Posts Tagged ‘Claims’

Home Health Agencies’ Claims for Ordered/Referred Services Must be Billed Using Individual Physician’s Name and NPI

Authored By: Todd J. Selby

In the near future, Regional Home Health Intermediaries (RHHIs) and Parts A and B Medicare Administrative Contractors (A/B MACs) will be contacting home health agencies (HHAs) that have previously submitted claims for ordered or referred services using a group name and national provider identifier (NPI).  HHAs will be informed they should begin submitting such claims using the ordering physician’s name and NPI, not a group name and NPI.  Once the Centers for Medicare & Medicaid Services (CMS) implements the edits for ordering/referring services into the coding system, claims submitted under a group NPI will be denied. (more…)

CMS Releases Final Rule Requiring Providers to Include NPI on Enrollment and Claim Filings

Authored By: David W. Bufford

The Centers for Medicare & Medicaid Services (CMS) just released a final rule requiring all providers of medical or other items or services and suppliers that qualify for a National Provider Identifier (NPI) to include their NPI on all applications to enroll in the Medicare and Medicaid programs and on all claims for payment submitted under the Medicare and Medicaid programs.  The final rule will be published in the April 27th Federal Register, and the rule will become effective 60 days after publication, June 26.

(more…)

CMS Postpones Two Anti-Fraud Initiatives

Authored By: David W. Bufford

The Centers for Medicare & Medicaid Services (CMS) has pushed back the start of two anti-fraud programs to June due to provider concerns.  Two pilot programs, one that would require prior authorization for scooters and power wheelchairs and one allowing recovery audit contractors (RAC) to review claims prior to payment, were initially slated to begin January 1, 2012.   (more…)

CMS Contractors to Review of Denials Relating to Face-to-Face Requirements for HHA Services

Authored By: Kendra Conover

The Centers for Medicare & Medicaid Services (“CMS”) has recently instructed contractors to reopen certain claims that were previously denied for failure to meet the “face-to-face” requirements in certain circumstances and assuming all content requirements of the certification and the face-to-face documentation are otherwise met.  It came to CMS’ attention that certain claims were being denied by some CMS contractors for patients who use Home Health Agency (“HHA”) services following an acute or post-actue stay when:

  • The HHA uses a single form (i.e., 485) for the plan of care and the certification with a single signature by the community physician who assumes oversight of the patient’s home healthcare.
  • The physician who cared for the patient in the acute or post-acute setting is the certifying physician and has provided and signed attached documentation of the face-to-face encounter.

CMS does not mandate that a specific form be used for the certification or plan of care.  Many providers, however, have chosen to use the no-longer-required CMS-485 form to satisfy the plan of care and the certification.  Since April 2011, providers who use this form typically attach the face-to-face encounter documentation to the CMS-485, as an addendum.  This is because the CMS-485 contains only one physician signature line for both the plan of care and the certification of eligibility.

In the case of patients admitted to an HHA following an acute or post-acute stay, the Medicare Benefit Policy Manual (“BPM”) language allows for one physician to sign the certification and face-to-face documentation, while a different physician can sign the plan of care.  If the face-to-face encounter documentation and the CMS-485 form collectively satisfy all of the  certification and plan of care content requirements as defined in Chapter 7 Section 30 of the BPM, Medicare contractors have been directed to accept a CMS-485 form signed by the community physician who assumes oversight of the patient’s home healthcare with an addendum containing the face-to-face encounter documentation requirements signed by a physician who cared for the patient in an acute or post-acute setting, to satisfy the certification, face-to-face encounter, and plan of care requirements.  In this scenario, the certifying physician is the acute or post-acute physician, has initiated content on the CMS-485, and has completed and signed the face-to-face encounter documentation.  The physician who signs the CMS-485 assumes care for the patient’s home healthcare.

 Additionally, CMS acknowledged that some contractors are denying claims for failure of the acute or post-acute physician to identify the community physician who will assume care for the patient.  CMS has not mandated the acute or post-acute physician to follow a specific documentation protocol to hand-off a patient to the community physician. Therefore, these claims will be reviewed as well.

If you have questions or concerns regarding the foregoing or would like additional information, please contact your regular Hall Render attorney, or Todd Selby at tselby@hallrender.com or 317.977.1440, or Kendra Conover at kconover@hallrender.com or 317.977.1456