Client Alerts
December 2011

CMS Initiates 90-Day Enforcement Discretion for 5010 Compliance
The Center for Medicare & Medicaid Services (CMS) recently announced that enforcement of the version 5010 HIPAA transaction standards will be delayed until March 31, 2012.  The official deadline to implement the standards remains January 1, 2012. However, CMS will not begin enforcement for 90 days to allow HIPAA-covered entities an opportunity to fine-tune their systems, according to a CMS press release.

The CMS stated that its decision was based on industry feedback revealing that, with only about 45 days remaining before the compliance date, testing between some covered entities and their trading partners has not yet reached a threshold whereby a majority of covered entities would be able to be in compliance by January 1.

The CMS indicated that while enforcement action would not be taken until March 31, OESS will continue to accept complaints associated with compliance with version 5010. Entities that are the subject of complaints must produce evidence of either compliance or a good faith effort to become compliant with the new version 5010 standards.

Medicare Skilled Nursing Facility Refund Request Error
Some healthcare providers have received letters from Medicare requesting a refund of payments made for services administered at a skilled nursing facility. The letters were generated due to a Medicare system error. Medicare has been flooded with phone calls about the problem. Unfortunately, Medicare’s customer service representatives have not been provided detailed information on how these claims are going to be resolved.

This Medicare error only impacts refund requests identified as overpaid based on the following:  “Based on Medicare Policy, within a Skilled Nursing Facility are subject to consolidated billing and should not be paid separately.” These services for which refunds are being requested are NOT subject to consolidated billing and should be reimbursed.

KeyMed Partners has investigated the issue and contacted Medicare to determine the best course of action to resolve the error. Medicare is advising that healthcare providers challenge the request for refund by submitting a Redetermination Form for each instance where a refund request was issued in error.

It is critical that challenges to the request for refunds be handled immediately to avoid offsets. Even though this is a Medicare system error, KeyMed Partners has  been told by Medicare that the claims will be offset unless they receive a challenge to the overpayment refund request.  If you would like KeyMed Partners to assist you with submitting Redetermination Forms, please provide us with the letter from Medicare. It has important information that must be included in order for the claim to be processed properly.
Download Medicare redetermination request form.

New Medicare Deductible
For calendar year 2012 there will be changes to the Medicare rates for deductibles, coinsurance and premium payments. Under Part B of the Supplementary Medical Insurance (SMI) program, all enrollees are subject to a monthly premium. Most SMI services are subject to an annual deductible and coinsurance (percent of costs that the enrollee must pay), which are set by statute. When Part B enrollment takes place more than 12 months after a person’s initial enrollment period, there is a permanent 10 percent increase in the premium for each year the beneficiary could have enrolled and failed to enroll.

•  Standard Premium: $99.90 a month
•  Deductible: $140.00 a year
•  Coinsurance: 20 percent

In addition, some beneficiaries may pay higher premiums based on their incomes. These amounts change each year. There may be a late-enrollment penalty.

Therapy Cap Values
The Centers for Medicare & Medicaid Services (CMS) has established the policy for outpatient therapy caps for Calendar Year 2012. Therapy caps for 2012 will be $1880.00. The Balanced Budget Act of 1997, P.L. 105-33, Section 4541(c) set annual caps for Part B Medicare patients. These limits change annually.

 The Deficit Reduction Act of 2005 directed the Secretary to implement a process for exceptions to therapy caps for medically necessary services. The Affordable Care Act extended the exceptions to therapy caps through December 31, 2010; and, the Medicare and Medicaid Extenders Act (MMEA) of 2010 extended the therapy caps exceptions through CY 2011. The exceptions process will continue unchanged for the time frame directed by Congress.

Note that the therapy caps apply to outpatient services and do not apply to Skilled Nursing Facility (SNF) residents in a covered Part A stay, including swing beds. Rehabilitation services are included within the global Part A per diem payment that the SNF receives under the prospective payment system (PPS) for the covered stay. Also, therapy caps do not apply to any therapy services billed under the home Health PPS, inpatient hospitals, or the outpatient department of hospitals, including critical access hospitals.

No Change For Direct Data Entry
In the initial Final Rule for Standards for Electronic Transactions, direct data entry was defined as “direct entry of data (for example, using dumb terminals or web browsers) that is immediately transmitted into a health plan’s computer.” An exception for direct data entry was later articulated in the August 17, 2000, Final Rule: A health care provider electing to use direct data entry offered by a health plan to conduct a transaction for which a standard has been adopted under this part must use the applicable data content and data condition requirements of the standard when conducting the transaction. The healthcare provider is not required to use the format requirements of the standard.

Subsequent modifications to the HIPAA Final Rules, published January 16, 2009, addressed direct data entry, but did not alter the definition and exception for use. The January 2009 version of Final Rule provided the following response in the preamble: “One commenter requested that we address expectations related to [CFR] Section 162.925[b] regarding health plan incentives to healthcare providers for using direct data entry (DDE) transactions. The commenter said there are instances where health plans offer more information about eligibility and benefit information on web sites than they do through the standard X12 270/271 transactions, which the commenter believes is an incentive for a provider to conduct a transaction using some means other than the standard transaction. The commenter requested clarification regarding the offer of more information through a non-standard transaction, even though the standard transaction contains the required amount of information. Since we [HHS] did not address this issue in the proposed rule, we [HHS] do not respond here, but may provide additional direction in a future Frequently Asked Question [FAQ] on the CMS website.”

KeyMed Partners Launches New Website
Visit www.KeyMedPartners.com

KeyMed Partners recently launched a totally revamped website. The new site offers extensive information on KeyMed’s full range of medical billing and A/R management services and our approach to increasing revenues and improving cash flow for our clients.

The News & Resources section of the site provides recent industry news, articles of interest and information about upcoming conferences. KeyMed will also be offering regular client alerts with time-sensitive information.

“Our clients are utilizing the web for information. They want 24-hour access to industry information as well as information about services that we offer,” said Joni Long, Vice President. “We improved the navigation to make things easier for visitors to find and added more detailed information.“