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Regulatory MonitoringArchive for January, 2009
Q: If I receive a demand letter from a RAC because a service didn’t meet Medicare’s medical necessity criteria for an inpatient level of service, can we re-bill all the services on an outpatient claim?A: Providers can re-bill for Inpatient Part B services, also known as ancillary services, but only for the services on the list in the Benefit Policy Manual. That list can be found in chapter 6, section 10: www.cms.hhs.gov/manuals/Downloads/bp102c06.pdf. Rebilling for any service will only be allowed if all claim processing rules and claim timeliness rules are met. There are no exceptions to the rules in the national program. The time limit for re-billing claims is 15–27 months from the date of service. These normal timely filing rules can be found in the Claims Processing Manual, chapter 1, section 70: www.cms.hhs.gov/manuals/downloads/clm104c01.pdf.
Editor’s note: Thanks to Barbara Aubry, RN, CPC, CHCQM, FAIHQ, regulatory analyst for 3M Health Information Systems, Inc, in Rockleigh, NJ, for providing this response.
The governor of Minnesota faces a dilemma because of the growing number of Medicaid-eligible patients in his state, the Minneapolis Star Tribune reports.
Governor Tim Pawlenty’s budget includes a $3 billion share for Medicaid, which is one-fifth of his budget. But cutting isn’t easy. He has a Legislature that wants to expand access to healthcare for the poor.
Read the full story in the Tribune.
A recent report by the Center for Studying Health System Change, a nonpartisan policy research organization, states that one in seven Americans under age 65 went without a prescription drug in 2007 because they could not afford it. The study shows the effect increased drug prices were having even before the economic recession went into full swing: in 2003, only one in 10 Americans said they couldn’t afford their prescriptions.
According to the study, people who were most likely to be unable to afford their prescriptions were uninsured and suffering from a chronic condition. Without their medications, their conditions were likely to worsen, causing them to seek expensive medical treatment.
However, in the recent survey, insured Americans were not immune to prescription pricing troubles. One in 10 Americans insured by their employer reported going without a prescription because of cost, also up from the last study in 2003.
Source: The New York Times
Nine out of 10 hospitals reported that borrowing money has become harder due to the economic recession, and the same number report that obtaining charitable funds has also become more difficult, according to the American Hospital Association (AHA).
A recent survey of 639 hospital CEOs showed that because of the lack of access to capital, hospitals have had to put projects on hold:
- 82% have put facility projects on hold
- 65% have put clinical technology projects on hold
- 62% have put information technology projects on hold
Putting projects on hold hinders hospitals’ ability to continually increase quality and efficient care, and to respond to community needs.
By Jackie Birmingham, RN, BSN, MS, CMAC.
A Medicare beneficiary (or authorized representative) who has been given an Advance Beneficiary Notice of Noncoverage (ABN) may elect to receive the item or service anyway. In this case, the beneficiary should indicate that he or she is willing to be personally and fully responsible for payment by marking options 1 or 2 in box G on the ABN form. This new version of the ABN is used before services are rendered (as the name implies) and it may be given by outpatient department staff.
Here are some more tips regarding filling out the ABN:
- Option 1 indicates the beneficiary or representative will pay for the service out of pocket, but the hospital will also bill Medicare to see whether Medicare will pay for the item or service. If Medicare does not pay, the patient has the opportunity to appeal, but there is no guarantee Medicare will pay for the item or service.
- Option 2 indicates the individual accepts full financial responsibility for the item or service. Medicare will not be billed, and the beneficiary cannot appeal. This option requires that the patient be informed of the cost of the service prior to receiving the service.
- When a beneficiary decides to decline an item or service, he or she should indicate this by marking option 3 in box G on the ABN form. Counseling the patient on this decision and documenting the discussion is important. The service has been ordered based on the patient’s physician’s advice, and if the patient declines the item or service, it is important to be sure that he or she is fully informed of the consequences of the decision.
- The beneficiary cannot refuse to sign the ABN and still demand the item or service.
- If a beneficiary refuses to sign a properly executed ABN, the notifier should consider not furnishing the item or service, unless the consequences (health and safety of the patient, or civil liability in case of harm) are such that this is not an option.
- Additionally, the notifier may annotate the ABN, and have the annotation witnessed, indicating the circumstances and persons involved.
By Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc.
Medicare has been going through a number of transitions recently. One of these transitions relates to the appropriate form of notice when certain providers, including hospitals and physicians, believe that the outpatient services ordered by the patient’s physician fall under the limitation on liability provisions of the Social Security Act. Under these provisions, the provider must provide advance written notice to the beneficiary (or his or her representative) prior to the performance of the services in order to be able to bill the beneficiary for those services if Medicare denies coverage.
Limitation on liability is likely to arise in the outpatient setting when the services ordered fail to meet Medicare coverage criteria for one of the following reasons:
- They fail to meet Medicare’s medical necessity guidelines;
- They are screening services that are provided more frequently than Medicare provides a benefit for; or
- They are custodial services.
In order to successfully shift financial liability to the patient, the provider must provide a prescribed form of notice prior to the performance of the services. Medicare is currently phasing out the prior prescribed forms (ABN-G and ABN-L), which continue to be effective through February 28, 2009. On and after March 1, 2009, however, providers must use the revised ABN form (CMS-R-131) in order for the advance notice to be effective when limitation on liability applies to outpatient services.
The revised form initially became effective for services provided on and after March 3, 2008, which gave providers a year to transition to the revised form. There are a number of technical requirements set out in the Medicare Claims Processing Manual, Chapter 30, that must be met if the ABN is to be effective. Most of the requirements that apply to the revised form are very similar to those that applied to the prior forms.
In September, 2008, Medicare issued Medicare Claims Processing Manual Transmittal 1587, which contained specific, updated instructions on completion and use of the revised ABN. The most significant change is the requirement that “Notifiers must make a good faith effort to insert a reasonable estimate for all of the items or services listed . . .” on the ABN. Nevertheless, Medicare permits a great deal of flexibility in meeting this standard. For example, so long as the estimate is within $100 or 25% of the actual costs, whichever is greater, the notifier will be considered compliant.
With just a month left during the ABN transition period, it is essential that providers assure that they are prepared to be fully compliant with the new requirements, including a good faith cost estimate, as set out in the updated sections in Chapter 30 of the Medicare Claims Processing Manual.
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