Manage My Practice

There’s a new ABN form required to be in use in January 2012 – read about it here in my article “Everybodys Favorite Form: New Advance Beneficiary Notice of Noncoverage (ABN) Form Begins in 2012″

Note from Mary Pat: The Advance Beneficiary Notice of Noncoverage (ABN) is a collection tool that many medical practices do not know how to implement. It is particularly difficult to determine who has ownership of this process, because the form must be completed and signed by the patient before the service is provided. The patient is in the exam room or the lab, ready for the service or test, and a knowledgeable staff person must step in, explain the rules and pricing and obtain the patient’s signature.

Blogger Charlene Burgett does a great job of explaining the ins and outs of using the ABN, and has agreed to share an article originally published on her blog “Conundrum” with MMP readers.

The use of the ABN is required by Medicare to alert patients when a service will not be paid by Medicare and to allow the patient to choose to pay for the service or to refuse the service.

If the practice does not have a signed ABN from the patient and Medicare denies the service, the charge must be written off and the patient cannot be billed for it. The only exception is for statutorily excluded services (those that Medicare never covers like cosmetic surgery and complete physicals for example). In this case, a practice can bill the patient for the non-covered service despite not having an ABN. It is, however, a good idea to have the ABN signed for non-covered services so the patient is made aware that they are responsible.

If the patient signs the ABN and is made aware of their financial responsibility you may require the patient to pay for this service on the date the service is provided. You may also charge the patient 100 percent of your fee. You do not have to reduce your charge to the Medicare allowable.

With a signed ABN, the practice has proof of the patient’s informed consent to provide the service and their agreement to be financially responsible for the service. In the past, Medicare had a Notice of Exclusion of Medicare Benefits (NEMB) that we could provide to the patient (no signature required) to alert them of Medicares non-covered services. The ABN has replaced the NEMB.

The typical reasons that Medicare will not cover certain services and that would be applicable are:

1. Statutorily Excluded service/procedure (non-covered service)
2. Frequency Limitations
3. Not Medically Necessary

Statutorily Excluded items are services that Medicare will never cover, such as (not a complete list):

• Complete physicals (excluding Welcome to Medicare Screenings, with caveats)
• Most immunizations (Hepatitis A, Td)
• Personal comfort items
• Cosmetic surgery

For these items, it is a good idea (not a requirement) to complete the ABN and have the patient check the appropriate box under options and sign the ABN. For the sake of the billing department, I strongly encourage the use of ABNs for statutorily excluded items.

Frequency Limitations are for services that have a specific time frame between services. For example, Medicare allows one pap smear every 24 months if the pap is normal. If the patient wants one every 12 months for their peace of mind, Medicare will pay for year one and the patient will pay for year two and that pattern continues. The ABN needs to be on file for the year that the patient is responsible for paying. If the patient fits Medicares guidelines for high risk they are allowed to have the pap every 12 months and no ABN is required.

Services that are not considered Medically Necessary are those that do not have a covered diagnosis code based on Local Coverage Determinations (LCD). One example is for excision of a lesion. If the lesion is being removed because the patient just doesnt like how it looks, that is considered cosmetic surgery. If the lesion is showing some changes (i.e. bleeding, growing, changing color, etc), then it is considered medically necessary because it potentially can be malignant. The removal needs to have diagnosis coding to substantiate the medical necessity and Medicare has Local Coverage Determinations that list all the codes/coding combinations that Medicare will approve for payment.

A rule of thumb in trying to discern the necessity of ABNs is to ask yourself if there may be some times that the service isnt covered by Medicare. The times the service isnt covered, an ABN is required. To illustrate this point, here are two examples:

• EKGs are covered for certain cardiac and respiratory conditions. The only time an EKG is covered for preventive screening is during the patients first year enrolled in the Medicare program and when being done during the Welcome to Medicare screening. After that time, Medicare will never cover an EKG for preventive screening. To notify the patient of this and to show that the patient agrees to be financially responsible for the EKG, an ABN should be completed.

• Another example is for the Tetanus immunization. Medicare will cover tetanus when medically necessary; if the patient has cut themselves and the tetanus is provided due to that injury. If the tetanus is provided to the patient because it has been ten years since the last tetanus and the tetanus is not in response to a recent injury, then it will be non-covered because it is not medically necessary and the ABN will need to be on file.

ABNs need to be completed in their entirety. The Options box can only be completed by the patient and it states that We cannot choose a box for you. That would appear to be coercion.

A blanket ABN, one that is signed by the patient for all services provided within a certain time period, is not acceptable and is illegal.

In addition, there is a small area to provide additional information that can be used by either the patient or the providers office. This could be anything pertinent to the information that the ABN covers. The bottom of the form is where the patient signs and dates. We keep the original ABN in the chart behind the progress note for that day. Providers MUST provide a copy of the signed ABN to the patient.

The current ABN form with instructions can be found here.

If a service is denied by Medicare and the physician does not have a signed ABN prior to the service being rendered, the service can not be billed to the patient and will need to be written off. Sometimes a patient may refuse to sign the ABN – if this happens it is appropriate for the physician to document the refusal and sign, along with having a witness sign. Medicare will accept this and the patient can be billed for the service if denied by Medicare.

How does Medicare know whether or not you have a signed ABN? You tell them, by adding a modifier to the CPT code when completing the claim form. The appropriate modifiers are:

GA: The ABN is signed, but the service may not be covered.

GY: A statutorily excluded service.

GZ: The service is expected to be denied as not reasonable or necessary. This is typically used when there is a secondary payer that requires the Medicare denial before they pay benefits.

The use of the ABN is often misunderstood; however, it is the only way a patient can be informed about their financial responsibility prior to agreeing to a service being rendered. This is an issue that the OIG has reportedly been interested in investigating for fraud and abuse.

Charlene Burgett, MA-HCM

Note: Readers, how do you make the ABN work in your practice? Do you train the clinical staff, the physicians, or other staff to recognize the “ABN Moment”? How do you make it work? Please share your ideas by responding with a comment.

Today I was fortunate enough to attend an outreach session designed to educate hospitals, physicians and other providers about Recovery Audit Contractors (RAC), specifically Connolly Consulting, the RAC for North Carolina. Although I cannot vouch that the information I am sharing for Region C will be consistent for the other three RACs, the fact that there is a standard handout being used for all RAC outreach sessions makes me think there’s a very good chance that CMS is encouraging a high level of consistency.

If you read the recent Manage My Practice article here by Carla Hannibal, you already know that the RACs were established after CMS demonstration projects proved “to be successful in returning dollars to the Medicare Trust Funds and identifying monies that need to be returned to providers. It has provided CMS with a new mechanism for detecting improper payments made in the past, and has also given CMS a valuable new tool for preventing future payments.” (CMS website)

Each RAC bid for and won the jurisdiction as follows:

• Region A: CT, DE, DC, MD, ME, MA, NH, NJ, NY, PA, RI, VT Diversified Collection Services (DCS) -1-866-201-0580, website here
  

• Region B: MN, WI, IL, IN, OH, MI, KY CGI Technologies and Solutions -1-877-316-7222, website here

• Region C: AL, AR, CO, FL, GA, LA, MS, NC, NM, OK, SC, TN, TX, VA, WV and the territories of Puerto Rico and U.S. Virgin Islands. Connolly Consulting, Inc. -1-866-360-2507, website here

• Region D: WA, OR, ID, CA, NV, MT, WY, UT, AZ, ND, SD, NE, KS, IA, MO, AK, HI HealthDataInsights, Inc.-Part A: 866-590-5598, Part B: 866-376-2319, e-mail: website here

Each RAC is required to provide outreach education sessions in their region prior to sending out any letters. Any hospital or physician who bills fee-for-service programs (Part A and/or Part B) for Medicare beneficiaries is eligible for a RAC audit.

These are the important points that I took away from attending this outreach program:

1. RACs may review claims as far back as October 1, 2007.
2. RACs review claims after they have been paid using the same Medicare policies used to pay the claim initially.
3. There are two types of reviews: Automated Reviews which do not request the medical record and Complex Reviews which will request the medical record.
4. Automated Reviews are “done deals” and the claim will be adjudicated and a letter sent detailing the dollars requested.
5. Providers may return the payment by writing a check, allowing a recoupment from future payments or may apply for an extended payment plan.
6. Complex Reviews entail a request for medical records. Records can be mailed, faxed, or sent on a CD/DVD. Mailed records must be sent in a tamper-proof package, and should be sent via trackable carriers (FedEx, UPS, Registered USPS.) Multiple records may be sent in one package if each record set is in a separate envelope inside the package.
7. Note: if faxing, fax the records to yourself to check for readability before you fax to the RAC.
8. Email records are currently not acceptable due to HIPAA.
9. Providers have 45 days plus 10 mailing days for a total of 55 days to send the records, but extensions are available if this is not abused. If you do not communicate with your RAC about any problems you are having sending the records (e.g. you can’t find the record!), you risk having the claim(s) automatically recouped. The Connolly representative even mentioned something to the effect that she wasn’t above calling the practice/entity CEO to let them know that their contact person wasn’t playing by the rules.
10. Once a claim has been reviewed and a Complex Review is in play, the provider will receive a Demand Letter from the RAC and the provider will have a “discussion period” to contact the RAC and ask questions and/or provide additional information. The RAC representative emphasized to communicate, communicate, communicate and to call the RAC and speak to the reviewer of the claim. Once you have spoken to the reviewer, if you still disagree with the decision, you should ask to speak to the supervisor, and if there still is no agreement, you need to file an appeal.
11. Appeals must be filed within 120 days of the receipt of the demand letter from the RAC.

Here is a suggested action plan for physician practices to prepare for the RAC process:

1. Visit the CMS website here and click on Demonstration Projects to see what improper payments were found by the RAC demonstration projects.
2. Visit the CMS and OIG websites to see what improper payments were found by reading the OIG (Office of Inspector General) reports here and CERT (Comprehensive Error Rate Testing) reports here.
3. Conduct an internal assessment to see if you are in compliance with Medicare rules, and if not, identify corrective actions needed to bring your group into compliance. Corrective actions may include provider education and a periodic internal audit to rate the improvement.
4. Provide your RAC (they will tell you how to do this) with a contact person who will receive RAC letters and who will be the point person for providing the RAC with additional documentation. The RAC will also ask for information about providers and their NPIs, including any providers who were with the group between October 1, 2007 and now, even if the provider is no longer with you. Connolly suggests copying the list of providers you supply to the RAC and placing it in the personnel file of the contact person to be reminded of this important responsibility if this person leaves the organization.
5. Develop a basic tracking system for receipt of letters, and activity for each request.
6. VISIT YOUR RAC WEBSITE AT LEAST WEEKLY.

I have received lots of questions about what a RAC letter will look like, and the speaker today provided a sliver of information saying that the Region C letters will have the CMS logo at the top of the letter and Connolly’s logo at the bottom of the letter. Because your practice/entity will be providing the RAC with a contact person’s name, unless things are in total chaos at your place of business, the letters will go to the person you’ve entrusted with this important responsibility.

Here are some other questions and answers from the program today:

Q: Does the RAC pay for the copying/mailing for records?

A: They will pay hospitals, but will not pay physicians for record expense.

Q: If a claim is refunded to Medicare, must the patient be refunded their portion?

A: Yes.

Q:What determines which region the practice/entity belongs to for RAC?

A: The state that the practice/entity is located in.

Q: Are patients contacted if their claim is audited?

A: They receive a notice if the claim is adjusted in any way.

Q: I heard that there are consultants selling RAC insurance – is that a good idea?

A: There is no such thing as audit insurance, but there is such a thing as appeal insurance.

Q: Will a claim be audited if a practice/entity self-audits, finds an error and corrects it?

A: As long as an amended claim is filed by the provider, RAC will not audit the claim.

Q:Who sets the guidelines for medical necessity?

A: The medical director of the RAC.

Q: Are the number of claims that can be audited in each period counted by transaction lines (5 per CMS form) or by claim/single CMS form?

A: By transaction lines.

Q: Will the RACs extrapolate their findings?

A: The RACs are entitled to extrapolate their findings if they so choose.

Q: Are the RACs paid on a percentage of their findings?

A: Yes, RACs are paid a percentage of both overpayments and underpayments. The percentage ranges from 9% to 12.50% based on each RAC’s bid.

If this information is new to you, I suggest you click on some of the links provided in this article, start developing your RAC plan, and start educating your providers and staff. This topic is also a good one for sharing of best practices between local and regional groups. To get email updates on RAC from CMS, sign-up here. Remember to bookmark your RAC’s website and visit often!

Photo credit: Milosluz | Dreamstime.com

UPDATE: 2/11/2010

Clarification on H&P Requirement Prior To ASC Procedure (Angela Mason-Elbert of CMS:

“Each patient that is seen in an ASC must have a comprehensive medical history and physical assessment (H&P) not more than 30 days before the date of the scheduled surgery. The H&P is to determine if the patient has any underlying conditions that would put the patient at risk for having such a procedure or to identify any new or existing co-morbid conditions that would require additional interventions. Additionally, the H&P could provide evidence that the ASC is not the appropriate setting for this particular procedure. The H&P, as long as it is comprehensive, can be completed the day prior to the procedure and even on the day of the procedure. It does not have to be completed prior to scheduling the procedure.”

UPDATE 5/18/2009

(Finalized October 30, 2008)

The OPPS/ASC (Outpatient Prospective Payment System for Ambulatory Surgery Centers) final rule modernizes Medicares ASC Conditions for Coverage (CfC). The rule reflects current ASC practice by focusing on the care provided to patients and th impact of that care on patient outcomes. Specifically, the new CfCs:

• Define an ASC as a distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization and in which the expected duration of services would not exceed 24 hours following admission.

• Strengthen Patients rights regarding disclosure of physician financial interests in the ASC; advance directives; the grievance process; and confidentiality of clinical records.

• Impose stronger obligations on the governing body of an ASC to oversee its quality assessment and performance improvement (QAPI) program, while allowing ASCs flexibility to use their own information to assess and improve patient services, outcomes, and satisfaction.

• Emphasize the importance of infection control practices.

• Strengthen the requirements for assessing the patients condition at admission to verify that the surgery is appropriate and safe for the patient in an ASC setting, and at discharge to ensure appropriate post-surgical care for the patient.

• Require the ASC to adopt a disaster preparedness plan.

By Carla Hannibal, CMM,CPM,CIMBS

Recovery Audit Contractors (RACs) will pursue corrections of Medicare claims by auditing for overpayments and underpayments under Part A or B of the title XVIII of the Social Security Act. Health care providers will be affected as Medicare has recently contracted with RACs for 2009 and beyond. RACs will audit every United States and Peurto Rico health care provider who files with Medicare. The audit and recovery plan is expected to be in place by (more…)

From today’s US News & World Report:

This is the fourth year that U.S. News and the National Committee for Quality Assurance, managed care’s major accrediting and standards-setting body, have teamed up to rank healthcare plans. We release the rankings during open-enrollment season, when millions of Americans prepare to select their healthcare coverage for the next year.

How were plans rated?

The rankings … show how well plans do at preventing and treating illness and providing consumer services to members.

How is consumer service defined?

(Measures) …included members’ opinions about the ease of making appointments and getting care, doctors’ ability to communicate effectively, and satisfaction with claims handling.

I find these measures particularly interesting as only “satisfaction with claims handling” is a measure of the plan. “Making appointments” and “doctors’ ability to communicate effectively” are services provided by the participating physician, unless the physicians are employed by the plan. I would like to see measurements of plans be more along the lines of:

• clarity of plan details communicated to subscribers and physicians;
• ability of plan agents to communicate with consumers and physician offices about routine issues and priority issues;
• ability of the plan to provide the physician office (preferably electronically) with pre-authorizations and pre-notifications for services, procedures, surgeries, and implants in a timely and efficient manner. These functions, which are very critical to getting patients needed services in a timely and efficient manner, are not usually considered to be a part of the claims handling process.
• ability of the physician offices to obtain (electronic) information on individual plan benefits by subscriber or beneficiary OR electronic adjudication of the patient’s visit that day;
• ability of the payer to provide the physician office with info for giving patients real quotes on tests, therapies, procedures and surgeries so that patients can make informed decisions about the cost of their care prior to having a service.

I know that to measure this, the plans would have to collect data from the physician offices (and some do), and publish this (none do that I know of.) Kudos to any plans doing this (and write to me and tell me if they/you are) because it acknowledges that the physicians are stakeholders and are a critical part in satisfying consumers.

Medical Group Management Association (MGMA) recently sponsored a survey ..” to assess group practice professionals’ attitudes concerning payers in all 50 states.” Members who participated will receive a copy of the survey for responses from their state.

More on NCQA:

With the Centers for Medicare and Medicaid Services (CMS) revealing yesterday what the Medicare premiums and deductibles will be for 2009, it seems like a good time to brush up on Medicare and what choices providers have in enrolling and participating in Medicare.

Medicare is a health insurance program created in 1965 for:

• people age 65 or older,
• people under age 65 with certain disabilities, and
• people of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)

TRADITIONAL/ORIGINAL FEE-FOR-SERVICE MEDICARE

Medicare Part A - 99% of patients don’t pay a premium for Part A (hospital insurance) because they or a spouse already paid for it through their payroll taxes while working. The $1,068 deductible for 2009, paid by the beneficiary when admitted as a hospital inpatient, is an increase of $44 from $1024 in 2008. Part A helps cover:

• inpatient care in hospitals
• including critical access hospitals
• skilled nursing facilities (not custodial or long-term care)
• some hospice care
• some home health care

Medicare Part B – Part B (outpatient/doctor insurance) base premium for 2009: $96.40/month (no change from 2008.) Premiums are higher for single people over 65 making more than $85K per year and for couples making over $170K. Part B premiums cover approximately one-fourth of the average cost of Part B services incurred by beneficiaries aged 65 and over. The remaining Part B costs are financed by Federal general revenues. In 2009, the Part B deductible will be $135, the same as it was in 2008. Part B helps cover:

• doctors’ services and outpatient care
• some services of physical and occupational therapists
• some home health care

Medicare Part D - Starting January 1, 2006, Medicare prescription drug coverage became available to everyone with Medicare. In 2008, the deductible is $275, in 2009 it will be $295.

MEDICARE HEALTH PLANS (MEDICARE ADVANTAGE)

Medicare Part C – Medicare now offers beneficiaries the option to have care paid for through private insurance plans. These private insurance options are part of Medicare Part C, which was previously known as Medicare+Choice, and is now called Medicare Advantage. Medicare Advantage expands options for receiving Medicare coverage through a variety of private insurance plans, including private fee-for-service (PFFS) plans, health maintenance organizations (HMOs) and preferred provider organizations (PPOs), and through new mechanisms such as medical savings accounts (MSAs), as well as adding payment for additional services not covered under Part A or B.

COMPARISON OF MEDICARE PLANS

Original Medicare Plan

WHAT? The traditional pay-per-visit (also called fee-for-service) arrangement available nationwide.

HOW? Providers can choose to participate (“par”) or not participate (“non-par”.) Participating providers accept the Medicare allowable and collect co-insurance (20% of the allowable.) Reimbursement comes to the providers. Non-participating providers may charge 15% more (called the “limiting” charge) than the Medicare allowable schedule, but the patient will receive the check, which is why some non-par practices require payment at time of service for Medicare patients. To charge patients for non-covered services, patients must sign an ABN before the service is provided.

Original Medicare Plan With Supplemental Medigap Policy

WHAT? The Original Medicare Plan plus one of up to ten standardized Medicare supplemental insurance policies (also called Medigap insurance) available through private companies.

HOW? Medigap plans may cover Medicare deductibles and co-insurance, but typically will not cover anything Medicare will not. Medicare primary claims will “cross-over” to many Medigap secondary claims so the practice does not have to file the secondary Medigap claim. Patients may still have a small balance that is cost-prohibitive to bill for.

Medicare Coordinated Care Plan

WHAT? A Medicare approved network of doctors, hospitals, and other health care providers that agrees to give care in return for a set monthly payment from Medicare. A coordinated care plan may be any of the following: a Health Maintenance Organization (HMO), Provider Sponsored Organization (PSO), local or regional Preferred Provider Organ. (PPO), or a Health Maintenance Organization with a Point of Service Option (POS).

HOW? You have to have signed a contract or be grandfathered in (called an “all-products” clause) under an existing contract to see patients and get paid. Primary care providers may have to provide referrals and/or authorization for specialty services and providers. A PPO or a POS plan usually provides out of network benefits for patients for an extra out-of pocket cost.

Private Fee-For-Service Plan (PFFS)

WHAT? A Medicare-approved private insurance plan. Medicare pays the plan a premium for Medicare-covered services. A PFFS Plan provides all Medicare benefits. Note: This is not the same as Medigap.

HOW? Most PFFS plans allow patients to be seen by any provider who will see them. PFFS plans do not have to pay providers according to the Medicare fee schedules or pay in 15 days for clean claims. Providers may bill patients more than the plan pays, up to a limit. It would be a good thing to notify patients if your practice intends to bill above the plan payment.

Need more? Try CMS or Medicare.