Tuesday, September 2, 2014

Claim rejected for DME length of Medical Necessity



DME is equipment that can withstand repeated use, is primarily used for a medical purpose, and is not generally used in the absence of illness or injury. Examples include hospital beds, wheelchairs, and oxygen delivery systems. Medicare will cover medical supplies that are necessary for the effective use of DME, as well as surgical dressings, catheters, and ostomy bags. However, Medicare will only cover DME and supplies that have been ordered or prescribed by a physician. The order or prescription must be personally signed and dated by the patient's treating physician. 

DME suppliers that submit bills to Medicare are required to maintain the physician's original written order or prescription in their files. The order or prescription must include: 

o the beneficiary's name and full address;
o the physician's signature;
o the date the physician signed the prescription or order;
o a description of the items needed;
o the start date of the order (if appropriate); and
o the diagnosis (if required by Medicare program policies) and a realistic estimate of the total length of time the equipment will be needed (in months or years). 

For certain items or supplies, including supplies provided on a periodic basis and drugs, additional information may be required. For supplies provided on a periodic basis, appropriate information on the quantity used, the frequency of change, and the duration of need should be included. If drugs are included in the order, the dosage, frequency of administration, and, if applicable, the duration of infusion and concentration should be included. 

Medicare further requires claims for payment for certain kinds of DME to be accompanied by a CMN signed by a treating physician (unless the DME is prescribed as part of a plan of care for home health services). When a CMN is required, the provider or supplier must keep the CMN containing the treating physician's original signature and date on file.
Generally, a CMN has four sections:
  • Section A contains general information on the patient, supplier, and physician. Section A may be completed by the supplier.
  • Section B contains the medical necessity justification for DME. This cannot be filled out by the supplier. Section B must be completed by the physician, a non-physician clinician involved in the care of the patient, or a physician employee. If the physician did not personally complete section B, the name of the person who did complete section B and his or her title and employer must be specified.
  • Section C contains a description of the equipment and its cost. Section C is completed by the supplier.
  • Section D is the treating physician's attestation and signature, which certifies that the physician has reviewed sections A, B, and C of the CMN and that the information in section B is true, accurate, and complete. Section D must be signed by the treating physician.Signature stamps and date stamps are not acceptable.
By signing the CMN, the physician represents that:
o he or she is the patient's treating physician and the information regarding the physician's address and unique physician identification number (UPIN) is correct;
o the entire CMN, including the sections filled out by the supplier, was completed prior to the physician's signature; and
o the information in section B relating to medical necessity is true, accurate, and complete to the best of the physician's knowledge.

Saturday, August 30, 2014

Unemployment Insurance (UI)



September 1st 2014 is the US labor day, The Department of Labor's Unemployment Insurance (UI) programs provide unemployment benefits to eligible workers who become unemployed through no fault of their own, and meet certain other eligibility requirements.

In the United States unemployment benefits generally pay eligible workers between 40-50% of their previous pay. Benefits are generally paid by state governments, funded in large part by state and federal payroll taxes levied against employers, to workers who have become unemployed through no fault of their own. This compensation is classified as a type of social welfare benefit.

Eligibility :

In order to receive benefits, a person must have worked for at least one quarter in the previous year and have been laid-off by an employer. Workers who were temporary or were paid under the table are not eligible for unemployment insurance. If a worker quits or is fired they are not eligible for UI benefits. There are five common reasons a claim for unemployment benefits are denied: the worker is unavailable for work, the worker quit his or her job, the worker was fired, refusing suitable work, and unemployment resulting from a labor dispute. In practice, it is only practical to verify whether the worker quit or was fired.

Generally, the worker must be unemployed through no fault of his/her own although workers often file for benefits they are not entitled to; when the employer demonstrates that the unemployed person quit or was fired for cause the worker is required to pay back the benefits they received. The unemployed person must also meet state requirements for wages earned or time worked during an established period of time (referred to as a “base period”) to be eligible for benefits. In most states, the base period is usually the first four out of the last five completed calendar quarters prior to the time that the claim is filed. Unemployment benefits are based on reported covered quarterly earnings. The amount of earnings and the number of quarters worked are used to determine the length and value of the unemployment benefit. The average weekly in 2010 payment was $293.

Medicare Immediate Recoupment

Whether the provider, Novitas Solutions, or another entity identifies an overpayment, the overpaid funds must be reimbursed to Novitas Solutions in one of the following ways:

A.  Immediate Recoupment as a Means to Repay Medicare Debt - Part A and Part B

The immediate recoupment process is for providers who have received an overpayment demand letter and are actively billing Medicare.  Immediate recoupment is not an alternative for sending a voluntary refund to Medicare.

You may elect to have your overpayment(s) repaid through the immediate recoupment process and avoid paying by check or waiting for the standard recoupment that begins automatically on day 41 from the date of the initial demand letter.  A request for immediate recoupment must be received by Medicare in writing no later than 16 days from the date of the overpayment demand letter. You must specify whether you are submitting: 

1. A one-time request for all invoices included in the current overpayment demand letter and all future overpayments
2. A request for all invoices included in only the current overpayment demand letter received
The immediate recoupment process is optional and for your convenience.   You may find savings in check printing and postage since you are requesting to have your Medicare overpayment(s) withheld from your future Medicare claim payments.
    
Any principal balance remaining after the initial immediate recoupment attempt will continue to accrue interest and continue in the recoupment process and other collection activities until the overpayment is satisfied.   You may fax your immediate recoupment request directly to the following fax numbers:
  
Part A fax line: (412) 802-1836 
 
Part B PA/NJ/MD/DC/DE providers may fax to: (717)-728-8722 
 
Part B AR/CO/LA/MS/NM/OK/TX providers may fax to: (717)-728-8728 
 
As stated above, there are two immediate recoupment request options available: 

3. A one-time request for all invoices included in the current overpayment demand letter and all future overpayments
 
4. A request for all invoices included in only the current overpayment demand letter received
Note:

If you select option 1 above, for future overpayments the immediate recoupment process will automatically begin on day 16 from the demand letter dates (assuming the provider has paying claims).  The 16 day timeframe allows for the 15 day rebuttal period. 
 
If you select option 1 above, you can later fax or mail a written request to Medicare to discontinue participation in the immediate recoupment process at anytime.  Allow Novitas Solutions, Inc. 10 business days from receipt to stop the immediate recoupment process. 
 
If you select option 2 above, please note that the immediate recoupment process will occur at the demand letter level through our  current process which will not allow offset to begin until day 16 from the demand letter date (assuming the provider has paying claims).  The 16 day timeframe allows for the 15 day rebuttal period. 
 
A request for immediate recoupment must be in writing and may be submitted by fax or regular mail.  We do not currently offer the option for you to email us your request.  Novitas Solutions, Inc. preferred method is to recommend utilization of the fax process to insure efficiency, timeliness, and to decrease costs.  Please refer to the fax numbers listed above including separate fax numbers for Medicare Part A versus Medicare Part B.   Your request for immediate recoupment must include the following when submitting your request:

Your name and contact phone number (include area code)
Your Provider Transaction Account Number (PTAN)
Your National Provider Identification (NPI)
Your Provider signature or CFO’s signature authorizing the request
The Overpayment Demand Letter number located on the 1st page, at the right top of page
Identify which option you are requesting. 
Your request must specifically state you understand you are waiving potential payment of interest pursuant to Section 1893(f)(2) for overpayments.   Such interest may be payable for certain overpayments reversed at the Administrative Law Judge level or subsequent levels of appeal (935 Overpayments).

Medicare & Automobile Accident

Medicare is secondary to all accident related claims. Beneficiaries may not choose which of these claims will be paid by the automobile insurance and which claims will be paid by Medicare. Providers should submit all accident related claims to the automobile insurance before submitting them to Medicare. To avoid late claim filing, claims may be submitted to Medicare even though payment has not been received from the automobile insurer. In addition, conditional payment can be made by Medicare if 1) the automobile insurance will not pay promptly (within 120 days); or 2) due to physical or mental incapacity, the beneficiary fails to meet the claim filing requirements of the automobile insurer. Conditional payments are made on the condition that the beneficiary will reimburse Medicare if payment is later made by the automobile insurer.

If the automobile insurance benefits are exhausted, Medicare requires a statement of exhaustion from the automobile insurer. The itemized statement must include: the dates of service paid and the actual provider who was reimbursed. Note: Claim processing will be denied without this information.

Providers should complete item 10 of the CMS 1500 claim form if the services are related to an automobile accident. If there is information on our files which indicates that a beneficiary has been involved in an automobile accident, the claim will suspend for manual review. If the details referenced on the claim are not sufficient information to process the claim, a questionnaire will be sent to the beneficiary. If a response is not received from the beneficiary within 45 days, the claim will be denied.

How to get patient MSP information

The BCRC contractor became responsible for updating the Medicare MSP files, answering general MSP questions or responding to COB concerns. MSP data may be updated, as necessary, based on additional information received from patients, providers, attorneys, or third parties. Development may be required in order to confirm the information.

The BCRC contractor may be contacted at:

1-855-798-2627 or TDD/TYY 1-855-798-2627
Monday through Friday
8 a.m. to 8 p.m.

Or

Fax 734-957-9598
Or

Address general written inquiries to:
MEDICARE - MSP General Correspondence
P.O. Box 138897
Oklahoma City, OK 73113-8897
Special Projects
(e.g. all Product Liability Case Inquiries and Special Project Checks)
Special Projects
P.O. Box 138868
Oklahoma City, OK 73113
Self-Calculated Conditional Payment Amount Option and fixed Percentage Option
Self-Calculated Conditional Payment Amount/Fixed Percentage Option
P.O. Box 138880
Oklahoma City, OK 73113

Fax
1-405-869-3309
Please mail Voluntary Data Sharing Agreement (VDSA) correspondence to:
Voluntary Data Sharing Agreement Program
P.O. Box 660
New York, NY 10274-0660
Please mail Workers’ Compensation Set-Aside Arrangement (WCMSA) Proposal/Final Settlement to:
WCMSA Proposal/Final Settlement
P.O. Box 138899
Oklahoma City, OK. 73113-8899
Fax
1-405-869-3306
Use the MSP General Correspondence address if you do not see your special project.

What is Black Lung Benefits Act (BLBA)



Black Lung Benefit Act of 1973, It is USA government program, The Black Lung Benefits Act (BLBA) provides monthly payments and medical benefits to coal miners totally disabled from pneumoconiosis (black lung disease) arising from employment in or around the nation's coal mines. This Act also provides monthly benefits to a miner's dependent survivors if pneumoconiosis caused or hastened the miner's death. The Division of Coal Mine Workers' Compensation (DCMWC), within the U.S. Department of Labor Employment Standards Administration's Office of Workers' Compensation Programs (OWCP), adjudicates and processes claims filed by coal miners and their survivors under the BLBA.


Medicare and BLBA

Medicare is secondary for beneficiaries who have medical benefits under the Federal Black Lung Program. Medicare is secondary only for services provided for the treatment of lung conditions caused by mining. Claims for beneficiaries entitled to benefits under the Federal Black Lung Program may suspend for manual review. If the diagnosis or services reported on the claim are not related to the black lung condition, Medicare is primary and the claim will be released for final processing.

For some beneficiaries entitled to the Federal Black Lung Program, the coal mine operator is responsible for medical benefits. In these cases, providers should submit the claims to the coal mine operator or its Workers' Compensation plan for processing.

Monday, August 25, 2014

Modifier 24

Modifier 24
24 Modifier Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period: Physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure.

An E/M service can be coded with modifier 24 to indicate a visit in the postoperative period that is unrelated to the original procedure (surgery). This modifier is not valid when coded with surgeries or other types of services. It is not appropriate for modifier 24 to be coded with diagnostic tests performed in the postoperative period. These are not part of the global surgical allowance and are always considered separately.

In most cases, diagnosis codes that apply to the E/M service are different from the diagnosis codes indicated on the original procedure. However, in rare circumstances, the diagnoses are the same, but the services are unrelated; if so, this information should be documented with the claim, either in the narrative field on electronic claims or on an attachment with paper claims.

Hospital visits by the surgeon during the same hospitalization as the surgery are considered related to the surgery; however, separate payment for such visits can be allowed if one of the following conditions applies:

* Immunotherapy management furnished by the transplant surgeon. Immunosuppressant therapy following transplant surgery is covered separately from other postoperative services. That is, postoperative immunosuppressant therapy is not part of the global fee allowance for the transplant surgery. This coverage applies regardless of the setting.

* The surgeon provides critical care for a burn or trauma patient.
* The diagnosis is unrelated to the original surgery.

Outpatient visits during the postoperative period are allowed during a global fee period if the claim documentation demonstrates that the visit is for a diagnosis unrelated to the original surgery. Use modifier 24 in this situation.

Office visits during the postoperative period are not covered unless they are submitted with modifier 24 to indicate they are unrelated to the surgery. Modifier 24 is primarily for use only by the surgeon. A different diagnosis code may be sufficient to show the procedure is unrelated to the surgery; however, it may not be required. Documentation submitted should fully explain how the E/M service is unrelated to the surgical procedure.