Billing and Collections Q&#038;A

Running an O&P facility in today's landscape of enhanced scrutiny and changing billing requirements can leave even the most seasoned billing professional feeling frustrated. If you have a billing question or a question about a denial, "Got FAQs?" can help you sift through the confusion and get you the answers you need. This month's column addresses your questions about Medicare sequestration payment adjustments and verifying referring physician eligibility. Q: I noticed when I received my last Medicare explanation of benefits (EOB) that there was a reduction in the payment. We are located in Alabama, and the representative I spoke to at Medicare said the reduction was required under sequestration and applies to all claims received on or after April 1, 2013. She was very abrupt, and I have no idea what she is talking about. Can you help me better understand what this is? I am relatively new to billing for O&P and want to be able to explain to my boss why he is receiving less money. A: Effective April 1, 2013, Medicare began making two percent payment adjustments as required under sequestration. The payment adjustment, which will appear on the remittance advice as claim adjustment reason code (CARC) 223, is deducted from the calculated payment amount-based on the current fee schedule, which remains unchanged-after the approved amount is determined and the deductible and any applicable coinsurance are applied. Only the final payment amount is reduced. For example: A provider bills Medicare for $1,000, of which Medicare normally would pay 80 percent of the approved amount ($800). The patient is responsible for the remaining 20 percent ($200). But due to the mandated sequestration cut, Medicare deducts 2 percent from the $800, or $16. So instead of getting paid $800, the supplier receives $784. To read the Medicare article, "Sequestration Q&A," visit www.oandp.com/link/210 Q: The practitioner I work for said that I need to verify that we have the correct information for all of our referring physicians when we submit claims to Medicare or the claims will be denied. When I asked for clarification, he told me to go to the Internet and look it up. What should I look up? Can you translate his instructions based on this information? A: On April 25, 2013, the Centers for Medicare & Medicaid Services (CMS) announced that there will be a temporary delay in implementing ordering and referring denial edits of the Provider Enrollment, Chain, and Ownership System (PECOS) program due to technical issues. Originally, CMS had announced that beginning with dates of service on or after May 1, 2013, Durable Medical Equipment Medicare Administrative Contractors (DME MACs) claims must include a valid and eligible ordering/referring physician name and a National Provider Number (NPI) to be processed correctly. Under this process, if the ordering/referring physician name and NPI listed on your claim is invalid or ineligible, then your claim will be denied. If you have a list of existing ordering/referring physicians and you want to check that you have their correct information, that the physicians are registered in PECOS, and that they are a type or specialty that is eligible to order and refer Medicare beneficiaries to you, visit www.oandp.com/link/211 . You must have an active user ID and password to log into the Internet-based PECOS, which can be obtained via the National Plan and Provider Enumeration System (NPPES)/PECOS Identification and Authentication (I&A) system. To register, visit www.oandp.com/link/212 . Alternatively, a free online PECOS search is provided at www.oandp.com/pecos Although CMS has delayed this implementation, you may still want to look up your ordering/referring physician to validate the information so you are prepared when CMS announces the revised effective date. Lisa Lake-Salmon is the president of Acc-Q-Data, which provides billing, collections, and practice management software. She has been serving the O&P profession for more than a decade. We invite readers to write in and ask any questions they may have regarding billing, collections, or related subjects. While every attempt has been made to ensure accuracy, The O&P EDGE is not responsible for errors. For more information, contact lisa@opedge.com or 800.279.1865 visit www.acc-q-data.com

Billing and Collections Q&A

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Related posts:

Cassie Peeters, CP

An Introduction to the Amputee Coalition

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