MEDICARE COMPLIANCE

CMS has made the following updates to the MMSEA section of the CMS website: http://www.cms.gov/

September 30, 2010

• Posted the September 22, 2010 NGHP Town Hall Teleconference Transcript to the NGHP Transcripts section page.
• Moved the January 28, 2010 NGHP Town Hall Teleconference Transcript to the Mandatory Insurer Reporting section page under NGHP Transcripts.
• Moved the May 26, 2009 Alert: Compliance Guidance Regarding Obtaining Individual HICNs and/or SSNs for Group Health Plan from the What’s New section page to the GHP Alerts section page.
• Moved the August 24, 2009 – HICN, SSN Collection – NGHP Model Language from the What’s New section page to the NGHP section page.
• Moved the August 24, 2009 Alert – Compliance Guidance Regarding Obtaining Individual HICNs and/or SSNs for NGHP Reporting from the What’s New section page to the MMSEA 111 Alerts section page.
• Moved the May 27, 2010 – May 27, 2010 – Updating Language – ALERT For Liability Insurance (including Self-Insurance), No-Fault Insurance, and Workers’ Compensation RREs – Periodic Workers’ Compensation and No-Fault Payments from the What’s New section page to the MMSEA 111 Alerts section page.

Synergy can assist your firm with Medicare Compliance and understanding MMSEA Section 111 Reporting Requirements. Contact us today for more information on how we can benefit your firm! (877)907-5436 / info@synergysettlements.com.

In CMS’ efforts to improve the quality of care, as of October 1, 2008 Medicare will not pay for certain injuries/conditions acquired during inpatient care, these injuries/conditions have been named by CMS as “never events” or “hospital acquired conditions” (HACs). CMS has advised state Medicaid Agencies to amend their statutory language to ensure that payment is not made through Medicaid for those beneficiaries that may have dual eligibility.

On February 8, 2006 President George Bush signed the Deficit Reduction Act (DRA) of 2005. Pursuant to Section 5001(c) of DRA the Secretary must identify the following conditions:“(a) high cost or high volume or both,

(b) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, and

(c) could reasonably have been prevented through the application of evidence-based guidelines.”

If any of the following conditions was not present at the time of admission additional payment will not be made by Medicare. In an attempt to enforce this rule CMS has created POA, which is a coding mechanism used to indicate when a HAC was present to prevent Medicare from being the responsible payer.

For FY 2009 the 10 categories of HACs include:

1. Foreign Object Retained After Surgery
2. Air Embolism
3. Blood Incompatibility
4. Stage III and IV Pressure Ulcers
5. Falls and Trauma
   • Fractures
   • Dislocations
   • Intracranial Injuries
   • Crushing Injuries
   • Burns
   • Electric Shock
6. Manifestations of Poor Glycemic Control
   • Diabetic Ketoacidosis
   • Nonketotic Hyperosmolar Coma
   • Hypoglycemic Coma
   • Secondary Diabetes with Ketoacidosis
   • Secondary Diabetes with Hyperosmolarity
7. Catheter-Associated Urinary Tract Infection (UTI)
8. Vascular Catheter-Associated Infection
9. Surgical Site Infection Following:
   • Coronary Artery Bypass Graft (CABG) – Mediastinitis
   • Bariatric Surgery
     • Laparoscopic Gastric Bypass
     • Gastroenterostomy
     • Laparoscopic Gastric Restrictive Surgery
   • Orthopedic Procedures
     • Spine
     • Neck
     • Shoulder
     • Elbow
10. Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE)
• Total Knee Replacement
• Hip Replacement

CMS has opted to leave the list of HACs for FY 2010 unchanged. CMS will take this time to evaluate the program in order to assist with future decision making of the program.

Lien Settlement Solutions can assist your firm in understanding the changes in Medicare policies and guidelines. Call us today for more information on Medicare and Compliance at (877)907-5436 or email us at info@lienss.com. We are the Lawyer’s Complete Solution to Lien Resolution! 

CMS finds insurers requests for SSN’s appropriate for Section 111 MMSEA purposes: http://www.cms.gov/MandatoryInsRep/Downloads/RevisedCollectionSSNEINs.pdf

In order for CMS to accurately coordinate payments made by Medicare to ensure appropriate payment, Medicare requires the HICN (Health Insurance Claim Number) or the SSN and the EIN (Employer Identification Number). Medicare has collected this information from beneficiaries since the inception of the Medicare program. This information is used for the administration of the Medicare program, the beneficiaries personal information is protected by the Privacy Act of 1974 and the Health Insurance Portability and Accountability Act Privacy Rule.

CMS’ clarification of the appropriateness of request/release of this information arises from overwhelming concerns of the plaintiff and plaintiff attorneys. What will the defense do with this information once it has been provided? Section 111 requires the SSN if the HICN is unavailable if the insurers are unable to report to the COBC (Coordination of Benefits Contractor). Could the “plaintiff” be found non compliant under Section 111 for not providing the requested information for accurate reporting of claims? This is yet to be determined.

As stated by CMS the, “collection of HICN’s, SSN’s, and EIN’s for purposes of compliance with the reporting requirements under Section 111 of Public Law 100-173 is appropriate.”

Lien Settlement Solutions can assist your firm in navigating MMSEA Guidelines and Medicare Compliance. For more information about Medicare Compliance and Lien Resolution, contact us at 1(877)907-5436 or info@lienss.com.

Medicare claim denial is unfortunately a common problem that Medicare beneficiaries are faced with. Medicare has the highest denial rate of any insurer pursuant to the 2008 National Health Insurer Report Card commissioned by the American Medical Association (AMA, www.ama-assn.org):

Before we start making hasty assumptions about government health care programs, lets look at some of the reasons why claims have been denied by Medicare. 33.6% of adjustments and 33.7% of denials are due to inaccurate reporting by the providers. Some of the common billing errors that providers make are:

• Submission of incomplete or invalid information.
• The provider is unable to confirm Medicare status of the patient (requests reimbursement for non Medicare patients).
• Evaluation and management (E&M) procedure codes and the place of service do match.
• ICD9 Codes are invalid or incomplete.
• Claims with a beneficiary that has been involved in an accident are processed incorrectly.

One common error that we (LSS) have assisted many beneficiaries with, is the submission of a claim by a provider to Medicare. The claims are usually for injuries that are un-related to an accident, but are submitted by the provider as “accident related.” With this inaccurate information, the claim is rightfully denied by Medicare. Because Medicare is secondary to all accident related treatment Medicare will deny any claim that they believe has a primary payer. At this point it is now the unfortunate responsibility of the beneficiary, who are often elderly, to deal with the burden of having the claim re-submitted for appropriate payment. For those that have addressed invalid Medicare denied claims, being on the phone for hours simply to reach someone that can assist is time that many of us do not have. These claims that are being denied by Medicare can be avoided if physicians report/submit complete and accurate claims. When a claim is reported/submitted correctly to Medicare not only can we avoid denied claims, but conditional payments can be made by Medicare when appropriate. A conditional payment is a payment made by Medicare for an accident related treatment when:

• Payment is not received by the primary insurer within 120 days (from the date of service or discharge).
• The primary payer (insurer) denies the claim.
• The beneficiary fails to file a proper claim because of physical or mental incapacity.

A conditional payment is made conditioned upon reimbursement to the Medicare Trust Fund at the time of a settlement, judgment, or award. Because it can sometimes take several years for a claim to settle Medicare will make a conditional payment, as it would be unfair to the Medicare provider(s) and the other insurers to withhold payment. In any event, whether we are dealing with the reimbursement of conditional payments or denied claims by Medicare, addressing these matters with the appropriate Centers for Medicare and Medicaid (CMS) offices can be a tedious process. So let’s help Medicare help us. How you can help Medicare have a more efficient claims process, while avoiding future problems with your medical bills:

• If you have been involved in an accident and the treatment that you are receiving is un-related to the accident, let the provider know that the treatment is un-related to the accident and reinforce that it should be billed to Medicare for primary payment.
• If the treatment is related to an accident let the provider know. Explain that your primary insurer should be billed “not” Medicare. The provider can later bill as a conditional payment to Medicare if necessary (it is not “required” that the provider submit a conditional payment claim).
• Do not mention Medicare to your provider for any accident related treatment (per Medicare claims representative). Your primary insurer should be paying.
• If you are receiving treatment for both un-related and accident related injuries/conditions on the same date of service, and the primary reason for the visit is for un-related injuries/conditions. Confirm with your provider what the primary service is. If the reason for your visit is un-related to the accident, ensure that the physician bills Medicare with explanation of the bill, due to the accident related treatment being provided on the same DOS.

(e.g. You have a liability case open/closed, where you sustained injuries to your neck and low back. On 1/1/09 you receive treatment for an injury to your ankle, which you injured while at “home” and the provider also takes a look at your neck and back, which is related to your liability case. The physician should be billing Medicare, due to the primary service provided being un-related to the liability claim). Remember that Medicare is primary for all OTHER treatment; any treatment related to an accident is the responsibility of the insurer and should be considered primary.

Question: I have a case where the hospital has a claim that needs to be submitted to Medicaid for payment. However, since the hospital knows that there is a liable third party, they are refusing to submit the claim to Medicaid. How can I force the hospital billing office to submit the claim for payment? – FL Attorney

Answer: In this instance, the provider has the right to go either way, so there is no real avenue to “force” a provider to bill Medicaid for services. Under Medicaid’s provider agreement, the hospital has the right to bill all other insurers first, with Medicaid being the final payer. On the other hand, Medicaid has the right to subrogate for payments made when a third party is responsible.

Medicaid as Final Payer – Why the Provider can bill liable insurer: FL Statute 409.907(3)(f) – Medicaid Provider Agreement (3) The provider agreement developed by the agency, in addition to the requirements specified in subsections (1) and (2), shall require the provider to: (f) Bill other insurers and third parties, including the Medicare program, before billing the Medicaid program, if the recipient is eligible for payment for health care or related services from another insurer or person, and comply with all other state and federal requirements in this regard.

Medicaid Right of Recovery – Why the Provider can bill Medicaid even if there is a liable third party: FL Statute 409.910(4)(a)(b) – Responsibility for payments on behalf of Medicaid-eligible persons when other parties are liable.(4) After the agency has provided medical assistance under the Medicaid program, it shall seek recovery of reimbursement from third-party benefits to the limit of legal liability and for the full amount of third-party benefits, but not in excess of the amount of medical assistance paid by Medicaid, as to: (a) Claims for which the agency has a waiver pursuant to federal law; or (b) Situations in which the agency learns of the existence of a liable third party or in which third-party benefits are discovered or become available after medical assistance has been provided by Medicaid.

So if the provider wants to receive payment from the third party insurer, they have the right to do so, though the payment may not be received as quickly. If Medicaid is billed, it is still the responsibility of the third party to reimburse Medicaid for payments made on their behalf. To answer your question, there is no way to force the submission of a claim, however, you can make the provider aware that they may receive payment from Medicaid sooner, if the case has yet to settle with the liable party. Hope this helps!