sheets on Medicare Enrollment Reporting Responsibilities

The Centers for Medicare & Medicaid Services (CMS) recently revised Fact Sheets addressing the types of Medicare enrollment information changes that trigger reporting responsibilities for physicians, non-physician practitioners, and group practices. The Fact Sheets can be found on the Medicare Provider-Supplier Enrollment/Overview page of the CMS website and include the following:

• Reporting Responsibilities for Individual Physicians Enrolled in the Medicare Program
• Reporting Responsibilities for Individual Non-Physician Practitioners Enrolled in the Medicare Program
• Reporting Responsibilities for Physician Group Practices Enrolled in the Medicare Program

CMS has also revised its Physicians, Non-Physician Practitioners, and Other Health Care Suppliers Brochure, which is posted on the Medicare Provider-Supplier Enrollment/Overview page of the CMS website.

UPDATE: CMS to Hold Special Open Door Forum on Internet-Based Medicare Enrollment

The Centers for Medicare & Medicaid Services (CMS) will hold a Special Open Door Forum to discuss the implementation of the Internet based Provider Enrollment, Chain and Ownership System (PECOS) for physicians and non-physician practitioners.

The Special Open Door Forum will take place from 2:00 3:30 p.m. - 3:30 5:00 p.m. (ET) on January 1413, 2009. During the Special Open Door Forum, CMS is expected to discuss:

• Advantages of Internet based PECOS;
• Use of National Plan and Provider Enumeration System User ID and password;
• Process associated with submitting an enrollment application via Internet based PECOS; and
• Certification Statement and supporting documentation.

Afterwords, conference call participants will have an opportunity to ask questions.

To participate in the Special Open Door Forum, one must dial 1-800-837-1935 and reference conference ID 73178380. CMS also intends to post an audio recording of the conference call on the Special Open Door Forums page of the CMS website, which will be accessible beginning January 23, 2009.

CMS reports that physicians and non-physician practitioners in 44 states and the District of Columbia can use Internet based PECOS to enroll, make a Medicare enrollment change, view their Medicare enrollment information, and check the status of a Medicare enrollment application. By the end of January 2009, CMS intends to expand the availability of Internet based PECOS to physicians and non-physician practitioners in:

• California;
• Texas;
• Virginia;
• Oklahoma;
• New Mexico;
• Colorado; and
• Puerto Rico.

In 2009, CMS expects to make Internet based PECOS available to organizational providers and suppliers (except suppliers of durable medical equipment, prosthetics, orthotics and supplies).

Related Posts:

• CMS Makes Internet-Based Medicare Enrollment Available
• CMS Expands Internet-Based Medicare Enrollment

CMS Makes Internet-Based Medicare Enrollment Available

The Centers for Medicare & Medicaid Services (CMS) recently announced that the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) is available in the District of Columbia and 15 states.

CMS reports that PECOS will allow physicians and non-physician practitioners to enroll, make a change in their Medicare enrollment, view their Medicare enrollment information on file with Medicare, and check on the status of a Medicare enrollment application via the Internet.  PECOS is currently available to physicians and non-physician practitioners in the District of Columbia and the following 15 states: 

• Delaware
• Idaho
• Illinois
• Iowa
• Kansas
• Minnesota
• Missouri
• Nebraska
• Maryland
• Michigan
• New Jersey
• North Carolina
• Pennsylvania
• Tennessee
• Wisconsin

CMS reports that it will expand the availability of PECOS for physicians and non-physician practitioners to all states over the next 2 months. CMS also intends to make PECOS available next year to all providers and suppliers (except suppliers of durable medical equipment, prosthetics, orthotics, and supplies). Physicians and non-physician practitioners may access PECOS here.

For additional information on PECOS, visit the Internet-Based PECOS page of the CMS website. For commentary on PECOS, visit the The HIT Transition Weblog's post entitled "Online Medicare Enrollment Via NPPES Signon."

CMS to Host End Stage Renal Disease Open Door Forum

The Centers for Medicare & Medicaid Services (CMS) will hold the first End Stage Renal Disease (ESRD) Open Door Forum of 2008 at 2:00 p.m. (EDT) on April 17, 2008.  The focus of the Open Door Forum will be the ESRD conditions for coverage Final Rule that CMS released on April 3, 2008.

There are 2 ways to participate in the Open Door Forum. To participate by telephone, one must dial 1-800-837-1935 and reference conference ID 30068679.  To participate in person, one must RSVP by 2:00 p.m. (EDT) on April 15, 2008 to ESRDODF-L@cms.hhs.gov, and include your name, organization, phone number, and “ESRD” in the subject line.  The Open Door Forum will take place at the Hubert H. Humphrey Building, 200 Independence Avenue S.W., Washington, D.C. 

Beginning on April 21, 2008, CMS will also make an audio recording available.  To access the audio recording, one must dial 1-800-642-1687 and enter the conference ID.  The recording will expire after 3 business days.