DME MAC Provider Outreach Collaboration

Transcription

1 DME MAC Provider Outreach Collaboration Participating vs. Nonparticipating Suppliers Assigned vs. Nonassigned Claims Frequently Asked Questions 2016 Copyright, CGS Administrators, LLC. Created December

2 Presenters Kari O Hara Noridian Healthcare Solutions Jurisdiction A Charity Bright CGS Administrators, LLC Jurisdiction B Michael Hanna CGS Administrators, LLC Jurisdiction C Cindy White Noridian Healthcare Solutions Jurisdiction D 2016 Copyright, CGS Administrators, LLC. Created December

3 Agenda Mandatory Claim Submission Participating vs. Nonparticipating Supplier Mandatory Assignment / Fragmented Billing Documentation Requirements Resources Questions 2016 Copyright, CGS Administrators, LLC. Created December

4 Mandatory Claim Submission 2016 Copyright, CGS Administrators, LLC. Created December

5 Mandatory Claim Submission Section 1848 (g) (4) of the Social Security Act requires physicians and suppliers to submit claims for covered items and services Applies to all physicians and suppliers who provide item and services to Medicare beneficiaries May not charge the beneficiary for preparing or filing the Medicare claim. Providers and suppliers are not required to submit claims for the following: Used DME purchased from a private source Third party biller claims Foreign claims Medicare as a secondary payer (MSP) claims, when a provider does not possess information necessary for filing an MSP claim 2016 Copyright, CGS Administrators, LLC. Created December

6 Mandatory Claim Submission (cont.) Suppliers are not required to submit claim for noncovered services Unless beneficiary requests a claim be submitted, if so the supplier must submit a claim Timely Filing Must be filed within one calendar year after the date of service Timely filing denials May only charge the beneficiary for the deductible, 20% coinsurance, and/or noncovered services if claim is denied due to timely filing. Violations May be subject to civil monetary penalties of up to $10, 000 per violation 2016 Copyright, CGS Administrators, LLC. Created December

7 Frequently Asked Question If a supplier is not accredited for a particular product category can the supplier provide the item as a cash sale, collect payment from the beneficiary and not submit the claim to Medicare? Response: An Advance Beneficiary Notice (ABN) must be executed as the supplier number requirements are not met. The ABN should indicate the reason that Medicare will not pay so that the beneficiary may make an informed consumer decision. The beneficiary would then need to pay out-of-pocket for the item and no claim would be filed to Medicare Copyright, CGS Administrators, LLC. Created December

8 Participating vs. Nonparticipating 2016 Copyright, CGS Administrators, LLC. Created December

9 Participating Suppliers What is a participating supplier? A supplier who agrees to accept assignment on all services for Medicare beneficiaries A supplier who agrees to accept the Medicare allowed amount as payment in full Only collects deductible, 20% coinsurance, and statutorily noncovered services Medicare payment is sent to the supplier 2016 Copyright, CGS Administrators, LLC. Created December

10 Nonparticipating Suppliers What is a nonparticipating supplier? A supplier who has the choice of submitting claims either assigned or nonassigned Collects deductible, 20% coinsurance, and statutorily noncovered services May bill beneficiary for the difference between the submitted amount and Medicare allowed amount Medicare payments sent to the beneficiary when billed nonassigned 2016 Copyright, CGS Administrators, LLC. Created December

11 Frequently Asked Question Is there a limit on how much a supplier can charge for an item when billing nonassigned? Response: Limiting charge does not apply to DMEPOS items because they are not paid under the Physician Fee Schedule. A supplier who chooses not to accept assignment of Medicare benefits are not a party to the Medicare payment transaction between Medicare and the Medicare beneficiary. Therefore, Medicare cannot issue any guidance on what a supplier can charge when billing nonassigned Copyright, CGS Administrators, LLC. Created December

12 Participation Agreement Complete CMS-460 Participating Physician or Supplier Agreement form Within 90-days of initial enrollment During annual open enrollment period Signed by Authorized or Delegated Official on file with the National Supplier Clearinghouse Participation agreement is valid for a 12-month period Begins January 1 of each calendar year Participation status is associated with tax ID and not location Suppliers with multiple locations under the same tax ID cannot have different participation statuses 2016 Copyright, CGS Administrators, LLC. Created December

13 Frequently Asked Question Is participation status associated with an entity or is it associated with location? Response: Participation status is associated with an entity (tax ID number) and not a location. Per the National Supplier Clearinghouse (NSC) website: A business entity with multiple locations under the same tax ID number cannot choose to have different participation statuses for each location. All locations will automatically be assigned the same status (participating or nonparticipating) depending on what the entity has chosen Copyright, CGS Administrators, LLC. Created December

14 2017 Participation Open Enrollment Period 2017 Annual Participation Open Enrollment Period Begins mid-november - December 31, 2016 No change in status No action necessary, status will remain the same Nonparticipating status to participating status: Submit a completed and signed CMS-460 Participation Agreement Authorized or Delegated Official on file with NSC must sign Submit to NSC by December 31, 2016 Participating status to non participating status: Submit a request on your company's letterhead Authorized or Delegated Official on file with NSC must sign 2016 Copyright, CGS Administrators, LLC. Created December

15 Advantages of Participating Medicare pays you directly; you only need to collect the 20% coinsurance and deductible from the patient. Medicare will automatically forward Medigap claims to the proper insurer for payment. Participation improves relationships with beneficiaries because it reduces their out-of-pocket expenses Copyright, CGS Administrators, LLC. Created December

16 Mandatory Assignment / Fragmented Billing 2016 Copyright, CGS Administrators, LLC. Created December

17 Mandatory Assignment for Covered Drugs Billed to Medicare Section 114 of the Benefits Improvement and Protection Act of 2000 (BIPA) Mandatory assignment applies to Medicare-covered drugs Claims billed as unassigned will be processed as assigned Suppliers may not bill charges to any beneficiary beyond the Medicare Part B deductible and coinsurance Does not apply to dispensing fees 2016 Copyright, CGS Administrators, LLC. Created December

18 Mandatory Assignment for DMEPOS Competitive Bidding Program Claims All DMEPOS Competitive Bidding Program claims are subject to mandatory assignment. Contract suppliers can choose to be participating or nonparticipating suppliers May submit nonassigned claims for non competitively bid items Noncontract suppliers must accept assignment for competitively bid items Traveling beneficiaries Grandfathering 2016 Copyright, CGS Administrators, LLC. Created December

19 Frequently Asked Question Is it appropriate for a nonparticipating supplier to submit a nonassigned claim for a dually eligible (Medicare/Medicaid) Medicare beneficiary? Response: No, it would not be appropriate. Dually eligible Medicare beneficiary claims must be billed as assigned Copyright, CGS Administrators, LLC. Created December

20 Violation of Assignment Physician/Supplier is in violation in any of the following circumstances: Collects or attempts to collect from the beneficiary or any other person any amount exceeding the Medicare allowed amount Charges enrollee for paperwork involved in filing an assigned claim Penalties of Violation of Assignment Agreement may include: Criminal and civil monetary penalties Exclusion from the Medicare program or state health care programs 2016 Copyright, CGS Administrators, LLC. Created December

21 Fragmented Billing Nonparticipating supplier Accepts assignment for some services and requests payment from beneficiary for other services when services are performed at the same place and on the same occasion. May choose to accept assignment on a claim by claim basis but decision applies to all services performed at the same place and on the same occasion Copyright, CGS Administrators, LLC. Created December

22 Fragmented Billing Exception Mandatory Assignment Situations Supplier may choose to not accept assignment for other services at the same place or occasion 2016 Copyright, CGS Administrators, LLC. Created December

23 Frequently Asked Question In overutilization situations where the beneficiary doesn t meet coverage criteria, would it be considered fragmented billing to bill what is reasonable and necessary as assigned and the amount that is not reasonable and necessary as nonassigned? Response: Yes, this would be considered fragmented billing because all of the items are being provided at the same place and on the same occasion. However, in some cases you may be able to execute an ABN and bill using upgrade modifiers for any amount in excess of what is reasonable and necessary Copyright, CGS Administrators, LLC. Created December

24 Frequently Asked Question Can an oxygen supplier switch assignment anytime during the five-year period? Response: Nonparticipating suppliers may accept assignment on a claim by claim basis. 42 CFR Section (g)(3) requires that before furnishing oxygen equipment, the supplier must disclose to the beneficiary it s intentions as to whether it will or will not accept assignment of all monthly rental claims for the duration of the rental period Copyright, CGS Administrators, LLC. Created December

25 Documentation Requirements 2016 Copyright, CGS Administrators, LLC. Created December

26 Beneficiary Authorization All DMEPOS claims (assigned and nonassigned) require a signed beneficiary authorization Once the supplier has obtained the patient's one-time authorization, later claims for those same services can be filed without obtaining an additional signature from the patient. Any supplier using the one-time authorization procedure agrees to the following: Authorization must be renewed if a new item is rented or purchased. Retaining the signed and dated one-time payment authorization form in the supplier's file. The one-time authorization applies to assigned or nonassigned claims with the exception of DME rentals. The one-time authorization for DME rental claims is limited to assigned claims. The supplier would be unable to bill Fee-For-Service Medicare if there is not an authorization Copyright, CGS Administrators, LLC. Created December

27 Frequently Asked Question Question: Is it acceptable to have the beneficiary sign all authorizations when initially dispensing the rental equipment? Response: No. Non assigned DME rental claims require a separate authorization for payment of each claim. Allowing the beneficiary to sign all authorizations at the initial issuance of the equipment would cause significant risk for suppliers and beneficiaries. Therefore, each request for payment needs to be signed in coordination with the applicable rental claim Copyright, CGS Administrators, LLC. Created December

28 Frequently Asked Question What are the documentation requirements for the supplier when submitting a nonassigned claim? Response: The Medicare documentation requirements are the same regardless of whether a claim is submitted as assigned or nonassigned. If a nonassigned claim is stopped for review (either pre-pay or post-pay) the supplier is responsible for responding to the entity and providing documentation. In addition, a nonassigned claim may be denied as Contractual Obligation and the supplier held responsible for the payment Copyright, CGS Administrators, LLC. Created December

29 Advance Beneficiary Notice of Noncoverage An ABN should be issued prior to dispensing an item or service expected to be disallowed for the following reasons: Lack of medical necessity Prohibited, unsolicited telephone contacts Supplier number requirements not met Denial of an Advanced Determination of Medicare Coverage (ADMC) request Noncontract supplier furnishing competitively bid DMEPOS items in a competitive bid area (CBA) 2016 Copyright, CGS Administrators, LLC. Created December

30 Refund Requirements Refund requirements apply to assigned and nonassigned claims for DMEPOS services disallowed due to one of the following reasons mentioned on the previous slide. Refund requirements state that suppliers must make refunds of any amounts collected if the beneficiary was not properly notified of possible disallowed Medicare claims. The refund requirement provisions require that the beneficiary is notified and agrees to be financially liable Copyright, CGS Administrators, LLC. Created December

31 Resources 2016 Copyright, CGS Administrators, LLC. Created December

32 Contacts Jurisdiction A Provider Contact Center Jurisdiction B Provider Contact Center Jurisdiction C Provider Contact Center Jurisdiction D Provider Contact Center Copyright, CGS Administrators, LLC. Created December

33 Questions 2016 Copyright, CGS Administrators, LLC. Created December

34 Thank You 2016 Copyright, CGS Administrators, LLC. Created December

35 Disclaimer The presentation herein was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference. The presentation herein was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. The Centers for Medicare & Medicaid Services (CMS) employees and agents, including CGS and its staff, make no representation, warranty, or guarantee that this compilation of Medicare information is error free and will bear no responsibility or liability for the results or consequences of the use of this guide. This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. Official Medicare Program provisions are contained in relevant laws, regulations, and rulings Copyright, CGS Administrators, LLC. Created December