Wednesday, May 13, 2015

Prior Authorization Process for Repetitive Scheduled Non-Emergent Ambulance Transport

Fact sheets: Prior Authorization Process for Repetitive Scheduled Non-Emergent Ambulance Transport


OVERVIEW

The Centers for Medicare & Medicaid Services (CMS) will begin implementing a prior authorization demonstration program for repetitive scheduled non-emergent ambulance transport in New Jersey, Pennsylvania, and South Carolina. CMS will test whether prior authorization helps reduce expenditures, while maintaining or improving quality of care. CMS believes using a prior authorization process will help ensure services are provided in compliance with applicable Medicare coverage, coding, and payment rules before services are rendered and claims are paid. 

BACKGROUND
In 2012, CMS launched a prior authorization process for certain power mobility devices in seven demonstration states (California, Florida, Illinois, Michigan, New York, North Carolina, and Texas).  Since implementing the demonstration, CMS has observed a decrease in expenditures for power mobility devices.  CMS will leverage this success by creating a prior authorization process for certain non-emergent services under Medicare. CMS seeks to use this process to address growing concerns about beneficiaries receiving non-medically necessary repetitive scheduled non-emergent ambulance transport services. New Jersey, Pennsylvania, and South Carolina were selected for initial implementation of this process because of their high utilization and improper payment rates for these services.

Under Section 1115A of the Social Security Act, the Secretary has authority to test innovative payment and service delivery models to reduce program expenditures, while preserving or enhancing the quality of care furnished to individuals under such titles.

Prior authorization will not create new clinical documentation requirements. Instead, it will require the same information necessary to support Medicare payment, just earlier in the process.  Prior authorization allows providers and suppliers to address issues with claims prior to rending services and to avoid an appeal process. This will help ensure that all relevant coverage, coding, and clinical documentation requirements are met before the service is rendered to the beneficiary and before the claim is submitted for payment. 

PRIOR AUTHORIZATION PROCESS
The model will establish a prior authorization process for repetitive scheduled non-emergent ambulance transport services. This process will allow all relevant documentation to be submitted for review prior to rendering services.  CMS or its contractors will review the request and provide an affirmative or non-affirmative decision. A claim submitted with an affirmative prior authorization will be paid so long as all other requirements are met. A claim submitted with a non-affirmative decision will be denied.  Unlimited resubmissions are allowed. If a provider or supplier chooses to forego prior authorization and submits a claim without prior authorization decision, that claim shall undergo pre-payment review.

CMS Medicare Review Contractors will review prior authorization requests to ensure requests are consistent with all existing applicable regulations, National Coverage Determination and Local Coverage Determination requirements, and other CMS policies. Decisions on initial requests will be postmarked within 10 business days and subsequent requests will be processed within 20 business days.  A provisional affirmative prior authorization decision will affirm a specified number of trips within a specific amount of time. The prior authorization decision, justified by the beneficiary’s condition, may affirm up to 40 round trips (which equates to 80 trips) per prior authorization request in a 60-day period. 

To address circumstances where applying the standard timeframe for making a prior authorization decision could seriously jeopardize the life or health of the beneficiary, CMS will include an expedited review process.  The request for an expedited review must provide rationale supporting the expedited review request.  Such a request must include documentation that shows that applying the standard timeframe for making a decision could seriously jeopardize the life or health of the beneficiary.  In these situations, the review entity will make reasonable efforts to communicate the decision within 2 business days of receipt of all applicable Medicare required documentation. 

Under this model, if a prior authorization has not been requested before the fourth round trip in a 30-day period, claims will be subject to pre-payment medical review. CMS believes that the repetitive scheduled non-emergent ambulance transport trips for a beneficiary will generally be scheduled through one provider or supplier at the beginning of the authorization period. CMS will allow one ambulance provider or supplier to request prior authorization per beneficiary per time period. Any provider or supplier submitting claims for which no prior authorization request is recorded will be subject to 100 percent medical review.

Tuesday, April 14, 2015

Physician Signature Requirements for Diagnostic Testing


Medicare has identified a recent increase in the number of CERT errors attributed to the lack of physician orders for diagnostic tests. A diagnostic test includes all diagnostic x-ray tests, all diagnostic laboratory tests, and other diagnostic tests furnished to a beneficiary.

An 'order' is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physician/practitioner (e.g., if test X is negative, then perform test Y). An order may be delivered via the following forms of communication:

A written document signed by the treating physician/practitioner, which is hand-delivered, mailed, or faxed to the testing facility;

A telephone call by the treating physician/practitioner or his/her office to the testing facility; and
An electronic mail by the treating physician/practitioner or his/her office to the testing facility.
If the order is communicated via telephone, both the treating physician/practitioner or his/her office, and the testing facility must document the telephone call in their respective copies of the beneficiary's medical records.

NOTE: While a physician order is not required to be signed on orders for clinical diagnostic tests paid on the basis of the clinical laboratory fee schedule, the physician fee schedule, or for physician pathology services; the physician must clearly document, in the medical record, his or her intent that the test be performed.    Failure to do so may result in denial of the service which may subsequently lead to the patient being responsible for payment.   Furthermore, the absence of a signature on an order may lead to a medical record audit of the ordering physician to verify that the physician's intent is indeed documented as directed in the regulation.   Therefore, Novitas recommends that physicians provide their signature on all orders for diagnostic and laboratory services.

Make sure that your office, billing, and/or laboratory staffs are aware of this updated guidance regarding the signature requirement for diagnostic tests and are complying with this regulation.   Also, note that in keeping with standard auditing principles, items such as signatures, attestations, and other addendums which are added to the medical record after the date of the Additional Documentation Request (ADR) letter will generally not be considered as acceptable documentation.   Furthermore, providers who exhibit a pattern of adding documentation after ADR requests could be subject to corrective action.

If you receive a request for medical records from the CERT contractor or Novitas Solutions, it is critical that the signed physician order for all diagnostic tests be included.   Without the order, the services could be determined to be medically unnecessary and the claim will be denied.

Tuesday, March 10, 2015

Implementing new policies related to Medicare Part B inpatient services


Effective date October 1, 2014
Implementation date: February 10, 2015

Summary
The Centers for Medicare & Medicaid Services (CMS) recently announced changes to the Medicare Claims Processing Manual related to payment policies regarding payment of Medicare Part B inpatient services.

When an inpatient admission is found to be not reasonable and necessary, Medicare will allow payment of all hospital services that were furnished and would have been reasonable and necessary if the beneficiary had been treated as an outpatient. All hospitals billing Part A services are eligible to bill the Part B inpatient services, including short term acute care hospitals paid under the inpatient prospective payment system (IPPS), hospitals paid under the outpatient prospective payment system (OPPS), long term care hospitals (LTCHs), inpatient psychiatric facilities (IPFs) and IPF hospital units, inpatient rehabilitation facilities (IRFs) and IRF hospital units, Critical Access Hospitals (CAHs), children's hospitals, cancer hospitals, and Maryland waiver hospitals.
Implementing the Payment Policies Related to Patient Status from the CMS-1599-F

Provider Type Affected
This MLN Matters Article is intended for hospital submitting claims to Medicare Administrative Contrators (MACs) for services provided to Medicare beneficiaries.

What You Need to Know
Change Request (CR)959 incorporates changes to the "Medicare Claims Processing Manual" related to the payment policies regarding Patient Status from final rule CMS-1599-F. This includes payment of Medicare Part B inpatient services, and admission and medical review criteria for payment of hospital inpatient services under Medicare Part A.

Background
When an inpatient admission is found to be not reasonable and necessary, Medicare will allow payment of all hospital services that were furnished and would have been reasonable and necessary if the beneficiary had been treated as an outpatient, rather than admitted to the hospital as an inpatient, provided the allowed timeframe for submitting claims is not expired. Medicare will not allowed timeframe for submitting claims is not expired. Medicare will not allow payment for services that specifically require an outpatient status, such as outpatient visits, emergency department visits, and observation services that are, by definition, provided to hospital outpatients and not inpatients.

Specific changes to the "Medicare Claims Processing Manual" as a result of CR8959 involve Chapter 240 of that manual. Specifically, inpatient routine services in a hospital generally are those services included by the provider in a daily service charge--sometimes referred to as the "Room and Board" charge. They include the regular room, dietary and nursing services, minor medical and surgical supplies, medical social services, psychiatric social services, and the use of certain equipment and facilities for which a separate charge is not customarily made to Medicare Part A. Many nursing services provided by the floor nurse (such as IV infusions and injections, blood administration, and nebulizer treatments, etc.) may or may not have a separate charge established depending upon the classification of an item or service as routine or ancillary among providers of the same class in the same State. Some providers established customary charging practice resulting in separate charges for these services following the "Provider Reimbursement Manual" )PRM-1) instructions. However, in order for a provider's customary charging practice to be recognized it must consistently follow those instructions for all patients and this must not result in as inequitable apportionment of cost to the program. If the PRM-1 instructions have not been followed, a provider cannot bill these services as separate charges. Additionally, it is important that the charges for services rendered and documentation meet the definition of the Healthcare Common Procedure Coding System (HCPCS) in order to separately bill.

All hospital billing Part A services are eligible to bill the Part B inpatient services, including short term acute care hospitals paid under the Inpatient Prospective Payment System (IPPS), hospital paid under the Outpatient Prospective Payment System (OPPS), long term care hospitals (LTCHs), inpatient psychiatric facilities (IPFs) and IPF hospital units, inpatient rehabilitation facilities (IRFs) and IRF hospital units, Critical Access Hospitals (CAHs), children's hospitals, cancer hospitals, and Maryland waiver hospitals.

Hospitals paid under the OPS would continue billing the OPPS for Part B inpatient services. Hospitals that are excluded from payment under the OPPS in 42 Codes of Federal Regulations (CFR) 419.20 (b) would be eligible to bill Part B inpatient services under their non-OPPS Part B payment methodologies.

Beneficiaries are liable for their usual Part B financial liability. Beneficiaries would be liable for Part B copayments for each hospital Part B inpatient service and for the full cost of drugs that are usually self-administered. If the beneficiary's liability under Part A for the initial claim submitted for inpatient services they received, the hospital must refund the beneficiary the difference between the applicable Part A and Part B amounts. Conversely, if the beneficiary's liability under Part A is less than the beneficiary's liability under Part B for the inpatient services they received, the beneficiary may face greater cost sharing.

Timely filing restrictions will apply for Part B inpatient services. Claims that are filed beyond one (1) calendar year from the date of service will be rejected as untimely and will not be paid.

Wednesday, February 25, 2015

EHR Incentive Program: How to Report Once in 2014 for Medicare Quality Reporting Programs


Providers participating in the 2014 Physician Quality Reporting System (PQRS) program may be eligible to report their quality data one time only to earn credit for multiple Medicare quality reporting programs. Individual eligible professionals and group practices will be able to report once on a single set of clinical quality measures (CQMs) and satisfy some of the various requirements of several of the following programs, depending on eligibility:
•    PQRS
•    Value-Based Payment Modifier (VM)
•    Medicare Electronic Health Record (EHR) Incentive Program
•    Medicare Shared Savings Program Accountable Care Organization (ACO)
•    Pioneer ACO
•    Comprehensive Primary Care Initiative (CPCI)

CMS aligned some of the reporting requirements for these programs starting in 2014 to reduce the burden of data collection. Those eligible professionals who choose to report once will reap several benefits:
•    Earn the 2014 PQRS incentive and avoid the 2016 PQRS payment adjustment.
•    Satisfy the CQM requirements of the Medicare EHR Incentive Program.
•    Satisfy requirements for the 2016 VM, ACO, and/or CPCI, if eligible.
Note: aligned reporting options are only available to eligible professionals beyond their first year of participation in the Medicare EHR Incentive Program.

How to Report Once

Individual eligible professionals and group practices must submit a full year (January 1 through December 31, 2014) of data to receive credit for the various programs. The following resources will help explain how providers can report their quality data one time for 2014 participation in applicable quality programs:
•    Reporting Once Interactive Tool: Provides reporting guidance based on how the eligible professional plans to participate in PQRS in 2014.

•    eHealth University Reporting Once Module: Explains how to report quality measures one time during the 2014 program year and satisfy quality reporting requirements PQRS, the Medicare EHR Incentive Program, the VM, and ACOs.

•    2014 CQM Electronic Reporting Guide: Provides an overview of 2014 CQMs and options for reporting them to CMS.

2014 QRDA III SEVT Testing Available

The Submission Engine Validation Tool (SEVT) for 2014 Quality Reporting Document Architecture (QRDA) III submission is available on the QualityNet Portal. CMS recommends QRDA submitters and certified EHR technology vendors use this tool for 2014 submission testing.

Friday, February 21, 2014

Denied as Admission date , ambulance drop off location required in claims

Admission Date REQUIRED


What this means: For the trading partner, Payer Path, this is a required field for ambulance claims.  This must be added in order for the claims to go through.

Provider action: Add the admission date

Rejection Removal: Rejections will not be removed by Gateway EDI as they are valid.

Re-filing:Once this is corrected, you would want to re-file any claims that rejected for this reason


Ambulance Drop-Off Location is required for Ambulance Claims.


What this means: One of the requirements for ambulance claims is that a drop off city, state and zip code are required

Provider action: Add the drop off location to your claim.

Rejection removal:  Rejections will not be removed by Gateway EDI as they are valid.  

Re-filing: Once this is corrected, you would want to re-file any claims that rejected for this reason.


Ambulance Pick-Up Location is required for Ambulance Claims.

What this means: One of the requirements for ambulance claims is that a pick up city, state and zip code are required

Provider action: Add the pick up location to your claim.

Rejection removal:  Rejections will not be removed by Gateway EDI as they are valid.  

Re-filing: Once this is corrected, you would want to re-file any claims that rejected for this reason.




Tuesday, May 22, 2012

When Tricare cover ambulance services

TRICARE covers ambulance services in the following circumstances:


•     Emergency transport to a hospital

•     Transfer from one hospital to another hospital more capable of providing the required care as ordered by a physician

•     Transfers between a hospital or SNF and another facility for outpatient therapy or diagnostic services ordered by a physician

•     Transfers to and from a SNF when medically indicated

Note: Payment of ambulance transfers to and from a SNF may be included in the SNF prospective payment system (PPS).

Air or boat ambulance is only covered when the pickup point is inaccessible by a land vehicle, or when great distance or other obstacles are involved in transporting the patient to the nearest hospital with appropriate facilities, and the patient’s medical condition warrants speedy admission or is such
that transfer by other means is contraindicated. TRICARE does not cover ambulance services for these conditions:

•     Non-emergency ambulance services used instead of a taxi service or other normal transportation means when the patient’s condition would permit
use of regular transportation (Ambulance transportation is covered under the TRICARE Extended Care Health Option [ECHO] benefit when the beneficiary is being transported to and from institutions or facilities when the
beneficiary is receiving institutional care.)

•     Transport or tra nsfer of a patient primarily for the purpose of having the patient closer to home, family, friends, or a physician

•     Any type of medicabs or ambicabs that function as public passenger services transporting patients to and from medical appointments

Saturday, January 28, 2012

Ambulance billing - Denied and Non Covered Service

Denied Services
Program payment will not be made when other transportation could be utilized without endangering the patient’s health, whether such means of transportation is actually available.
A claim may be denied on the grounds that the use of an ambulance service was unreasonable in the treatment of the illness or injury involved.
Non-Covered Services
Medicare does not cover the following services:
 Transportation in Ambi-buses, ambulettes (Mobility Assistance Vehicle (MAV)), Medi-cabs, vans, privately owned vehicles, taxicabs or wheelchair vans.
 Parking fees.
  Tolls for bridges, tunnels and highways.