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Changes To the Advance Beneficiary Notice of Non-Coverage

By | Department of Health and Human Services, Medicare | No Comments

The Advance Beneficiary Notice of Non-Coverage (ABN), is a notice given to Medicare beneficiaries to convey that Medicare is not likely to cover the service provided, or it is issued by providers in situations where Medicare payment is expected to be denied.

It is important to note that physicians’ offices must complete the ABN and deliver the notice to beneficiaries or their representative for review, and any questions raised during that review must be answered before it is signed.  This ensures that the patient or their representative has time to consider the options and make an informed choice.

Once all the blanks are completed and the form is signed, the physician’s office then gives a copy to the beneficiary or representative.  CMS mandates that the provider retain a copy of the ABN on file.

All of this is required before providing the items or services that are the subject of the ABN.  If these procedures are not followed or the form is filled out incorrectly, the ABN is considered invalid.  In certain cases, an invalid ABN could require repayment by the provider for all services rendered, as well as sanctions.

To quote Medicare, “Medicare will hold any provider who either failed to give notice when required, or gave defective notice, financially liable.  Additionally, when authorized by law and regulations, sanctions under the Conditions of Participation (COP) may be imposed.  A provider who gave defective notice may not claim that she/he did not know or could not reasonably have been expected to know that Medicare would not make payment as the issuance of the notice (albeit defective) is clear evidence of knowledge.”

As a chiropractic compliance consultant, I’m always asked about filling out an ABN for non-covered services (i.e. therapies, exams, and x-rays).  The ABN is only required when you feel a service will be denied, and for chiropractic physicians, the adjustment is the only covered service.

If you wish to issue an ABN as a courtesy to the beneficiary, advising them of any financial liability for services that Medicare never covers (anything that’s not an adjustment), you can.  This is called a voluntary ABN and this is considered non-valid by Medicare.  If an office chooses to issue a voluntary notice, the beneficiary doesn’t need to choose an option box and is not required to sign the notice.

 

A better way to do this would be to design a statement form that tells the patient that Medicare only covers the adjustment and that the patient will be financially responsible for non-covered services provided as part of your treatment.

The ABN is approved by the Executive Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 and is subject to re-approval every 3 years.

With that said, the form has been revised to include language informing beneficiaries of their rights to CMS non-discrimination practices and how to request the ABN in an alternative format if needed.

Providers are expected to exclusively use the current version of the ABN, and even though there are no changes to the form itself, providers must pay attention to the OMB approval date on the notice and obtain the current version.  The date of mandatory use of the new ABN starts with claims made on or after 06/21/2017.

The new ABN form may be downloaded using the following links:

English version:

https://complianceandauditingservices.com/wp-content/uploads/2017/06/ABNEnglish2020v508.pdf

Spanish Version:

https://complianceandauditingservices.com/wp-content/uploads/2017/06/ABNSpanish2020-v508.pdf

You should be able to click on the links. If you have problems with the link just copy and paste it into the browser, then click enter.

Hopefully, this Compliance & Auditing Services notice will give you time to switch to the newly approved notices.

If you have any questions or need help, don’t hesitate contacting Compliance & Auditing Services.

All the Best,

Dr. John Davenport
Chief Compliance Officer
Compliance & Auditing Services

 

Get Ready for Medicare Provider Enrollment Revalidation

By | Compliance, Medicare | No Comments

Section 6401 (a) of the Patient Protection and Affordable Care Act established a requirement for all enrolled providers to revalidate their Medicare enrollment information roughly every five years to prevent fraud within the Medicare system by ensuring that Medicare provider records are accurate.

Cycle 2 Revalidation began on February, 2016. Basically this means a physician’s maintenance of the Medicare billing privileges cycle. Simply put, revalidation is re-enrollment and all providers are required to revalidate their enrollment information.

If the provider doesn’t submit a complete revalidation application by their specific due date, the Medicare Administrative Contractor (MAC) may hold your Medicare payments or deactivate your Medicare billing privileges.

Typically, your Medicare Administrative Contractor (MAC) will send a revalidation notice within two to three months prior to your revalidation due date either by mail or to the email address reported on prior applications indicating the providers due date.

Note that your MAC must receive your enrollment application within 60 days of the revalidation request.

The best way to prevent a lapse in coverage is to verify your due date, listed on  Data.CMS.gov/revalidation. The list will include all enrolled providers and will display the provider’s revalidation due date. In addition, a crosswalk to the organizations that the individual provider reassigns benefits will also be available as well.

For providers not up for revalidation, the list will display a “TBD” (To Be Determined) in the due date field. This means the provider’s due date is more than 6 months away.

The list was revised on April 10, 2017. All dates are updated every 60 days at the beginning of the month and are listed up to 6 months in advance. Do not submit a revalidation if you have not received an email/mailed letter from your MAC requesting you to revalidate, or your due date is not listed on the CMS revalidation website. If you do, it will be considered an unsolicited revalidation and will be returned.

If you are within 2 months of the listed due date on the CMS revalidation website and have not received a notice from their MAC to revalidate, as a chiropractic consultant I recommend that you make every effort to submit your revalidation application immediately.

The most efficient way to submit your revalidation information is thru the Internet Based PECOS. Here you can review information currently on file, update and submit your revalidation and electronically sign after uploading the supporting documents. If you wish, you can just print out your revalidation , sign and date it  and then mail your paper certification along with supporting documentation to your Medicare Administrative Contractor (MAC).

It is important that providers check their due date immediately in order to avoid a hold on your Medicare payments.

If you have any questions or need help, don’t hesitate contacting the ACS or Dr. Davenport at complianceandauditingservices.com.

All the Best,

Dr. John Davenport DC, CCSP, FIAMA, MCSP, CIC

Certified Compliance and Insurance Consulting Services

Medicare Access and CHIP Reauthorization Act of 2015

By | Department of Health and Human Services, Medicare | No Comments

girl-studying-stressed-istock_000022144730smallStarting with the reporting year 2017, the current fee for service method of reimbursing physicians is going to evolve into a value-based methodology. Ignoring these changes can have a profound effect on your cash flow and profitability.

In the past, physicians were paid based on volume or utilization. The reimbursement rates were governed by something known as the SGR (Sustainable Growth Rate).

The government is replacing SGR with MACRA, which stands for the Medicare Access and CHIP Reauthorization Act of 2015. MACRA will reimburse physicians based no value rather than volume.

The reason for the change is that the government needed to replace the Sustainable Growth Rate formula because it became too difficult to manage, and wanted to combine all existing quality reporting programs into one system.

The government also wanted to develop a framework for rewarding providers for giving better care, not just more care.

There are essentially two different pathways in MACRA, but the one that most physicians will engage in is known as the Merit Based Incentive Payment System known as MIPS.

The MIPS program simply wraps up PQRS, the Value Based Modifier and the Medicare Electronic Health Record Incentive Program or meaningful use into one single program.

There are four components to MIPS:

50% of the component is based upon quality. The definition of quality is simply related to how well you comply with the current PQRS program.

25% of the net component is based upon what’s known as advancing care information. For all practical purposes this is our current Meaningful Use program.

15% is based upon clinical practice improvement activities. Here providers will have to choose some activities which improve their clinical care. This really hasn’t been well defined yet for chiropractic.

10% of the component will be based upon resource use, which means cost. This means that your cost per diagnosis will be benchmarked against your peers.

In the end, the MIPS program ultimately defines the financial impact for clinicians by creating a composite score for each provider.

In an attempt to motivate providers, by having an effect on their reputation, the providers composite score is also going to be placed on the CMS new public website known as, “Physician Compare.”

Without getting into too much detail, the end financial result of the MIPS program is fairly straightforward, the maximum penalty that can be levied is 9% for each provider and is going to be determined by
competing with your peers.

Remember that the 2019 reimbursement year is a reflection of what happens in 2017. That’s why it’s urgent that you prepare yourself since we’re rapidly approaching that starting date.

Dr. John Davenport DC, CCSP, FIAMA, MCSP

Compliance & Auditing Services

Immediate Action Required: Health Care Providers MUST Comply!

By | Department of Health and Human Services, Medicare | No Comments

Immediate Action Required by Health Care Providers to Comply With Section 1557 of the Affordable Care Act

On May 18, 2016, the U.S. Department of Health and Human Services (“HHS”) Office of Civil Rights (“OCR”) issued the Final Rule implementing the prohibition of discrimination under Section 1557 of the Affordable Care Act (ACA) of 2010.

Under Section 1557, individuals are protected from discrimination in health care on the basis of race, color, national origin, age, disability, and sex, including discrimination based on pregnancy, gender identity, and sex stereotyping.

Though Section 1557 has been in effect since the enactment of the ACA in 2010 and the HHS Office for Civil Rights (OCR) has been enforcing the provision since it was enacted, the Final Rule explains consumer rights under the law and provides additional clarification on enforcement and administrative remedies. In addition, it further defined who is considered a covered entity and their obligations.

The Final Rule applies to those who provide or administer health-related services or insurance coverage and receive “federal financial assistance,” which includes Medicare (except for Part B), Medicare Advantage Plans, Medicaid, Children’s Health Insurance Fund (CHIP) and receive meaningful use payments.

Under the Final Rule, all covered practices are required to “take reasonable steps to provide meaningful access to each individual with limited English proficiency eligible to be served.”

Section 1557 also states that “access services must be provided free of charge” and health care providers are expected to treat the costs of providing auxiliary aids and services as part of the annual overhead costs of operating a business.

Though doctors can claim a tax credit of up to 50 percent for eligible access expenditures over $250, but less than $10,250, the total amount is limited to $5,000 per tax year.

Eligible access expenditures include the costs of:

  1. Qualified interpreters (Meaning an interpreter who is able to interpret effectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary)
  2. Note takers
  3. Transcription services
  4. Written materials
  5. Telephone handset amplifiers
  6. Assistive listening devices and listening systems
  7. Telephones compatible with hearing aids closed caption decoders, open and closed captioning
  8. Text telephones (TTYs)
  9. Videotext displays, or other effective methods of making aurally delivered materials available to the deaf or hard of hearing.

No one disagrees that there should be effective communication, but it seems unfair that physicians have to bear the total cost, which is estimated at $120 to $200 per visit, when reimbursement doesn’t come close to covering it.

Among other things, the Final Rule requires effected health care providers to include a non-discrimination notice and taglines in “significant publications” or “significant communications” targeted at patients or the public.

Though HHS does not specify which communications are considered significant, HHS does provide some examples such as patient handbooks, consent and complaint forms, initial patient paperwork, outreach publications, marketing materials and any notice “requiring a response from an individual” – which could include patient bills or notices to contact the practice to schedule an appointment. The notice/taglines can be part of the publication or a separate insert.

Additionally, taglines must be in at least the top 15 non-English languages spoken in the State in which the entity does business. For small sized communications such as postcards; the final rule requires entities to post a nondiscrimination statement and taglines in at least the top two non-English languages spoken by individuals with limited English proficiency in the State.

The provisions of the final rule became effective on July 18, 2016. In addition, the rule’s notice requirements, specifically the posting of a nondiscrimination notice and taglines are effective within 90 days of the effective date.

The Office for Civil Rights (OCR) is responsible for enforcing civil rights laws and complaints to OCR can result in investigations by HHS and the Department of Justice. In addition, an individual can sue you in civil court for a Section 1557 violation.

The director for the Office for Civil Rights, Jocelyn Samuels, sent a memorandum out to the U.S. Department of Health and Human Services stating, “I wanted to take this opportunity, as we reflect on the critical importance and impact of Federal civil rights laws and our role as public servants, in their vigorous enforcement, to underscore our authority and important responsibility to enforce Section 1557.”

Discrimination claims are not covered under traditional medical liability insurance and any judgments will come out of the doctors’ own pocket.

Steps Providers Should Take Immediately To Protect Themselves:

  1. Prepare and post all required “notice” communications and make sure websites are updated accordingly.
  2. Establish a means of providing required language support. This may require contracting with an outside vendor and/or addressing other forms of access to language support within the practice.
  3. Review all existing entity policies and/or create new policies, procedures addressing non-discrimination (including gender identity and gender transition) in health services, auxiliary aid, and language access requirements.
  4. Educate and train employees and staff. 
  5. Create and document a grievance procedure. 
  6. Submit an assurance of compliance form to OCR.

 

Again, remember that this applies only to practices which accept Medicare Advantage plans (Medicare Part A), Medicaid, Childrens Health Insurance Plans (CHIP), or have received Meaningful Use dollars.  This does not apply to Medicare Part B.