Current Medicare News
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Audit & Enforcement
07.14.08 CMS: RAC corrects $1 billion in Medicare payments
The Centers for Medicare & Medicaid Services (CMS) has released a report that shows that the Recovery Audit Contractors (RAC) demonstration program that was launched in 2005 to detect and correct underpayments and overpayments under part A or B of the Medicare program is succeeding. According to the CMS Web site, the RAC program has corrected more than $1.03 billion in improper Medicare payments as of March 27, 2008. Approximately 96 percent ($992.7 million) of the improper payments were overpayments collected from providers, while the remaining four percent ($37.8 million) were underpayments repaid to providers.
CMS officials say that the report also will help the agency improve the program as it goes nationwide within two years.
Read the RAC evaluation report
12.06.07 Georgia Medicare Part B Data Center Transition - Dark Day Planned
Cahaba GBA, in conjunction with the Infocrossing Data Center (ADC), Companion Data Services (CDS) the new Enterprise Data Center (EDC) and the Centers for Medicare and Medicaid Services (CMS), is in the process of transferring the Georgia Medicare Part B data center operations from Infocrossing to Companion Data Services. This transition is being done to accommodate the implementation of the Medicare Contractor Reform.
There will be a system “Dark Day” on Monday, January 28, 2008 in order to accommodate this data center transition. This means that the Georgia Part B claims system will not be available to Cahaba's Customer Service Representatives on this day. Electronic claims submissions will not be affected.
Georgia Part B claims processing and Cahaba's Provider Contact Center will resume normal operations beginning Tuesday, January 29, 2008. Our goal is to make this data center transition as seamless as possible for Georgia Part B providers, and there should be minimal if any impacts to providers or beneficiaries.
If you have any concerns or questions related to this transition, please contact Cahaba's Part B Provider Contact Center at 1.877.567.7271.
Coding
07.16.08 Medicare Improvements for Patients and Providers Act of 2008 becomes law
On July 15, the U.S. Congress voted overwhelmingly to override President Bush's veto of the Medicare Improvements for Patients and Providers Act of 2008 (H.R. 6331), allowing the bill to become law.
H.R. 6331 retroactively replaces the 10.6 percent payment cut that went into effect on July 1 with a 0.5 percent update extension through the end of 2008. It also provides an additional 1.1 percent update for 2009.
According to the Centers for Medicare and Medicaid Services (CMS), physicians, non-physician practitioners and other providers of services paid under the Medicare Physician Fee Schedule will begin receiving the 0.5 percent payment update in the second half of July.
Read full news article from MAG
07.16.08 New 2008 Medicare physician fee schedule payment rates effective for dates of service July 1, 2008 through December 31, 2008
The Medicare Improvements for Patients and Providers Act of 2008 was enacted on July 15, 2008. As a result, the mid-year 2008 Medicare Physician Fee Schedule (MPFS) decrease of 10.6 percent has been replaced with a 0.5 percent update, retroactive to July 1, 2008.
Physicians, non-physician practitioners and other providers of services paid under the MPFS should begin to receive payment at the 0.5 percent update rates in approximately 10 business days, or less. Medicare contractors are currently working to update their payment system with the new rates.
In the meantime, to avoid a disruption to the payment of claims for physicians, non-physician practitioners and other providers of services paid under the MPFS, Medicare contractors will continue to process the claims that have been on hold on a rolling basis (first in/first out) for payment at the minus 10.6 percent update level. After your local contractor begins to pay claims at the new 0.5 percent rate, to the extent possible, the contractor will begin to automatically reprocess any claims paid at the lower rates.
Under the Medicare statute, Medicare pays the lower of submitted charges or the Medicare fee schedule amount. Claims with dates of service July 1 and later billed with a submitted charge at least at the level of the January 1 – June 30, 2008, fee schedule amount will be automatically reprocessed. Any lesser amount will require providers to contact their local contractor for direction on obtaining adjustments. Non-participating physicians who submitted unassigned claims at the reduced nonparticipation amount also will need to request an adjustment.
04.03.08 Cahaba GBA Installing the April Release Update to the MCS System
The April release update to the MCS system will be installed on April 5 and 6. Some of the changes scheduled for implementation require screen changes within the MCS system that could effect claims processing for some EMC Claims received on or after April 1. To ensure all claims are processed correctly, EMC claims received from April 1 - 4, will be input to the system the week of April 7, after the MCS update is installed. The schedule is as follows:
- April 7: Process April 1 & 7 claims.
- April 8: Process April 2 & 8 claims.
- April 9: Process April 3 & 9 claims.
- April 10: Process April 4 & 10 claims.
All claims will be backdated to the original date of receipt. If you call Customer Service to check claim status via the IVR, please note the claims submitted between April 1 - 4, will not be in the system until on or after April 7. Please utilize your EDI Audit Trail reports to confirm receipt of your claims. If you have any questions, please contact the Cahaba GBA EDI Services Department at 866.582.3253.
03.11.08 Medicare Requires Physicians to Include NDC Drug Numbers on Claims Forms
As of April 7, Medicare is requiring physicians to include NDC drug numbers on claims forms for Medicaid/Medicare eligible patients. The rule is referenced below, with the change italicized.
Item 24 (Form CMS-1500 (08-05)) – The six service lines in section 24 have been divided horizontally to accommodate submission of both the NPI and legacy identifier during the NPI transition and to accommodate the submission of supplemental information to support the billed service. The top portion in each of the six service lines is shaded and is the location for reporting supplemental information. It is not intended to allow the billing of 12 service lines.
When required to submit NDC drug and quantity information for Medicaid rebates, submit the NDC code in the red shaded portion of the detail line item in positions 01 through position 13. The NDC is to be preceded with the qualifier N4 and followed immediately by the 11 digit NDC code (e.g., N499999999999). Report the NDC quantity in positions 17 through 24 of the same red shaded portion. The quantity is to be preceded by the appropriate qualifier: UN (units), F2 (international units), GR (gram) or ML (milliliter). There are six bytes available for quantity. If the quantity is less than six bytes, left justify and space fill the remaining positions (e.g. UN2 or F2999999).
03.04.08 Top 5 Reasons for Claims Rejections in February
View PDF
03.01.08 MAG Alert: Medicare Utilization Statistics Posted Online
The Centers for Medicare & Medicaid Services (CMS) posts Medicare payment data sorted by most costly and most used CPT codes on its Web site. Medicare utilization statistics for Part B (Supplementary Medical Insurance - SMI) are included in the downloadable data.
View CMS' Medicare Payment Data
02.08.08 Top 5 Reasons for Claims Rejections in January
View PDF
02.01.08 MAG Alert: Medigap (“Claim-Based”) Crossover
The Centers for Medicare & Medicaid Services (CMS) announced systematic requirements for the transitioning of its mandatory Medigap (“claim-based”) crossover process from its Part B contractors to the Coordination of Benefits Contractor (COBC) as far back as June 2007.
During the period from June through September 2007, CMS’ Coordination of Benefits Contractor (COBC) signed national crossover agreements with Medigap claim-based crossover insurers and assigned new 5-digit Coordination of Benefits (COBA) Medigap claim-based crossover identifiers to these entities for inclusion on incoming Medicare claims. CMS prepared a separate change request (CR 5662) that included the web site where provider billing staffs may go to obtain the listing of new COBA Medigap claim-based identifiers for purposes of initiating Medigap claim-based crossovers.
Read More
Go to CMS Web Site
11.19.07 2008 Ambulatory Surgical Center Payment System Changes
MM5680 - 2008 Ambulatory Surgical Center (ASC) Payment System Changes Section 626 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) requires the Centers for Medicare & Medicaid Services (CMS) to implement a new Ambulatory Surgical Center (ASC) payment system not later than January 1, 2008. In part, the law requires that ASCs be paid the lesser of the actual charge or the ASC fee schedule payment rates. In addition to the new payment instructions, ASCs will be paid a reduced amount for certain procedures when you receive a partial credit for more than 50 percent of the cost of a medical device. You will need to include an FC modifier on certain procedure codes that include payment for a device, to report that you received a partial credit for more than 50 percent of the cost of the device. For those procedure codes where the FC modifier may be applicable, CMS will provide Medicare contractors with a price for the procedure code, both with and without, the FC modifier. CR 5680 also includes a number of changes.
Read More
11.19.07 2008 Georgia Anesthesia Conversion Factors
The 2008 National Anesthesia Conversion Factor and the locality specific Anesthesia Conversion Factors were released by the Centers for Medicare and Medicaid Services (CMS) in November. Effective for services furnished on or after January 1, 2008, the following anesthesia conversion factors are being used to determine Medicare reimbursement:
Locality 001*
Participating: 17.90
Non-Participating: 15.61
Limiting Charge: 17.85
Locality 099**
Participating: 17.12
Non-Participating: 16.26
Limiting Charge: 18.70
*Atlanta Metropolitan Area
**Rest of Georgia
11.13.07 Modifications to the Healthcare Common Procedure Coding System (HCPCS) Code Set
The Centers for Medicare & Medicaid Services is pleased to announce the scheduled release of modifications to the Healthcare Common Procedure Coding System (HCPCS) code set. These changes have been posted to the “Alpha-Numeric HCPCS” list online. All changes are effective January 1, 2008, unless otherwise indicated in the effective date column.
View HCPCS Code Set Changes
Payment
CLICK HERE FOR ALL NPI UPDATES
06.11.08 CMS ensuring business name consistency for NPPES
In an effort to ensure that the data submitted to the National Plan and Provider Enumeration System (NPPES) for organization health care providers is accurate, Centers for Medicare and Medicaid Services (CMS) initiated an NPPES-IRS data match to ensure that the legal business name (LBN) and employer identification number (EIN) in NPPES are consistent with IRS data.
CMS sent letters to organization health care providers that have an EIN/LBN combination in NPPES that are different from the information maintained by the IRS. Health care providers must review and update their LBN and/or EIN in NPPES. If health care providers can not furnish data consistent with the IRS, CMS will deactivate the National Provider Identifier in NPPES. CMS will continue to match health care provider data in NPPES against IRS data to ensure the accuracy of NPPES data.
05.29.08 Claims Processors Report Increase in Rejected Medicare Claims
According to Modern Physician Online, health care industry claims processors and claims-flow watchers report at least four-fold increases in rejected Medicare claims, similar or even higher rejection rate spikes for Medicaid claims, and a doubling of rejection rates for claims processed by Blues plans on May 23, the first day a federally mandated National Provider Identifier was required.
Read Full Article
05.16.08 Urgent MAG Notice: AMA Compiling NPI Matching Problems
As you are aware, the National Provider Identifier (NPI) deadline is one week away. CMS has told AMA that they have no plans to extend the NPI contingency timeframe past May 23. During a recent Medicare exercise, the clearinghouses "stripped off" legacy numbers contained on any claims they received and forwarded them to Medicare with just the NPI numbers. Medicare reported that this resulted in a low claims rejection rate. The purpose of this effort was to determine what the situation may look like after May 23 when the NPI number will be the only identifier permitted on claims.
Read MAG Alert
05.05.08 Cahaba's NPI Update
Read NPI Update
05.01.08 Upgrade to PC-ACE Pro32™ Now Available!
The latest version of PC-ACE Pro32™, version 1.90.0.1.00, is now available online. Since this version is the one which will automatically stop sending legacy provider numbers on May 23, you will need to upgrade to this version as soon as possible.
Read Detailed Instructions
Click Here to Install Upgrade
05.01.08 Cahaba Announces Revised Advance Beneficiary Notice (ABN)
A revised Advance Beneficiary Notice (ABN) of Noncoverage (CMS-R-131) was released in March and providers are authorized to begin using the notice immediately. Beginning September 3, 2008, all providers, practitioners, and suppliers paid under Part B, as well as hospice providers and religious non-medical health care institutions (RNHCIs) paid exclusively under Part A, must use the revised ABN in place of the ABN-G (CMS-R-131-G) and ABN-L (CMS-R-131-L). Revised manual instructions in Chapter 30 of the Claims Processing Manual (Pub. 100-04) will be published within the next few weeks.
Click Here for Revised ABN and Form Instructions
04.30.08 May 7 is “Legacy Free” Day – An Opportunity to Check your NPI Readiness!
CMS, in collaboration with the Healthcare Information and Management Systems Society (HIMSS), has requested clearinghouses that submit claims to FFS Medicare to participate in a one day NPI preparation exercise. Specifically, on Wednesday, May 7, participating clearinghouses should submit Medicare claims with NPI-only in all provider identifier fields for which a provider uses NPI/legacy pairs. On May 8th, participating clearinghouses will revert back to sending Medicare NPI/legacy pairs as received from the providers.
On May 7, participating clearinghouses will send Medicare claims with NPI-only in provider fields, which originally contain NPI/legacy pairs from the provider. In other words, clearinghouses will strip the legacy identifiers when they are submitted as part of an NPI/legacy pair. Of course, fields already containing NPI-only will be sent to Medicare, as usual, and secondary provider identifier fields containing legacy-only will be sent to Medicare, as usual.
This exercise will help Medicare providers evaluate their NPI readiness prior to the May 23, 2008 deadline.
04.24.08 Medicare Announces Transition to New Accounting System
Cahaba Government Benefit Administrators, LLC will be transitioning to a new accounting system in late summer 2008. The new system is called Healthcare Integrated General Ledger Accounting System (HIGLAS). A transition plan has been developed to minimize disruption to the Medicare Contractor operations as well as to the provider community.
HIGLAS is an integrated, dual-entry accounting system that replaces the current Medicare Contractor’s accounting system with a single standard system. It will not replace the current claims processing system but will replace the current accounting functions that are now handled by the Contractor’s processing system. Once a claim is processed, HIGLAS will perform the payment calculation, formatting, and accounting.
The new system will improve accountability for Medicare payments to providers serving Medicare beneficiaries. The system will result in better recording, tracking, and collection of receivables in the Medicare Trust Fund.
HIGLAS performs seven major financial functions:
- Accounts Payable – Disbursing payments to providers and other entities.
- Accounts Receivable – Collecting overpayments made to providers and other entities.
- General Ledger – Posting and recording all financial transactions. Maintaining account balances by general ledger accounts.
- Cash Management – Reconciling Contractor’s bank statements.
- Administrative Accounting – Maintaining data used to generate financial statements required by the government. Supporting budget formulation and execution.
- Audit Control – Auditing the integrity of the data. Performing financial statement audits.
- Health care Transaction Base – Providing a federal document view of the data in HIGLAS.
HIGLAS will also produce many benefits in the administration of the Medicare Program:
- Strengthen management of accounts receivable and allow more efficient collection of outstanding debts.
- Improve CMS oversight of contractor financial operations.
- Produce automated financial statements resulting in fewer errors in financial reporting and reducing administrative costs.
- Eliminates redundant accounting processes.
- Reduces the number of contractor developed systems used to track financial data.
04.24.08 May 23rd is Only Four Weeks Away, Are You Prepared?
URGENT: CMS continues to be concerned about the low percentage of claims being submitted with an NPI alone in the primary provider identifier fields.
Don’t be Surprised on May 23 …TRY NPI-ONLY NOW
Now that the NPI is required on all Medicare claims in the primary provider fields, if your claims are being successfully processed with NPI/legacy pairs (and most are) now is the time to begin sending a small batch of claims with NPI alone. If the Medicare NPI Crosswalk cannot match your NPI to your Medicare legacy number, the claim with an NPI-only will reject. You can and should try sending NPI-only now!
If the claim is processed and you are paid, continue to increase the volume of claims sent with only your NPI. If the claims reject, go into your NPPES record and validate that the information you are sending on the claim is consistent with the information in NPPES. If it is different, make the updates in NPPES and resend a small batch of claims 3-4 days later. If your claims are still rejecting, you may need to update your Medicare enrollment information to correct this problem. Call the Customer Service Representative at your Medicare carrier, FI, or A/B MACor at your DME MAC to discuss your situation and, if necessary, have it investigated. Have a copy of your NPPES record or your NPI Registry record available. The contractor telephone numbers are likely to be quite busy, so don't wait.
04.04.08 MAG Alert: Begin Testing NOW for NPI-Only Deadline
CMS is concerned that the percentage of Medicare claims with NPI-only is not growing fast enough. The next milestone – May 23 – requires providers to take the next step so they do not risk disruption in cash flow. Begin billing with NPI-only now to test how the May 23-switch will impact you.
CMS encourages all health care providers to ensure they understand the readiness of other health plans with which they interact, especially if those health plans may be primary or secondary to Medicare. Medicare will only accept/send NPI-only transactions beginning May 23rd and providers from other plans need to understand what will happen if they are unable to send/receive NPI-only transactions.
Read More from NPI Update
03.25.08 NPI-Only Deadline is in Less than Two Months
As of May 23, 2008, the NPI will be required for all HIPAA standard transactions. This means:
- For all primary and secondary provider fields, only the NPI will be accepted and sent on all HIPAA electronic transactions (837I, 837P, NCPDP, DDE, 276/277, 270/271 and 835), paper claims (UB-04 and CMS-1500) and SPR remittance advice.
- The reporting of Medicare legacy identifiers in any primary or secondary provider fields will result in the rejection of the transaction.
REMINDER: Test NPI-Only Now!
Now that the NPI is required on all Medicare claims in the primary provider fields, if your claims are being successfully processed with NPI/legacy pairs (and most are) now is the time to begin testing claims using the NPI alone. If the Medicare NPI Crosswalk cannot match your NPI to your Medicare legacy number, the claim with an NPI-only will reject. CMS recommends that you should do this test now!
If the claim is processed and you are paid, continue to increase the volume of claims sent with only your NPI. If the claims reject, go into your NPPES record and validate that the information you are sending on the claim is consistent with the information in NPPES. If it is different, make the updates in NPPES and resend a small batch of claims three to four days later. If your claims are still rejecting, you may need to update your Medicare enrollment information to correct this problem. Call the Customer Service Representative at your Medicare carrier, FI, or A/B MAC enrollment staff or your DME MAC to discuss your situation and, if necessary, have it investigated. Have a copy of your NPPES record or your NPI Registry record available. The contractor telephone numbers are likely to be quite busy, so don't wait.
Doing this testing now will allow time for any needed corrections prior to May 23, 2008, the date when only the NPI will be accepted in all provider fields.
03.12.08 MM5890 - Additional Information on Reporting an NPI for Ordering/Referring and Attending/Operating/Other/Service Facility for Medicare Claims
Effective with claims received on or after May 23, Medicare will not pay for referred or ordered services or items; unless the fields for the name and NPI of the ordering, referring and attending, operating, other, or service facility providers are completed on the claims.
03.10.08 Ambulatory Surgical Center Fee Schedule Fact Sheet
The Ambulatory Surgical Center Fee Schedule Fact Sheet, which provides general information about the Ambulatory Surgical Center (ASC) Fee Schedule, ASC payments, and how ASC payment amounts are determined, is now available in print format from the Centers for Medicare & Medicaid Services Medicare Learning Network. To place your order click link below, scroll down to "Related Links Inside CMS" and select "MLN Product Ordering Page."
Order Hard Copies
03.10.08 The Medicare Appeals Process: Five Levels to Protect Providers, Physicians and Other Suppliers
The Medicare Appeals Process: Five Levels to Protect Providers,Physicians and Other Suppliers brochure has been updated and is now available to order print copies or as a downloadable PDF file.
View the PDF File
Order Hard Copies
03.05.08 Preparing for Full NPI Implementation in May
With May 23 less than three months away, CMS and the Medicare health care providers must make sure they are ready for full NPI implementation. Providers must be certain their NPI information and Medicare enrollment information is accurate and up-to-date before that date. Further, if providers' claims are being successfully processed with NPI/legacy pairs (and most are) now is the time for them to begin testing claims using only the NPI. Providers should start with small volumes of these NPI-only claims and gradually increase their submissions. Doing this testing now will allow time for any needed corrections prior to the May 23 deadline when claims must include the NPI only.
03.01.08 March 1 is Milestone for NPI
Effective today, all 837P and CMS-1500 claims must have an NPI or NPI/legacy pair in the required primary provider fields. Failure to include an NPI will cause the claim to reject!
CMS expects that, as of March 1:
- A small portion of claims will continue to be submitted without an NPI. These claims will be rejected. Providers have had over two years to acquire and test their NPI.
- Some rejections may occur because a contractor has not completed processing a provider's enrollment application, submitted by the provider to fix inconsistencies between a provider's NPI and Medicare's provider enrollment files.
Read More about NPI Implementation
02.19.08 Critical NPI Date Approaching for Medicare Blling
Beginning March 1, all Medicare claims must contain a National Provider Identifier. You may submit claims with a legacy number and an NPI or just an NPI, but no longer will Medicare accept claims with just the legacy number. Physicians who bill Medicare and are being paid for claims submitted with both an NPI and a legacy number are strongly urged to test their ability to get paid using just their NPI. To test this, they should submit one or two claims as soon as possible. This step is critical to ensuring that their claims will be processed without interruption beginning March 1.
02.15.08 Are you using the latest Cahaba GBA's EDI application?
CMS now requires that an NPI appear on an EDI application before it can be processed. Cahaba GBA has updated the Medicare Part B EDI application to reflect this change.
Please use this application to change vendors or billing services/clearing houses, or to set up providers initially for electronic claims filing and/or electronic remittance advice. EDI applications received without an NPI will be returned to the provider to be corrected. This will delay getting the provider set up to file electronic claims or to receive electronic remittances. If you have any questions, please contact Cahaba GBA EDI Services at 866.582.3253.
Download Updated EDI Application
01.30.08 CMS Delays Application of Expanded Anti-Markup Rule
In response to advocacy by the AMA, the Medical Group Management Association and others, including a letter signed by 47 national physician organizations, the Centers for Medicare & Medicaid Services (CMS) has issued a delay in the application of the expanded anti-markup rule that it published in the 2008 final physician fee schedule. CMS has postponed implementation of the rule until Jan. 1, 2009, instead of the scheduled effective date of Jan. 1, 2008.
The rule would have expanded the Medicare payment rule referred to as the anti-markup rule. In its current form, the anti-markup rule limits the payment a physician can receive for the technical component (TC) of services the physician purchases from an outside supplier. In its expanded form, CMS' new rule would have applied the same payment limitation to the professional component (PC) of purchased diagnostic tests, as well as to the TC and PC of services performed by employees of physicians or group practices if the services are performed outside of the office of the physician or group practice. The new provision defines the office of a group practice as space where the group provides substantially the full range of patient care services that it provides generally.
The delay is not that straightforward. It postpones application of this new rule except in the case of anatomic pathology diagnostic testing services furnished in space used by a physician group practice as a "centralized building," which essentially means that this postponement only applies to diagnostic pathology services when the group provides other patient care services at the site as well. This is intended to close a perceived loophole in the self-referral regulations that had allowed the operation of off-site "pod labs." CMS has stated its intention to use the one-year delay to clarify the application of the rule, issue an additional proposed rule, or both. The AMA will continue its efforts to ensure that the new rules do not have unintended negative consequences for patient access to diagnostic tests.
01.29.08 Important Information for Medicare Providers: Medicare's Key Dates
There are two key dates remaining for 2008 in Medicare's NPI implementation plan. There is also some confusion as to the difference between the implementation steps for March 1 and May 23.
March 1, 2008 Implementation Steps
- Medicare FFS 837P and CMS-1500 claims must include an NPI in the primary provider fields on the claim (i.e., the billing, pay-to, and rendering provider fields).
- You may continue to submit NPI/legacy pairs in these fields or submit only your NPI on the claim. You may not submit claims containing only a legacy identifier in the primary provider fields.
- Failure to submit an NPI in the primary provider fields will result in your claim being rejected or returned as unprocessable.
- Until further notice, you may continue to include legacy identifiers only for the secondary provider fields.
Key Point: Claims with only legacy identifiers in the primary provider fields will be rejected.
May 23, 2008 Implementation Steps
- In keeping with the Contingency Guidance issued on April 2, 2007, CMS will lift its NPI contingency plan, meaning that only the NPI will be accepted and sent on all HIPAA electronic transactions (837I, 837P, NCPDP, 276/277, 270/271 and 835), paper claims and SPR remittance advice. (Note that this date is one day earlier than that mandated by the National Enforcement Policy)
- This also includes all secondary provider fields on the 837P and 837I. The reporting of legacy identifiers will result in the rejection of the transaction.
- CMS will also stop sending legacy identifiers on COB crossover claims at this time.
Key Point: If the claim contains a legacy identifier in any field, it will be rejected.
01.29.08 Industry-Wide Enforcement of the NPI Compliance Date
The compliance date for the NPI for all HIPAA covered entities except small health plans was May 23, 2007. (Small health plans have until May 23, 2008 to comply.) Last year CMS announced that, through May 23, 2008, it would not impose penalties on covered entities that deploy contingency plans to facilitate the compliance of their trading partners. On May 24, 2008, CMS will lift its enforcement-leniency policy. Complaints will be investigated as they are today, but penalties will be a legitimate resolution if the entity does not demonstrate compliance or corrective action. CMS will continue to employ a complaint-driven approach to enforcement. For example, if a complaint is received alleging a failure to comply with the NPI requirements, CMS will contact the entity to secure evidence of compliance and the contingency plan that had been in place. If violations are identified, enforcement actions will take place.
This notice does not prohibit covered entities from lifting contingency plans prior to May 24, 2008.
In sum, no later than May 24, 2008, all covered entities are expected to be using the NPI in a compliant manner, and all contingency plans should be lifted.
01.29.08 NPPES and the NPI Enumerator: Misconceptions & Facts
In conversations and correspondence with health care providers, health plans, and others within the health care industry, it is very clear that there are misconceptions concerning the National Plan and Provider Enumeration System (NPPES) and the NPI Enumerator.
View Misconceptions & Facts
01.25.08 Hospice Payment System Fact Sheet Now Available
The Hospice Payment System Fact Sheet, which offers providers information about the Medicare hospice benefit, is now available from the Centers for Medicare & Medicaid Services Medicare Learning Network.
Download Hospice Benefit Fact Sheet
01.24.08 MAG Alert: Medicare Glitch Delays Payment, New Checks Have Been Sent
MAG has received a number of calls on Medicare payment delays since the beginning of January. Medicare has stated that there was a major glitch between the data and printing centers, which resulted in many payments not being issued for practices between January 3 - 23. Medicare has identified the problem and has reissued checks for this period which should be received by physicians within the next few days. A new process has been implemented to prevent such problems in the future.
This payment delay compounds the other major problem that physicians faced on January 1 when many were not getting paid because of incorrect NPI numbers. MAG reminds Members that the NPI number must CORRECTLY be included on all claims as of January 1 and in the correct spaces on the claims form. The Medicare carrier will no longer try to match up the NPI numbers with former legacy numbers and process the claim. Many physicians have had claim rejections because they still don't have correct matching NPIs with their legacy numbers and Medicare files.
Note: This issue did not impact providers who receive Electronic Remittance Advice (ERA) and Electronic Funds Transfer (EFT).
01.22.08 Updated Medicare Fee Schedule Now Online
The updated 2008 Medicare Fee Schedule with the .05 percent increase is now on the Cahaba Medicare Web site.
View Fee Schedules
01.22.08 CMS Extends 2008 Participation Enrollment Period
Because there was a change to the 2008 Medicare Physician Fee Schedule rates, CMS is extending the Participation Enrollment Period an additional 45 days. The participation decision period now runs through February 15, 2008. All participating status changes will be effective January 1, 2008.
Read More
01.16.08 NPI Claims Instructions and Tips for Implementation
DCH is gathering statistical data related to claims submitted during the dual submission period. The results indicate a high volume of claims have multiple Georgia Medicaid IDs that map to the NPI submitted on the claim. After the dual submission period has ended, any claim that does not map to a single Georgia Medicaid ID will suspend - DELAYING PAYMENT!
Also, Georgia Medicaid is implementing a contingency plan in order to avoid any potential business disruption as a result of requiring NPI as the primary identifier on X12N and NCPDP transactions.
Read More from Georgia DCH
12.21.07 Reminder: NPI Requirement on Medicare Electronic and Paper Institutional Claims Begins January 1st!
Effective 01.01.08, NPIs will be required to identify the primary providers (the Billing and Pay-to Providers) in Medicare electronic and paper institutional claims (i.e. 837I and UB-04 claims). You may continue to use the legacy identifier in these fields as long as you also use the NPI in these fields. This means that 837I and UB-04 claims with ONLY legacy identifiers in the Billing and Pay-to Provider fields will be rejected starting on 01.01.08. (Pay-to Provider is identified only if it is different from the Billing Provider.)
You may continue to use only legacy identifiers for the secondary provider fields in the 837I and UB-04 claims, until 05.23.08, if you choose.
Urgent: Test Your Claims Now! After you have submitted claims containing both NPIs and legacy identifiers and those claims have been paid, Medicare urges you to send a small batch of claims now with only the NPI in the primary provider fields. If the results are positive, begin increasing the number of claims in the batch.
(Reminder: For institutional claims, the primary provider fields are the Billing and Pay-to Provider fields. For professional claims, the primary provider fields are the Billing, Pay-to, and Rendering Provider fields. If the Pay-to Provider is the same as the Billing Provider, the Pay-to Provider does not need to be identified.)
11.27.07 Important NPI Compliance Dates for Medicare Providers
As of Oct. 29, 2007, all Medicare contractors have lifted the bypass logic and are editing against the Medicare crosswalk. As a result, claims that include non-matching NPIs and legacy identifiers are now being rejected. The following table is a review of the next set of dates which are crucial for compliance with the NPI regulations.
Jan. 1, 2008
- 837I electronic claims and UB-04 paper claims without an NPI in fields identifying the primary provider (billing and pay-to) will be rejected.
- Legacy identifiers paired with NPIs in the primary provider fields on the claim will still be acceptable as will legacy-only numbers in secondary provider fields.
March 1, 2008
- Medicare FFS 837P and CMS-1500 claims must include an NPI in the primary fields on the claim (i.e., the billing, pay-to, and rendering fields).
- You may continue to submit NPI/legacy pairs in these fields or submit only your NPI on the claim. You may not submit claims containing only a legacy identifier in the primary fields.
- Failure to submit an NPI in the primary fields will result in your claim being rejected or returned as unprocessable.
- Until further notice, you may continue to include legacy identifiers only for the provider secondary fields.
May 1, 2008
- In keeping with the Contingency Guidance issued on April 3, 2007, CMS will lift its NPI contingency plan, meaning that only the NPI will be accepted and sent on all HIPAA electronic transactions (837I, 837P, NCPDP, 276/277, 270/271 and 835), paper claims and SPR remittance advice.
- This also includes all secondary provider fields on the 837P and 837I. The reporting of legacy identifiers will result in the rejection of the transaction.
- CMS also will stop sending legacy identifiers on COB crossover claims at this time.
11.19.07 2008 Participation Enrollment & Medicare Part B Information (CD-ROM)
The 2008 Participation Enrollment & Medicare Part B Information (CD-ROM) was mailed Tuesday, November 13, 2007. The 2008 Medicare Physician Fee Schedule will not be included on the CD-ROM this year. The 2008 Medicare Physician Fee Schedule will be placed on the Carrier’s Web site at https://www.cahabagba.com/part_b/claims/Fee_schedule_allowances.htm once the final rule is put on display. Placing the fees on the carrier Web site assures that providers will have the most current and correct fees available.
View the 2008 Fee Schedule
11.13.07 Important NPI Information for Medicare Providers
As it gets closer to May 23, 2008, be sure to pay attention to information from Medicare and other health plans regarding NPI implementation timelines.
View Summary of Key NPI Dates
11.02.07 Medicare Final Rule Announces 2008 Physician Fees and Reforms for Accurate Payments and Quality
The Centers for Medicare & Medicaid Services (CMS) today issued a final physician payment rule designed to improve accuracy of Medicare payments and give physicians and health care professionals additional financial incentives to provide higher quality and value in the delivery of care.
Under the new rule, Medicare estimates that it will pay approximately $58.9 billion to about 900,000 physicians and other health care professionals. The revised payments, quality incentive rates and related policy changes, which will become effective January 1, 2008, are included in the Medicare Physician Fee Schedule (MPFS) final rule. The rule went on display today at the Federal Register.
View the Final Rule, Effective for Services On or After January 1, 2008
Physician Relations
06.18.08 CMS outlines e-records demo project
About 200 physicians from Georgia will be able to participate in a newly unveiled Centers for Medicare and Medicaid Electronic Health Record demonstration project. MAG recently attended a meeting related to the topic. More information/guidelines for the project will be posted as they become available.
View Medicare physician EHR demonstration project documents
06.12.08 MAG helps Georgia secure funds for e-records demo project
Atlanta - The Medical Association of Georgia (MAG) was instrumental in the process that will enable some 200 physicians from Georgia to participate in a Centers for Medicare and Medicaid Electronic Health Record demonstration project, MAG’s president said today. Jack M. Chapman Jr., M.D., explained that the project will provide participating doctors with incentive payments to convert from paper to electronic records systems.
Health and Human Services Secretary Michael Leavitt held a joint news conference with Gov. Sonny Perdue at the State Capitol in Atlanta on June 12 to announce that Georgia has been selected as one of the 12 of the states that will be participating in the Medicare Health Records Demonstration Project. A number of dignitaries were on hand for the event, including (from left) MAG Executive Director David Cook, Secretary Leavitt, Georgia State Medical Association Immediate Past President Lawrence L. Sanders Jr., M.D., and James R. Morrow Jr., M.D., who is with North Fulton Family Medicine and a MAG member.
Read full press release
Read MAG news article
06.05.08 Centers for Medicare & Medicaid Changing DMEPOS Payment System
The Centers for Medicare & Medicaid Services (CMS) has announced that Medicare is changing the way it pays for certain Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS), how much it pays for these items (e.g., hospital beds, diabetic supplies, power wheelchairs and walkers), and who may supply them. CMS is stressing that the changes apply to all Medicare beneficiaries, which means that many Medicare beneficiaries will need to change the suppliers.
CMS says the new program will begin July 1, 2008 in 10 communities, including Charlotte-Gastonia-Concord, NC-SC; Cincinnati-Middletown, OH-KY-IN; Cleveland-Elyria-Mentor, OH; Dallas-Fort Worth-Arlington, TX; Kansas City, MO-KS; Miami-Fort Lauderdale-Miami Beach, FL; Orlando-Kissimmee, FL; Pittsburgh, PA; Riverside-San Bernardino-Ontario, CA; and, San Juan-Caguas-Guaynabo, PR. It says the program will expand to 70 additional areas in 2009 and then ultimately the rest of the U.S.
CMS says that patients who live in or travel to one of those 10 designated areas and need medical equipment or supplies in one of the 10 product categories listed below must now get the equipment or supplies from a Medicare-contracted supplier.
The 10 product categories include ...
- Oxygen supplies and equipment*
- Standard power wheelchairs, scooters and related accessories
- Complex rehabilitative power wheelchairs and related accessories*
- Mail-order diabetic supplies
- Enteral nutrients, equipment, and supplies*
- Continuous Positive Airway Pressure (CPAP) devices and Respiratory Assist Devices (RADs) and related supplies
- Hospital beds and related accessories*
- Negative pressure wound therapy pumps and related supplies and accessories
- Walkers and related accessories
- Support surfaces, including group 2 mattresses and overlays (in Miami-Fort Lauderdale-Miami Beach, FL only)*
* NOT included in San Juan-Caguas-Guaynabo, PR
Download DMEPOS Tip Sheet
Identify Medicare Contract Suppliers
05.13.08 Alert: Railroad Medicare Receiving Higher Call Volume
The toll-free telephone number for Railroad Medicare is 877.288.7600 for the IVR line and 866.899.5227 for provider enrollment. Railroad Medicare is receiving a much higher volume of calls than usual, which has resulted in some callers receiving busy signals. Many callers are asking questions regarding the implementation of the National Provider Identifier (NPI) and the effect on Medicare claims. We apologize for any inconvenience this causes and thank you for your patience. Please contact the office at one of the above listed numbers for additional assistance.
Due to an increase in call volume, beginning Thursday, May 1, the office will have separate phone numbers to reach its Interactive Voice Response (IVR) system and Customer Service Representatives (CSR). The new CSR Only phone number is 888.355.9165 and will be in service effective May 1. The IVR Only phone number will continue to be 877.288.7600.
If you are calling for claims status or eligibility you will continue to call the IVR at 877.288.7600. If your call is one that requires the expertise of a CSR after May 1, you will need to call the new CSR only toll-free number at 888.355.9165.
Please be aware that if you inadvertently call the CSR-only line (888.355.9165) and your call is one that CMS mandates should be handled through our IVR (877.288.7600) you will be instructed to redial the IVR-only line (877.288.7600).
04.24.08 AMA Discusses Alternative Reporting Periods and Criteria for 2008 Physician Quality Reporting Initiative (PQRI)
On April 16, CMS announced the establishment of alternative reporting periods and criteria for satisfactorily reporting quality measures under the 2008 Physician Quality Reporting Initiative (PQRI). These changes, authorized by the Medicare, Medicaid and SCHIP Extension Act of 2007 establish the following:
- Alternative reporting criteria for satisfactorily reporting measures groups (Click Here for List) related to diabetes, end-stage renal disease, chronic kidney disease and preventative care; and
- Alternative reporting periods and alternative criteria for satisfactorily reporting through registry-based reporting.
Click Here to Read AMA's Full Memo on the Changes
04.22.08 2008 Physician Quality Reporting Initiative (PQRI) National Provider Call
The Centers for Medicare & Medicaid Services' (CMS) Provider Communications Group will host the second in a series of national provider conference calls on the 2008 Physician Quality Reporting Initiative (PQRI). This toll-free call will take place from 1:30 - 3:30 p.m., EST, on Wednesday, April 30. In order to receive the call-in information, you must register for the call.
Download Conference Call Power Point Presentation
Click Here to Register for Call
04.21.08 Quality Reporting Initiative Will Help Improve Health Care for Beneficiaries and Provide Incentives for Eligible Professionals
The Centers for Medicare & Medicaid Services (CMS) announced steps it is taking to encourage physicians and other eligible professionals to take part in the Physician Quality Reporting Initiative (PQRI), a program designed to improve the quality of care provided to Medicare beneficiaries. These steps, including a variety of new reporting options, will make it easier for eligible professionals to participate and receive feedback on their performance.
The 2008 PQRI Program allows the use of 119 measures that were published in the Physician Fee Schedule for 2008.
Click Here for Details on How an Eligible Professional Can Qualify
Download 2008 PQRI: Establishment of Alternative Reporting Periods and Reporting Criteria
04.14.08 Register NOW for DMEPOS Accreditation 101 for Physicians and Rehabilitation Providers
The Centers for Medicare & Medicaid Services (CMS) will host an audio conference/Q&A session regarding Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) accreditation on April 22 from 1 - 2:30 p.m. ET. This audio conference is designed to provide guidance to Physicians and the Rehabilitative industry that provides DMEPOS supplies/equipment to Medicare beneficiaries. In order to receive the call-in information, you must register for the call.
Click Here to Register for the Call
04.14.08 CMS Releases Revised CMS-855 Medicare Enrollment Applications
The Centers for Medicare & Medicaid Services (CMS) issued revised CMS-855 Medicare enrollment applications in March 2008. With the exception of providers enrolling as a specialty hospital on the CMS-855A, Medicare contractors will continue to accept the 2006 version of the Medicare enrollment application through June 2008. Providers and suppliers should begin to use the new Medicare enrollment applications immediately. Initially, these applications will be available only from the CMS provider enrollment web site.
Read More Information
Download Revised Form
03.25.08 Medicare Trustees Report Released; Projects 41 Percent Payment Cut
View 2008 Medicare Trustees Report
03.19.08 AMA Poll Shows Public is Concerned about Medicare Payment Cuts
The AMA issued reports with the most recent survey results on the Medicare cuts. The opinion poll found that eight out of 10 Americans are concerned about access to care for seniors and baby boomers because of the pending cuts. Medicare payments to physicians will be cut 10.6 percent on July 1, growing to about 40 percent over the next decade if Congress does not intervene.
Read AMA's Press Release
View Survey Results
03.11.08 CMS Issues Winter Newsletter
View CMS Newsletter
02.15.08 MAG, AMA Encourage Members to Contact Senators to Prevent Medicare Payment Cuts
Though we were successful in preventing a 10 percent cut to Medicare physician payments in January 2008, Congressional intervention only delayed the cuts for six months. The upcoming President's Day Congressional Recess - February 15-25 - is a critical opportunity to reach out to members of the United States Senate and impress on them the importance of meeting their self-imposed deadline of July 1, 2008 for preventing cuts to Medicare that will endanger the access to care of millions of beneficiaries.
To assist you in this endeavor, the AMA has developed several advocacy resources that we encourage you to use in reaching out to your U.S. Senators. To read more, click on any link below:
Talking Points
Facts on Medicare’s Physician Payment Update Formula
Facts on Medicare Advantage Program
State-by-State Figures
Breakdown of Gap Between Payment, Practice Costs
Sample Letter to Send to Patients
01.29.08 CME and CEU Credit Now Available for Practice Management
The AMA’s Office of Special Groups and AMA Bookstore will host a 90-minute web conference titled ‘Medicare’s Pay-for-Reporting Bonus (PQRI) – What’s in it for you?’, on Thursday, February 21. Medical practices that report on a designated set of quality measures can earn a bonus payment of up to 1.5 percent of total allowed charges for covered Medicare physician fee schedule services. This web conference will detail how to report the required data, with or without an EMR system. The registration fee for AMA members is $125 ($200 for non-members), and includes 1.5 AMA PRA Category 1 CreditsTM or 1.5 CEUs toward renewal of PAHCOM Medical Manager certification and a free supplemental publication from AMA press.
The program is geared toward doctors and practice managers in small to medium-sized group practices. The faculty for this program, Max Reiboldt, CPA, is CEO, Managing partner, with the healthcare consulting firm, The Coker Group.
Read More
01.17.08 AMA conducting Physician Practice Information Survey
For the first time in nearly a decade, the American Medical Association (AMA), and more than 70 other health care professional organizations, have worked together to coordinate a comprehensive multi-specialty survey of America’s physician practices. The survey will collect up-to-date characteristics of thousands of physician practices from virtually all specialties, and be used in efforts to positively influence national decision makers to ensure accurate and fair representation for all physicians and patients.
Getting our nation’s policy-makers to understand today’s landscape and the requirements for care is critical. This data will allow medicine to articulate the challenges of running a practice that provides expert patient care, while operating a business that is sustainable. The study results will not only help in the short-term but will allow future generations of doctors to continue providing superior care to their patients.
One particularly important section of the study pertains to practice expenses and the amounts that are attributable to you. The Centers for Medicare and Medicaid Services have indicated that the results of this study will be used to help determine physician payment. Please encourage your staff to make this information available as the survey’s success depends on accurate and complete data. This information will remain confidential. The survey firm, Dmrkynetec, will not identify any individuals or entities participating in this research.
Dmrkynetec, a survey firm with extensive experience in the area of physician practice finance, has been retained to administer the survey. Dmrkynetec will contact randomly selected physicians and practice managers in order to collect their confidential responses. Please watch for this survey and complete it thoroughly and accurately. Do your part to represent our profession!
11.19.07 2008 PQRI Medicare Physician Fee Schedule Summary Document
The link to the 2008 PQRI Medicare Physician Fee Schedule summary document is now working.
View Summary of Provisions
11.13.07 Medicare Part D: What to look for in 2008
Read an end-of-year message regarding Medicare Part D by William Rogers, M.D., FACEP, Director of the Centers for Medicare & Medicaid Services (CMS) Physician’s Regulatory Issues Team.
View PDF
Prescription Drug Plan
04.04.08 New Medicare Standards Will Help Doctors Offer Lower-Cost Generic Options When Writing Prescriptions
People who are eligible to enroll in Medicare’s prescription drug program are expected to experience greater safety, increased use of lower-cost generic equivalents, and more efficient communication between their doctor and pharmacy as a result of a new regulation issued today by the Centers for Medicare & Medicaid Services (CMS). The final rule establishes Part D e‑prescribing standards for four types of information: formulary and benefits, medication history, fill status notification, and identification of individual health care providers.
View the Final Rule on Part D E‑prescribing Standards
11.16.07 2008 Open Enrollment for Medicare Part D Prescription Drug Coverage and Medicare Advantage Plans Underway
The U.S. Department of Health and Human Services (HHS) announced that, beginning today, Medicare beneficiaries will be able to begin making enrollment changes in their health and prescription drug coverage for 2008, if necessary. The Medicare annual Open Enrollment Period for prescription drug plan runs from November 15 through December 31, 2007.
In addition, for Medicare Advantage (MA) plans only, beneficiaries can make one change in enrollment - enrolling in a new plan, changing plans or canceling a plan - between January 1 and March 31, 2008.
"Now is the time for beneficiaries to prepare and compare their health and prescription drug coverage options and choose the plan that best meets their needs," HHS Secretary Mike Leavitt said. "We intend to keep building on the success the program has achieved thus far. The most recent satisfaction rate stands at 86 percent, the estimated average premium is 40 percent lower than originally estimated and total estimated costs are running $188 billion below initial projections. Part D is a program that is working well and is helping Medicare beneficiaries with their prescription drug costs."
HHS' Centers for Medicare and Medicaid Services (CMS) encourages all beneficiaries to act soon to compare their current plan with other plan options. If they are satisfied with their current plan, they do not need to do anything in order to maintain their coverage. CMS wants eligible beneficiaries who do not have prescription drug coverage to know that, if they wait, they may pay a penalty on their premium.
During this coordinated election period, beneficiaries are encouraged to review their prescriptions and other health needs when assessing the plan options described in the "Medicare & You" handbook or on www.medicare.gov. In addition, CMS recommends that beneficiaries gather any Medicare or Social Security mailings they received and materials made available by local counselors to use as a reference when speaking with a 1-800-Medicare representative or entering information on www.medicare.gov.
CMS also encourages people to take advantage of the enhanced online Medicare Prescription Drug Plan Finder options available on www.medicare.gov. This feature offers information on available drug plans, including out-of-pocket costs and pharmacy networks. The enhanced online Medicare Prescription Drug Plan Finder and Medicare Options Compare tools enable beneficiaries to compare drug plan options for prescription drug plans and Medicare Advantage plans in their area. CMS continues to refine its educational tools, so beneficiaries will find it easier to locate information about available health and drug plans.
Related Links
- American Medical Association 2007 Medicare Physician Payment Cut Action Kit
- CAHABA GBA and CMS Updates
- CMS Medicare Learning Network
- CMS NPI Lookup Function
- NPI News
*Many of the documents listed here are available in PDF format and can be viewed using Adobe Acrobat Reader.® This free software can be downloaded from the Adobe® site, http://www.adobe.com.