Fraud & Abuse Training required for Medicare Advantage Plans

CMS has required that all providers who provide health care services to Medicare members under Medicare Advantage or Medicare Part D Programs complete compliance training on Fraud and Abuse by December 31, 2009. Many providers are unaware of this mandate, but the insurance carriers are taking it seriously. We have been advised by two insurance carriers that offer Medicare Advantage Programs that they will be enforcing the compliance training requirement.

If providers do not complete the compliance training the carriers can withhold payment for services or worse, terminate the provider’s contract. One of the carriers we have spoken with advised us that if the provider does not have a certificate on file stating they have completed the compliance training then they will withhold all payments. The other carrier stated that initially they will not withhold payment, but will contact any providers who do not have the certificate on file to discuss the training. However, if the providers who have not completed the training do not make attempts to comply they will eventually begin to withhold payments.

CMS offers an online training that takes about 85 minutes to complete. It can be found at . Some carriers who offer Medicare Advantage Plans are also offering their own compliance training plans that CMS is recognizing. Our local BC offers an online slide presentation that only takes about 10 minutes that qualifies. At the end of the training there is a certification statement that is to be completed. In this case, BC will keep the certification statement on file for the provider and will verify to any other insurance carriers of Medicare Advantage Plans that the provider has completed the training.

The compliance officer for the provider’s office must complete the training. Then they are responsible for educating their staff, either by having each staff member complete the training as well, or by having them complete a training that the compliance officer puts together as a result of the training they took. The training must be repeated on a yearly basis.

Medical billing information

ICD-10 Update

The October 1, 2013 deadline for ICD-10 codes is going to be here quicker than we think. The sooner we start to prepare for it, the better. There is already a lot of information available about ICD-10’s including training sessions and webinars. The ICD-10’s are more complicated than the ICD-9’s and many feel that the transition to the ICD-10’s will be the most challenging transition since the inception of coding. There are over 155,000 codes in the ICD-10 set which is about ten times the number of codes in the ICD-9 set.

It is important that providers prepare for the transition. If you are a billing service, the diagnoses should come over to you already coded, but it will still be important that you understand the new system. It is said that many insurance carriers will not be ready by the deadline, but don’t count on that meaning that the deadline will be extended.

The American Academy of Professional Coders, AAPC, has released an online code conversion tool. The tool which is available on their website at will allow users to convert ICD-9 codes to ICD-10 codes and vice versa. The conversions are based on the General Equivalency Mapping files published by the CMS. The tool is available to users free.

Medical Billing Services

Medicare Requiring Referring Providers be registered with PECOS

CMS, Centers for Medicare and Medicaid Services, has implemented a new policy regarding payment for durable medical equipment, prosthetics, orthotics, and supplies. In order for a supplier to receive payment for these supplies, Medicare is verifying that the ordering/referring provider on a DMEPOS claim (1) has a current enrollment record in Medicare (i.e., the ordering/referring provider enrolled or updated his/her enrollment record within the past five years and the NPI is in the record) and (2) is of a specialty that is eligible to order and refer.

In order to verify this CMS is requiring that the ordering/referring provider is registered with the database of a program titled the Medicare Provider Enrollment, Chain, and Ownership System (PECOS). The ordering/referring providers must be listed in the PECOS database with their individual National Provider Identifier (NPI) number and must have enrolled or updated their entry in the database since November 2003. If the ordering/referring provider is not registered with PECOS the claim for the durable medical equipment, prosthetic, orthotic or supply will be denied.

Many providers are unaware of this new policy. It was first introduced on April 24, 2009 in a one time notification issued by CMS entitled “Change Request (CR) 6421” and it was only followed up with one article in the Medicare Learning Matters. This new policy was implemented in two stages. In the first stage, from October 5, 2009 thru January 3, 2010 CMS began comparing the DMEPOS claims with the PECOS system. If the claims were submitted electronically and the information on the ordering/referring provider was not on the PECOS system, or didn’t match the information on the PECOS system then the provider would receive a warning. However, if the claims were submitted on paper, no warning was issued.

The second phase was supposed to began on January 4, 2010. This deadline has been extended to April 5, 2010. Beginning on that date, any claims that do not contain the ordering/referring provider’s individual NPI and if that provider is not registered on the PECOS system, the claims will be denied. Also, if the information does not match what is on the PECOS system the claims will be denied.

The problem with this new policy is that it is the supplier’s claims that will be denied, even though it is not their information that is not accurate, or not enrolled in the PECOS system. The supplier has no control over whether the referring/ordering provider complies with this new policy. CMS is supposed to be making a national list of eligible referring/ordering providers available online prior to the April 5, 2010 deadline. At least then a supplier can check to see if the referring/ordering provider is eligible before providing the supplies.

This policy is (or should be) a concern for anyone who is a Medicare DME supplier. You will now have to verify that the provider who is referring the patient or ordering the supplies is compliant with this new policy otherwise they will not be paid for there services. This one will be interesting to see.

Medical Billing Articles

All Billing Services should have a Compliance Plan in addition to a contract

Most billing services know and understand the importance of having a well written contract but not all realize that they also should have a compliance plan in place. A compliance plan is for the protection of both the billing service and the provider. Each provider that they bill for should be given a copy of their compliance plan, and the plan should be reviewed on a regular basis.

Improper billing practices can lead to civil or criminal offenses. More and more providers are turning to third party billing services due to the complexity of billing. Some third party billing services also provide coding and other services as well. It is important that the provider is aware of the third party billing services policies and procedures regarding claims submission and coding. It is best that the policies and procedures are outlined in writing to protect both the provider and the billing service.

In 1998 the Office of the Inspector General issued a guideline for compliance plans for third party billing services. The complete guideline can be found at . This guideline includes general principles that can apply to any compliance plan as well as guidelines specific to third party billing services. It identifies risk areas specific to third party billing services such as billing for services not documented, unbundling, upcoding, and inappropriate balance billing. There are seventeen specific risk areas identified.

It also suggests seven steps to prepare an effective compliance plan. The suggested steps are:

1. Implement written policies, procedures, and standards of conduct.
2. Designate a Compliance Officer and compliance committee
3. Conduct effective training and education
4. Develop open lines of communication
5. Enforce standards through well-publicized disciplinary guidelines
6. Conduct internal monitoring and auditing
7. Respond promptly to detected offenses and develop corrective action

If you do not currently have a compliance plan you should implement one as soon as possible. The above list of suggestions should help. When your compliance plan is complete make sure you give a copy to each of the providers you bill for.

Medical Billing Information

Medicare Enrollment Completing the 855I

Our newest book, “Medicare Credentialing – Completing the 855I Correctly” is going to be available later this week. We are really excited about the marketing leads that offering the service of Medicare credentialing can generate. We will be sending out an email later this week announcing the release of our ebook and we’ve decided to give away one free download to someone who is serious about getting their business going. If you are serious about using Medicare credentialing to find new leads for your medical billing service, leave us a blog post telling us why you want a copy of our new book and how you will use it to increase your business. We will pick the best entry and send a free download to that person. Good luck!!

Here’s more information about how you can get lots of new marketing leads by offering Medicare credentialing services.

Medicare Provider Credentialing