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Medicare Part B Presents: Medicare Updates 2013

Office Managers Meeting

January 17, 2013

All Current Procedural Terminology (CPT) codes and descriptors used in this presentation are copyright© by the American Medical Association. All rights reserved.

The information enclosed was current at the time it was presented. Medicare policy changes frequently; links to the source documents have been provided within the document for your reference. This presentation 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.

Novitas Solutions employees, agents, and 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 presentation is a general summary that explains certain aspects of the Medicare program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings.

Novitas Solutions does not permit videotaping or audio recording of training events.

Disclaimer

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Medicare Administrative Contractor (MAC)

Jurisdiction 12 and Jurisdiction H

◦ Medicare Part B

J12 - Delaware, District of Columbia (DC), Maryland, New

Jersey, and Pennsylvania; and

JH – Arkansas, Louisiana, Mississippi, Colorado, New Mexico,

Oklahoma and Texas

Novitas Solutions

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Comprehensive Error Rate Testing Program

Contractor Updates

New Quarterly Updates

Recurring Updates/Reminders

Medicare Initiatives and Incentive Programs

Preventive Services

Fraud Prevention

Self Service Options

Agenda

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Provide a clear understanding of the changes in Medicare and to assist the provider community in complying with new guidelines by providing educational information and resources

Explain the Comprehensive Error Rate Testing (CERT) Program and provide tips in preventing the most frequent errors

Identify and promote the use of self service options and preventive services

Objectives

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Comprehensive Error Rate Testing (CERT)

Program

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National Claim Paid Error Rate: ◦ 9.2 % Physician/Lab /Ambulance

Impacts all providers submitting Fee for Service claims

Limited random claim sample

Record requests must be received within 30 days from the initial CERT letter

Right to Appeal? Yes

Comprehensive Error Rate Testing (CERT)

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Insufficient documentation: ◦ Missing documentation requirements to support the need for a service based on a related Local

Coverage Determination (LCD) specifically Chiropractic Services, Physical and Occupational Therapy services;

◦ Medical Record Documentation and/or physician signature was missing or was not legible; ◦ Medical record was missing the operative report to support the medical necessity and intent for the

procedure requiring pathology services;

◦ Medical record lacked sufficient documentation to support the medical necessity of the procedure/service performed;

◦ Medical record did not contain a valid physician’s order, documented order intent or clinical indication for the service;

◦ No documentation of the physical therapy certified plan of care; ◦ Documentation that did not support the Internal Classification of Disease (ICD-9) Code billed; and

◦ Documentation that did not adequately describe the service defined by the reported Current Procedural Terminology (CPT) code or Healthcare Common Procedure Coding System (HCPCS) code.

Medical necessity errors: ◦ Medical record documentation did not support the medical necessity for an annual Pap smear for a

beneficiary that was not at a high risk for cervical cancer;

◦ Medical record documentation did not support the medical necessity for an Electrocardiography (ECG) to be performed;

◦ Medical record lacked sufficient documentation to support the medical necessity of the procedure/service performed; and

◦ Related services that were required as a result of the primary service were denied because the medical necessity of the primary service was not justified, e.g. venipuncture.

Incorrect coding errors: ◦ Documentation did not substantiate the level of care billed based on one or more of the key

components (history, exam, medical decision making); ◦ Requirements for critical care, discharge day management, ambulance and infusion services,

Electroencephalograms (EEGs), dialysis services and Mohs Micrographic surgeries were not met.

Common Errors

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Medical Record Requests

Common Errors

Articles and Frequently Asked Questions

References and Contact Information

https://www.novitas-solutions.com/cert/index.html

Comprehensive Error Rate Testing (CERT) Center

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Contractor Updates

Changes and Updates Specific to Novitas Solutions

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New Medical Policy Center

New Medical Policy Search

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New Fee Schedules Center

Part B Redetermination Requests may be faxed

Complete and print the online redetermination request form (use as fax cover sheet) ◦ https://www.novitas-solutions.com/partb/forms/pdf/partb-

redeterm-form.pdf

Sign the request form and include the claim number

Limit 1 request per claim, not to exceed 200 pages

1-888-541-3829 ◦ Available 24 hours a day, 7 days a week

Part B Redeterminations- Fax Option

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New Quarterly Updates

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New Multiple Procedure Payment Reductions (MPPR)

Change Request #7848 ◦ Effective: January 1, 2013 Implementation: January 7, 2013

Key Points: ◦ New Payment reduction for the technical component (TC)

of diagnostic cardiovascular and ophthalmology procedures

◦ Applies when multiple procedures are furnished to the same patient on the same date of service

◦ Does not apply to the professional component( PC)

For more information: ◦ http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2012-

Transmittals-Items/R1149OTN.html

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Cardiovascular services, full payment is made for the TC service with the highest payment under the MPFS. Payment is made at 75 percent for subsequent TC services furnished by the same physician (or by multiple physicians in the same group practice, i.e., same Group National Provider Identifier (NPI)) to the same patient on the same day.

Ophthalmology services, full payment is made for the TC service with the highest payment under the MPFS. Payment is made at 80 percent for subsequent TC services furnished by the same physician (or by multiple physicians in the same group practice, i.e., same Group NPI) to the same patient on the same day.

The MPPRs apply to TC services and to the TC of global services.

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2012-Transmittals-Items/R1149OTN.html

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7848.pdf

New Multiple Procedure Payment Reductions (MPPR)

National Coverage Determination (NCD) for Transcatheter Aortic Valve Replacement (TAVR) Change Request #7897

◦ Effective: May 1, 2012 Implementation: January 7, 2013

Key Points: ◦ A NCD was issued covering TAVR under Coverage with Evidence

Development (CED)

◦ When the procedure is furnished for the treatment of symptomatic aortic stenosis and according to an FDA-approved indication for use with an approved device, CED requires that each patient be entered into a qualified national registry or participate in a qualifying clinical study

For More Information: ◦ http://www.cms.gov/Regulations-and-

Guidance/Guidance/Transmittals/2012-Transmittals-Items/R147NCD.html

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New CLIA Waived Tests

Change Request # 8054 ◦ Effective: January 1, 2013 Implementation: January 7, 2013

Key Points: ◦ Latest tests approved by the Food and Drug Administration

(FDA) as waived tests under the Clinical Laboratory Improvement Amendments of 1998 (CLIA)

For more information: ◦ http://www.cms.gov/Regulations-and-

Guidance/Guidance/Transmittals/Downloads/R2553CP.pdf

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Upcoming Changes

Change Request 7786- Expand Place of Service Address to Include Full Address ◦ Implementation Date: April 1, 2013 ◦ For more information:

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2012-Transmittals-Items/R1111OTN.html

Posting the Limiting Charge after Applying the e-Prescribing (eRx) Negative Adjustment ◦ Implementation Date: January 7, 2013 ◦ For More Information:

http://www.cms.gov/Regulations-and Guidance/Guidance/Transmittals/2012-Transmittals- Items/R1106OTN.html

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Change Request #7794

Effective: July 1,2012, Implementation: October 1,2012

Key Points: ◦ Medicare will pay for influenza virus vaccine code Q2034

(Influenza virus vaccine, split virus, for intramuscular use (Agriflu))

◦ Annual Part B deductible and coinsurance amounts do not apply

◦ Contractors will add influenza virus vaccine code Q2034 to existing influenza virus vaccine edits

For More Information: ◦ http://www.cms.gov/Regulations-and-

Guidance/Guidance/Transmittals/2012-Transmittals-Items/R2446CP.html

New Influenza Virus Vaccine Code

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Change Request #7900 ◦ Effective: January 1, 2013 Implementation: January 7, 2013

Key Points ◦ Eight new services and are being added for 2013

◦ Eight revised Current Procedure Terminology (CPT) codes to replace existing CPT codes that are being deleted in 2013

For more information: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2012-Transmittals-Items/R2606CP.html

Expansion of Medicare Telehealth Services in 2013

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Change Request #8111 ◦ Effective date: January 1, 2013

◦ Implementation date: January 7, 2013

Key Points: ◦ Additional modifiers have been added to the list

of NCCI-associated modifiers

◦ NCCI-associated modifiers should NOT be used to bypass an NCCI edit unless the proper criteria for use of the modifier are met

National Correct Coding Initiative (NCCI) Associated Modifier Changes (Additions)

Additional NCCI Modifiers: ◦ LM (left main coronary artery)

◦ RI (ramus intermedius)

◦ 24 (unrelated evaluation and management service by the same physician during a postoperative period)

◦ 57 (decision for surgery)

For more information: ◦ http://www.cms.gov/Regulations-and-

Guidance/Guidance/Transmittals/Downloads/R1136OTN.pdf

National Correct Coding Initiative (NCCI) Associated Modifier Changes (Additions)

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National Correct Coding Initiative (NCCI) The Centers for Medicare & Medicaid Services (CMS)

developed NCCI to: ◦ Promote national correct coding methodologies ◦ To control improper coding

Columns One/Column Two Correcting Coding edit file ◦ Hospital CCI edit ◦ Physician CCI edit

Applies to Bill ◦ By the same physician or provider ◦ For the same beneficiary ◦ On the same date of service

Use modifiers to report special circumstances

http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html

Column One/Column Two Correct Coding Edit File

Column 1 Column 2

*=In

existence

prior to

1996

Effective

Date

Deletion

Date

*=no data

Modifier

0=not allowed

1=allowed

9=not

applicable

97150 97532 20020401 * 1

97150 97533 20020401 * 1

97150 97535 19970401 * 1

97150 97537 19970401 * 1

97150 97542 19970401 * 1

97150 97760 20060101 * 1

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Change Request #8052 ◦ Effective: January 1, 2013 Implementation: January 7, 2013

Part B ◦ Deductible $147.00, Coinsurance 20%

Part A ◦ Deductible $1,184.00

◦ Coinsurance

$296.00 a day for 61st-90th day

$592.00 a day for 91st-150th day (lifetime reserve)

$148.00 a day for 21st-100th day (Skilled Nursing Facility)

For more information: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2012-Transmittals-Items/R81GI.html

2013 Deductibles and Coinsurance

Change Request #8129 ◦ Effective: January 1, 2013

◦ Implementation January 7, 2013

Key Points ◦ $1,900 combined for Physical Therapy and

Speech-Language Therapy

◦ $1,900 for Occupational Therapy

Fore more information: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2012-Transmittals-Items/R2600CP.html

2013 Therapy Cap Values

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Pre-Approvals No Longer Necessary

An Additional Development Request will be sent for Date of Services 10/1/2012 thru 12/31/2012

No Plans for Pre-Approval for 2013 ◦ Pub. 100-02, Medicare Benefit Policy Manual,

Chapter 15, section 220

◦ Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, section 3.3.1.3

◦ Pub.100-04, Medicare Claims Processing Manual, Chapter 5, section 20

2012 Manual Medical Review of Therapy Services

Change request# 8126 ◦ Effective: January 1, 2013

◦ Implementation: January 7, 2013

Key Points: ◦ Updates the list of codes that sometimes or always

describe therapy services

◦ Sometimes therapy codes:

G0456- Neg pres wound < 50 sq cm

G0457- Neg pres wound > 50 sq cm

◦ 42 HCPCS have been added to the “always therapy” list http://www.cms.gov/Outreach-and-Education/Medicare-Learning-

Network-MLN/MLNMattersArticles/Downloads/MM8126.pdf

2013 Annual Update to the Therapy Code List

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Change Request (CR) #8005 ◦ Effective: January 1, 2013 Implementation: January 7, 2013

Key Points ◦ New claims-based data reporting

◦ 42 New G-codes, to report patient function

◦ 8 New Modifiers, to describe severity

For more information: ◦ http://www.cms.gov/Regulations-and-

Guidance/Guidance/Transmittals/2012-Transmittals-Items/R2603CP.html

MM8005 - http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8005.pdf

New Claim-Based Therapy Reporting Requirements

Change Request #7631

Effective: April 1, 2013, Implementation: April 1, 2013

Key Points:

◦ Adds special considerations provisions regarding use of POS codes 22 and 24, for outpatient hospitals and Ambulatory Surgery Centers

◦ The POS code to be used by the physician and other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service

◦ Two (2) exceptions to this face-to-face provision/rule in which the physician always uses

the POS code where the beneficiary is receiving care as a hospital inpatient or an outpatient of a hospital, regardless of where the beneficiary encounters the face-to-face service

◦ In cases where the face-to-face requirement is obviated such as those when a physician/practitioner provides the PC/interpretation of a diagnostic test, from a distant site, the POS code assigned by the physician /practitioner will be the setting in which the beneficiary received the TC of the service

For more information: ◦ http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNMattersArticles/downloads/MM7631.pdf

Revised and Clarified Place of Service (POS) Coding Instructions

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Medicare learning Network (MLN) Matters Special Edition Article SE1226

SE1226: Reminder of Importance of Correct Place of Service Coding on Medicare Part B Claims

Medlearn Matters MLN SE1226

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1226.pdf

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Medicare learning Network (MLN) Matters Special Edition Article SE1226 Physicians are required to identify the

place-of-service on the health insurance claim forms that they submit to Medicare contractors. The correct place-of- service code ensures that Medicare does not incorrectly reimburse the physician for the overhead portion of the payment if the service was performed in a facility setting.

Overview of place of service coding https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html

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Effective Date: April 1, 2013

Implementation Date: April 1, 2013

Updates the current Place of Service (POS) code set to add a new code:

18 – Place of Employment/Worksite

Medicare learning Network (MLN) Matters Article MM8125

Place of Employment/Worksite –

A location, not described by any other POS code, owned or operated by a public or private entity where the patient is employed, and where a health professional provides on-going or episodic occupational medical, therapeutic, or rehabilitative services to the individual.

Place of Service Code 18

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Change Request # 7600

Effective: April 1, 2012 Implementation: October 1, 2012

Key Points:

◦ New physician specialty codes for Sleep Medicine (C0) and Sports Medicine (23)

For more information: ◦ http://www.cms.gov/Regulations-and-

Guidance/Guidance/Transmittals/2012-Transmittals-Items/R2462CP.html

New Physician Specialty Code for Sleep Medicine and Sports Medicine

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Upcoming Changes

Change Request 7786- Expand Place of Service Address to Include Full Address ◦ Implementation Date: April 1, 2013

◦ For more information: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2012-Transmittals-Items/R1111OTN.html

Posting the Limiting Charge after Applying the e-Prescribing (eRx) Negative Adjustment ◦ Implementation Date: January 7, 2013

◦ For More Information:

◦ http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1106OTN.pdf

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Recurring Updates & Reminders

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ICD-10 compliance date delayed to October 1, 2014

Keep Up to Date ◦ Sign up for CMS ICD-10 Industry Email Updates-

http://www.cms.gov/Medicare/Coding/ICD10/CMS_ICD-10_Industry_Email_Updates.html

◦ Follow @CMSGov on Twitter

◦ Subscribe to Latest News Page Watch -

https://public.govdelivery.com/accounts/USCMS/subscriber/new?topic_id=USCMS_609

ICD-10 Delayed

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Change Request # 7834

Effective and Implementation: August 27, 2012

Key Point(s): ◦ In order to be granted a timely filing extension, the provider,

supplier, or beneficiary must furnish an official letter from the Social Security Administration (SSA) that the beneficiary was retroactively entitled to Medicare on or before the date of the furnished service

◦ If an official SSA letter to the beneficiary is not submitted, Medicare contractors must check the Common Working File (CWF) database

For more information ◦ http://www.cms.gov/Outreach-and-Education/Medicare-Learning-

Network-MLN/MLNMattersArticles/Downloads/MM7834.pdf

Modifying the Timely Filing Exceptions on Retroactive Medicare Entitlement and Retroactive Medicare Entitlement Involving State Medicaid Agencies

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October Update to the CY 2012 Medicare Physician Fee Schedule Database (MPFSDB) – MM8017 http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/2012-Transmittals-Items/R2530CP.html

2013 Annual Update for the Health Professional Shortage Area (HPSA) Bonus Payments http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/2012-Transmittals-Items/R2526CP.html

October 2012 Update of the Ambulatory Surgical Center Payment

System (ASC) http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/2012-Transmittals-Items/R2525CP.html

2013 Healthcare Common Procedure Coding System (HCPCS) Annual Update Reminder

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2012-Transmittals-Items/R2529CP.html

Part B Recurring Updates

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Part B

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SE1242 – 2012-2013 Seasonal Influenza (Flu) Resources for Health Care Professionals ◦ http://www.cms.gov/Outreach-and-

Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1242.pdf

SE1229 – A Physician’s Guide to Medicare Part D Medication Therapy Management (MTM) Programs ◦ http://www.cms.gov/Outreach-and-

Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1229.pdf

Special Edition (SE) Articles

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Medicare Initiatives

and Incentive Programs

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The Affordable Care Act authorized PQRS payment

through 2014

.5% incentive payment for 2012-2014

The Center for Medicare and Medicaid Services (CMS)

Posted to PQRS Website: ◦ 2012 Measures Codes

◦ 2012 PQRS Reporting System Implementation Guide

◦ 2012 PQRS Measures Groups

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/pqrs/index.html

2012 Physician Quality Reporting System (PQRS) Program

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2012 - 1%, 2013 - .5%

2013 (98.5%) payment adjustment based on claims submitted between January 1 and June 30, 2012

Significant Hardship Categories ◦ The eligible professional is unable to electronically prescribe due to local, state,

or federal law, or regulation

◦ The eligible professional has or will prescribe fewer than 100 prescriptions during a 6-month reporting period (January 1 through June 30, 2012)

◦ The eligible professional practices in a rural area without sufficient high-speed Internet access (G8642)

◦ The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing (G8643)

For more information on the eRx Incentive Program ◦ http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/ERxIncentive/index.html

◦ http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7879.pdf

2012 Electronic Prescribing (eRx) Incentive Program

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Individual eligible professionals who meet one of the criteria are automatically excluded from the 2013 Electronic Prescribing (eRx) payment adjustment:

◦ The eligible professional is a successful electronic prescriber during the 2011 eRx 12- month reporting period

◦ The eligible professional is not an MD, DO, podiatrist, Nurse Practitioner, or Physician Assistant by June 30, 2012, based on primary taxonomy code in the National Plan and Provider Enumeration System (NPPES)

◦ The eligible professional does not have at least 100 Medicare Physician Fee Schedule (MPFS) cases containing an encounter code in the measure’s denominator for dates of service from January 1, 2012 through June 30, 2012

◦ The eligible professional does not have 10% or more of their MPFS allowable charges (per TIN) for encounter codes in the measure’s denominator for dates of service from January 1, 2012 through June 30, 2012

◦ The eligible professional does not have prescribing privileges and reported G8644 on a billable Medicare Part B service at least once on a claim between January 1, 2012 and June 30, 2012.

For more information: ◦ http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNMattersArticles/Downloads/SE1206.pdf

2013 Exclusion Criteria

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If you have questions regarding the eRx Incentive Program, eRx payment adjustments, or need assistance submitting a hardship exemption request, please contact the QualityNet Help Desk at 866-288-8912 (TTY 877-715-6222) or via qnetsupport@sdps.org.

They are available Monday through Friday from 7am to 7pm CST.

Questions on eRX

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Several new resources can help you successfully navigate the Medicare EHR Incentive Program: ◦ A new attestation page on the Centers for Medicare/Medicaid

Services website, where participants in the Medicare EHR Incentive Program can find important information on attestation

◦ The Meaningful Use Attestation Calculator allows Eligible Professionals (EPs) and eligible hospitals to check whether they have met meaningful use guidelines before they attest in the system. The calculator prints a copy of each EPs or eligible hospital's specific measure summary.

◦ The Eligible Professional User Guide and the Eligible Hospital and Critical Access Hospital User Guide provide step-by-step guidance for EPs and eligible hospitals on navigating the attestation system.

Electronic Health Record (EHR) Incentive Program

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EHR Incentive payments are distributed based on each year of participation, and follow a specific payment schedule

◦ Medicare Learning Network Matters Special Edition (SE) article SE1111 – Medicare Electronic Health Record (EHR) Incentive Payment Process

Additional incentive for services provided in a Health Professional

Shortage Area (HPSA)

EHR payments will be issued by a Payment File Development

Contractor

Questions about your EHR incentive payment should be directed to:

◦ EHR Information Center at 1-888-734-6433 or 1-888-734-6563 (TTY)

◦ Hours of Operation: 7:30 a.m. – 6:30 p.m. (Central Time) Monday through Friday, except federal holidays.

Electronic Health Record (EHR) Incentive Program

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Preventive Services

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Preventive Services Annual Wellness Visit Bone Mass Measurements Cancer Screenings Cardiovascular Disease

Screening Colorectal Cancer

Screening Depression Screenings Diabetes Screening Tests Diabetes Self-Management

Training Glaucoma Screening Hepatitis B Vaccine Human Immunodeficiency

Virus (HIV) Screening Influenza Virus Vaccine

Initial Preventive Physical Examination

Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD)

Medical Nutrition Therapy Prostate Cancer Screening Pneumococcal Vaccine Screening Mammography Screening Pap Test Screening Pelvic Exam Smoking and Tobacco Use

Cessation Counseling Ultrasound Screening for

Abdominal Aortic Aneurysm

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Medicare Learning Network (MLN) Products for Preventive Services

Help Keep Your Medicare Patients Healthy In 2012!

Ensure your patients take advantage of Medicare-covered preventive services.

Medicare covers a wide array of preventive services for eligible beneficiaries, including cancer screenings, certain immunizations, among others.

The Medicare Learning Network (MLN) Preventive Services Educational Products Web Page provides descriptions and ordering information for MLN preventive services educational products and resources for health care professionals and their staff. ◦ http://www.cms.gov/MLNProducts/35_PreventiveServices.asp

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Preventive Services

Quick Reference Chart for Medicare Preventive Services ◦ http://www.cms.gov/Outreach-and-

Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MPS_QuickReferenceChart_1.pdf

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Fraud Prevention

Recovery Auditor (RA)

Aims to ensure correct payments are made to legitimate providers for covered appropriate and reasonable services in all federal health care programs

Expanded federal government effort to reduce fraud and other improper payments health care programs to help ensure long-term viability

Federal government recovered $4 billion last year Fraud prevention efforts focus on a more proactive “prevention and detection” model that will help prevent fraud and abuse before payment is made. This information is available in the Fraud Prevention Toolkit on the web at: https://www.cms.gov/Partnerships/04_FraudPreventionToolkit.asp#TopOfPage

Fraud Prevention Initiative

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Recovery Auditors (RA) detect and correct past improper

payments so that Centers for Medicare/Medicaid Services

(CMS) and Carriers, Fiscal Intermediaries (FIs) and

Medicare Administrative Contractors (MACs) can

implement actions that will prevent future improper

payments.

RA for Jurisdiction 12 is Performant Recovery ◦ http://www.dcsrac.com/

For more information about the Recovery Audit Program ◦ http://www.cms.gov/rac/

Recovery Audit Program

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Medicare Learning Network Special Edition (SE) Article SE1036 ◦ Fourth in a series of articles that will disseminate

information on Recovery Auditor (RA) demonstration high dollar improper payment vulnerabilities

◦ Two high risk vulnerabilities for physician claims: Other Services with Excessive Units

Units billed exceeded the number of units per day based on the Current Procedural Terminology (CPT) code descriptor, reporting instructions in the CPT book, and/or other local or national policy

Duplicate Claims Physician billed and was paid for two claims for the same

beneficiary, for the same date of service, same CPT code, and same physician

◦ http://www.cms.gov/MLNMattersArticles/downloads/SE1036.pdf

Recovery Auditor (RA) Demonstration High-Risk Vulnerabilities for Physicians

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OIG Work Plan 2013

OIG Work Plan outlines their current focus areas and states the primary objectives of each project

Specific Items Include: ◦ Inpatient Billing for Medicare Beneficiary

◦ Same Day Readmission

◦ Compliance with Medicare Transfer Policy

◦ Place of Service

https://oig.hhs.gov/reports-and-publications/workplan/index.asp

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Self Service Options

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Jurisdiction 12 Contact Information

Provider Customer Contact Center

Interactive Voice Response (IVR)

1-877-235-8073

Hours of Operation

◦ Monday-Friday 8 am – 4 pm

Call Flow ◦ Customer Service Center

◦ https://www.novitas-

solutions.com/csc/index.html

1-877-235-8073

Hours of Operation

◦ Monday: 6 am- 8 pm

◦ Tuesday-Friday: 4 am- 8 pm

◦ Saturday: 6 am- 4 pm

Step-by-Step Guide ◦ Customer Service Center

◦ https://www.novitas-

solutions.com/csc/index.html

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Our website offers a wide variety of valuable resources

including: ◦ Customer Service Center

◦ A/B Reference Manual

◦ Appeals Center

◦ Electronic Billing (EDI)

◦ News and Bulletins

◦ Self-Service Tools

◦ Evaluation and Management (E/M) Center

◦ Medical Policy Center

◦ Training and Events Center

For additional resources visit: ◦ Part B- https://www.novitas-solutions.com/partb/index.html

Medicare Part B Center

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Weekly Podcast

◦ Weekly podcast of the latest Medicare Updates and other

informative topics

◦ Subscribe- https://www.novitas-solutions.com/podcasts/

Web Updates

◦ Daily E-mail of the latest Medicare Updates

◦ Subscribe- https://www.novitas-

solutions.com/mailinglists.html

Stay Up-to-Date

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MLN Matters articles have been consolidated with the transmittals

If you are looking for 2012 MLN Matters articles, go to the

URL for the 2012 transmittals, www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2012-Transmittals.html

Sort by article number (MM Article #) or key in article # in the “Filter on” field

From the Centers for Medicare and Medicaid Services (CMS) homepage, http://www.cms.gov/ , click on Transmittals in the Top 5 Links section at the bottom right hand side of the page

Finding MLN Matters Articles

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The CMS website offers a wide variety of valuable

resources including:

◦ CMS Internet Only Manuals (IOMs)

◦ Medicare Learning Network (MLN) Matters Articles

◦ Open Door Forum

For additional resources visit: ◦ http://www.cms.gov/

Centers for Medicare & Medicaid Services (CMS)

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QUESTIONS?????

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